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MEDICAL PROFESSIONALISM PERILOUS TIMES

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MEDICAL PROFESSIONALISM PERILOUS TIMES Powered By Docstoc
					      MEDICAL
PROFESSIONALISM IN
  THE 21st CENTURY:

IS THERE A NEED FOR
  REVITALIZATION?
Socrates: “Tell me: is a doctor in the
    precise sense…a money-maker
    or someone who treats the sick?
    Tell me about the one who is
    really a doctor.”
Thrasymachus: “He’s the one who
    treats the sick.”
                  Plato, The Republic
 Today at the dawn of a new
  century, genuine medical
  professionalism is in peril
 Trade or profession?
 Market economy a primary
  diminishing factor
“Medicine is, at its center, a moral
 enterprise grounded in a covenant
 of trust. Today, this covenant is
 significantly threatened.”
                       Ludmerer
        MEDICAL
    PROFESSIONALISM
• Definitions
  • Evolution
    •Concerns
      •Revitalization
        •Conclusions
DEFINITIONS
       A PROFESSION
“A profession…is an occupation that
 regulates itself through systematic,
 required training and collegial
 discipline; that has a base in
 technical, specialized knowledge;
 and that has a service rather than a
 profit orientation, enshrined in its
 code of ethics…”
                      Starr
       A PROFESSION
 Training is intellectual and
  involves knowledge
 Work pursued primarily for
  others
 Success should be measured by
  more than financial return
            Justice Louis Brandeis
      SEVEN PILLARS OF A
         PROFESSION
1.   Technical skill and    4. A knowledge of
     craftsmanship,            literature and the
     renewed by                arts
     continuing education   5. Personal integrity
2.   A sense of social      6. Faith in the meaning
     responsibility            and value of life
3.   A knowledge of         7. The grace of humility
     history
                                       E.P. Scarlett
   THE PROFESSIONAL
 Patients first
 Service/public leadership
 Nonjudgmental care
 Collaboration
 Lifelong learning
THE NON-PROFESSIONAL
 Dishonest       Lacks
 Greedy           interpersonal
 Impaired
                   skills
                  Conflict of
 Abuses power
                   interest
                  Self-serving
EVOLUTION OF THE
  PROFESSIONS
    EVOLUTION OF THE
      PROFESSIONS

 The Hippocratic Oath
  - A vow of service
    EVOLUTION OF THE
      PROFESSIONS
 American society has pitted a belief
  in egalitarianism against an ideal
  of individual achievement
 Precarious existence in a
  democratic society
 Near demise with election of
  Andrew Jackson
 Lincoln reversed the trend
    EVOLUTION OF THE
      PROFESSIONS
 In United States professional
  designates an independent status
  with self-regulation
 A social contract – in exchange for
  elevated status and a regulated
  market professionals must
  demonstrate civic responsibility and
  community leadership
             THE PROFESSION OF
                 MEDICINE
Ideal                Foundational                   Reality
                        Value
Evidence-based         Truth/Science              Uncertainty

Caring, healing           Curing                Risk-harming

Open heart/mind    Accepting, Empathetic   Arrogant, unmoved

Error-free              Right action           Mistake-prone

Analytic                Reflective         Hassled, knee-jerk

Self-sacrificing         Altruistic                Avaricious



                                                  -Inui
  THE PROFESSIONS AND
    THE UNIVERSITY

 Standardization
 Professional degree
          20th    CENTURY

 Post WWII – many critics
 Self interest
 Monopolistic
 Personal gain
“No longer seen as working quietly for
 the public good the American medical
 profession took on a sinister, even anti-
 social characteristic, in its role in the
 culture at large. Some influential
 critics also revised the profession’s
 history from a glorious narrative
 success to a more ominous tale of
 hubris.”
                    Rosemary Stevens
21st CENTURY
 CONCERNS
    THE NEW CENTURY
 Specialization of medicine
 Faculty reward systems
    Publish or perish
 Generational gaps
THE CHANGING FACE OF
      MEDICINE
 Medicine in midst of major
  ongoing reorganization in response
  to drastic regulatory and
  organizational changes
 The growth of HMOs
 The result is less and less control
  by physicians
THE DOCTOR’S DILEMMA

  Patient-Centered        Marketplace
 Advocates for        Proxies for the plan
  patients
 Optimal effective    Low cost care
  care


                                     Benson
THE DOCTOR’S DILEMMA

   Patient-Centered       Marketplace
 Managed care         Managed cost
 Concern for          “Distributive ethic”
  individual
 Bedside rationing    Centralized rule-
                        based rationing

                                       Benson
 Profound influence of a market
 economy with perverse financial
 incentives threatens to reduce the
 medical profession to a lowest
 common denominator
 Physician practice recast as a
  profit center rather than a group
  of healers
 Substitution of a calculation of cost
  benefit for the ethical relations of
  care and trust
 Erosion of patients’ TRUST!
“Failure to affirm the primacy of the
 patients’ welfare will result in a
 loss of the public trust and
 medicine’s slide from a revered
 profession to an occupation
 populated with technical experts”

