Professionalism: The “good doctor” discussion

The day has finally come. You obtained your undergraduate degree years ago, studied your glutes off in medical school, and now, at long last, you’ve completed a gruelling residency during which you got less sleep than a cappuccino taste tester. Congratulations. Your mother must be proud.

After all, you are now a full-fledged medical professional. Right? Well, let’s not get ahead of ourselves.

“It’s possible to have a member of a profession who isn’t professional,” says Michael Yeo, a philosophy professor at Laurentian University in Sudbury, Ontario. “Profession is a neutral term, a descriptive term. Professional is a valuative term. Being professional is good. Being unprofessional is bad. Professionalism has a noble, honorific, evaluative dimension. To be a professional is to excel in certain ways.”

Professionalism in medicine is, in essence, a conversation about what it means to be a good doctor. It has been a major topic of discussion in the field for many years and will likely remain so for years to come. Physicians still debate how to define it, how to assess it and how to teach it. Younger doctors sometimes have different ideas on what it means to be a professional than older colleagues. The rise of commercialism and use of technologies, among other changes, have added new elements to the discussion.

“There has certainly been an intense discussion over the past 20 years about what it means to be a professional in medicine,” says Frederic Hafferty, a professor of medical education and associate director of the program in professionalism and ethics at the Mayo Clinic in Rochester, Minnesota. “My one criticism, and I use criticism in the analytic sense, would be that during the course of all that discussion — which is very, very important — what patients and the public think about what it means to be a medical professional has not been part of the discussion. In the UK [United Kingdom] and Canada, the public has been more explicitly involved, but not so much in the US [United States].”

“To be brief, what changed medicine in America, and ultimately had ripple effects on how it was practised all over the advanced world, was money,” says Dr. Arnold Relman, professor emeritus of medicine and social medicine at Harvard Medical School in Boston, Massachusetts.

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What gave rise to all this concern about eroding professionalism in the first place? Some peg it to the end of a lengthy bear market in the early 1980s, which was followed by a raging bull market. Suddenly, investors had billions of dollars and needed somewhere to invest them. Many choose to invest in health care.

“To be brief, what changed medicine in America, and ultimately had ripple effects on how it was practised all over the advanced world, was money,” says Dr. Arnold Relman, professor emeritus of medicine and social medicine at Harvard Medical School in Boston, Massachusetts, and former editor in chief of the New England Journal of Medicine. “Money began to flow into the system in huge amounts and it became a huge part of the economy. That influenced the way medicine was provided.”

The influence of money eventually caused many within the medical profession to fret about the behaviour of its members. The concern was akin to one expressed in a well-known Bible verse (Matthew 6:24): “No one can serve two masters. ... You cannot serve both God and money.” Substitute “patients” for “God” and you get the gist.

Had doctors become less professional? Were they financially obsessed? Less altruistic? In some countries, such as Canada, there has also been concern that the growing influence of government diminished medical professionalism by undercutting the autonomy of physicians.

“The consensus is that changes in society and the health care system are posing threats to traditional medical professionalism,” says Dr. Richard Cruess, a professor of surgery at McGill University’s Centre for Medical Education in Montréal, Quebec. “Our behaviour is not as professional as it was 50 years ago.”

CMAJ will be exploring the topic of medical professionalism in a series of articles over the course of coming weeks, touching on various philosophic and practical issues, including:

• Definition: What does professionalism really mean in a medical context? Are the standard definitions too broad to be useful? Are there core elements that all physicians agree upon? Are those core elements static or dynamic? Are they culturally specific?

• History: Medicine is one of the world’s oldest professions. But when did its practitioners first attempt to conceptualize their ideal role in society? How has that concept changed over the centuries?

• Academia: Ethics used to be a hot topic in academic medicine, but then debate shifted to professionalism. Why? And what good is coming from all these papers about doctors written by doctors for doctors?

• Payment: How a person is paid at work can dramatically affect their behaviour at work. Are doctors any different? Do doctors in a fee-for-service system behave differently than those in a pay-for-performance system? Is there a system that best aligns the interests of patients with physician remuneration?

• Education: Science can be taught effectively in a classroom, but what about professionalism? Can you teach medical students to be more empathetic? Does exposing them to subjects outside the sciences help? Or is professionalism simply something doctors must learn on the job?

• Assessment: How do you measure a physician’s level of professionalism? Do the opinions of patients count, or only those of colleagues? Are there more objective means of measuring physician accountability? Do medical licensing bodies even attempt to assess professionalism?

• Internet: Patients can visit any number of websites and provide anonymous ratings of their doctors. Do doctors receive this feedback gracefully and make attempts to improve their practices? Are the comments usually accurate? How do doctors improve their online reputations?

• Social media: Many medical students and younger physicians, like almost all young people today, have embraced social media. But are they acting as professionally online as they do in person? Can social media be harnessed to improve medical professionalism?

• Public trust: Simply put, patients don’t trust the medical profession as much as in the past. Physicians still enjoy high status in society, but their standing is slipping. Is the profession concerned? What can be done to reverse it?

• Variety: Professionalism comes in different forms. There is nostalgic professionalism, interprofessionalism and the new professionalism. What do these terms mean? And who is talking about them? Physicians? Sociologists? Philosophers?