                         Hafferty
    THE NEW CENTURY
 Gradual disintegration of
  education community
 Disappearance of the master
  clinician
 Loss of role models
 Loss of mentors
 THE APPRENTICESHIP OF
   PROFESSIONALISM
 Acquisition of a knowledge base
 Acquisition of skills
 Acquisition of an understanding of
 ethical standards, social roles and
 responsibilities
        CURRICULUM

 Formal – what we say
 Hidden – what we do
FORMAL CURRICULUM
 Empathy
 Compassion
 Altruism
               }   What we
                    say
   HIDDEN CURRICULUM
 Most of the critical determinants of
  physician identity operate not
  within the formal curriculum but
  in a more subtle, less officially
  organized hidden curriculum
 The hidden curriculum functions
  at the level of organizational
  structure and culture
  HIDDEN CURRICULUM
 Weariness
 Strong distrust of emotions
 Failure of communication
  HIDDEN CURRICULUM
 Ethic of detachment
 Self-interest
 Over objectivity
 CYNICISM
     JOURNAL ARTICLES
1. “Burnout and Self-Reported Patient Care
   in an Internal Medicine Residency
   Program”
2. “Stress in Medical Residency: Status Quo
   After a Decade of Reform?”
3. “Who is sicker: Patients – or Residents?
   Residents’ Distress and the Care of
   Patients”
4. “Heeding the Plea to Deal with Resident
   Stress”
                           Annals of Internal Medicine
                                         March 5, 2002
   HIDDEN CURRICULUM
 2nd set of beliefs - as students,
 residents wend their ways through
 years of education they gradually
 adopt the medical culture and it’s
 value system as their own
 abandoning traditional values.
    ACADEMIC HEALTH
        CENTER
“Moral tone frequently subverts
 rather than supports the
 development of good professional
 morals.”
                    Huddle
    ACADEMIC HEALTH
        CENTER
 Profound impact of entire
 institutional environment on
 shaping the attitudes, values,
 beliefs, modes of thought and
 behavior of medical students,
 residents, and faculty
    ACADEMIC HEALTH
        CENTER
“Unless we can convert our learning
 environments from crucibles of
 cynicism into cradles of
 professionalism, no amount of
 effort in the admissions arena is
 going to suffice”
                          Cohen
“Today’s culture of medicine is
 hostile to altruism, compassion,
 integrity, fidelity, and self-
 effacement”

                     Coulehan
REVITALIZATION
      REVITALIZATION
 Current strategy is inadequate
 Production of highly skilled technicians
  but not necessarily true professionals
 Must strike a balance between explicit
  teaching and experiential learning
  incorporating the values of
  professionalism
           THE GENERATIONS
           Baby
Veterans   Boomers   Cuspers   Busters   Gen Nexters

1922-43    1944-59   1960-68   1969-79   1980-
“In order to define, teach and access
 professionalism it is imperative to
 understand generational
 differences, pinpoint conflicts and
 determine a more effective
 definition of professionalism
 acceptable to all .”

                  Wagoner and Clay
 Individuals from different
  generations eschew different goals
           BUT
 Current individuals are no less
  professional or altruistic than their
  predecessors
 Their core of professionalism
  remains intact
       REVITALIZING
     PROFESSIONALISM
 Faculty development critical
 System of evaluation
 Professional tone and awareness
  set from the top!
 Strong institutional support
       REVITALIZING
     PROFESSIONALISM
 Cognitive base
 Experiential learning
 Continuity
 Role Modeling
 Mentorship
“If the most powerful learning is
  experiential, and students are close
  observers of the scene in academic
  health centers, essentially we as faculty
  are challenged to change what we
  think, say, and do as individuals and as
  members of a community .”
                              Inui
                              2003
       REVITALIZING
     PROFESSIONALISM
“The clinical learning environment must
 be transformed so that students and
 residents can see and experience the
 ideals of medical professionalism at
 work in shaping patient care and can
 better understand society’s
 expectations of them as future
 practitioners.”
                               Whitcomb
         REVITALIZING
       PROFESSIONALISM
 Role of associations important to:
     - set and maintain standards
     - to expand and disseminate knowledge
     - to inform the public
 Institutions and professional societies are
  necessary to support and stabilize
  professionalism
       ACADEMIC HEALTH
           CENTER
“The  greatest challenge in improving
 the teaching of professionalism is
 to modify the internal culture of
 the academic health center so that
 it better reinforces the values that
 medical educators wish to impact.”
                         Ludmerer
                         1999
“The profession of medicine is under
 siege. Our resistance must be
 professionalism.”
                         Harris
                         2000
       CONCLUSIONS
I. Time honored characteristics of a
    profession
   Specialized education
   Autonomy to set standards
   Commitment to service
        CONCLUSIONS
II. Profound changes in the
    delivery of health care have
    introduced real and significant
    challenges in regards to
    medical professionalism
         CONCLUSIONS

III. Genuine medical
     professionalism is in peril
       CONCLUSIONS
IV. The hidden curriculum must be
    recognized, discussed, and
    addressed
       CONCLUSIONS
V. The 21st century demands a
   revitalization of medical
   professionalism which can and
   must be accomplished in our
   academic health centers

  HEREIN LIES OUR FUTURE!
At its best a professional life
enables the individual freedom to
find fulfillment as one advances
the well being of society. The
person who succeeds in becoming
a professional, mastering its
standards and aims, achieves a
substantial focus for living.

				
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posted:10/16/2011
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