Professionalism and Ethics in the ED
Author: Richard Frederick, MD, FACEP, Clinical Associate Professor of Surgery, Division of Emergency Medicine, University of Illinois College of Medicine, Attending Physician Department of Emergency Medicine, OSF Saint Francis Medical Center, Peoria, IL.
Peer Reviewer: Andrew D. Perron, MD, FACEP, Associate Residency Director, Department of Emergency Medicine, Maine Medical Center, Portland.
Emergency physicians (EPs), and physicians in general, have faced enormous tests of their core professionalism and ethical values in recent years. The unionization of resident physicians, the financial pressures of a managed care environment, and the thorny role of the pharmaceutical industry have presented new and difficult challenges for medicine. EPs and their actions are being examined ever more critically by the government, third-party payers, and by individual employers. We are being asked to do more for less in an increasingly hostile medicolegal environment. Additionally, much of the public trust that was once synonymous with medicine has been lost.
As a direct result of these difficult situations, a resurgence and redefinition of medical professionalism recently has occurred. Much of the current crisis in medical professionalism directly affects individual physicians in emergency departments (EDs). EPs practice medicine daily in an extreme environment and care for patients in their most vulnerable state. In addition to the often difficult rapid medical choices an EP is required to make, further challenges exist with documentation-based remuneration as well as a managed care environment. Professionalism is the core value that defines physicians as healers rather than market-based "health care providers" providing a service for a fee.
This article will discuss the history of medical professionalism in the Western world as well as explore some perceptions and controversies of professionalism as it applies to the emergency physician.
-The Editor
Introduction
Professionalism is a topic that has become increasingly important during the last several years.1-3 It is now one of six core competencies used to judge all post-graduate training programs, including emergency medicine.4 Several authors have expressed concern about how professionalism is incorporated in EP training programs.2,3,5 This concern comes, in part, due to a widespread feeling that medical professionalism is endangered.3,6,7
Medical professionals who graduated prior to the past few years probably have received little formal training regarding professionalism. However, professionalism is hardly a cutting edge theme or modern skill. Physicians in the past have used role models to learn professionalism without a formal curriculum. Some of these mentors likely left an indelible impression (good or bad) during a physician’s training.8 While learning by modeling is often effective, it also lacks reliability and reproducibility, and the present and future of medicine demand more formal training.
Definition
Professionalism as a concept can be difficult to define.3 Even though professionalism may not have been taught didactically in medical schools as recently as 20 years ago, the subject matter certainly was presented. Medical ethics and professionalism are inseparable, and often identical, disciplines. However, professionalism also focuses on the provider’s clinical competency, and this often is not stressed in the more traditional teaching of medical ethics.
There are numerous definitions and categorizations of professionalism in the literature.3,5,9 The simplest and most encompassing definition is putting the patients’ interests above those of self.1,6,10,11 This definition is quite easy to espouse but more difficult to follow in daily practice. It requires a focus and dedication that is not implicit in human nature. It is inherently human to demand primacy for one’s own self-interests. The definition provided by the American Board of Internal Medicine (ABIM) is perhaps more realistic. ABIM defines professionalism as "aspiring toward altruism, accountability, excellence, duty, service, honor, integrity and respect for others."3 This definition very appropriately sets these virtues as goals to aspire toward, allowing for the inevitable human frailty and failure. The acknowledgement of that frailty is important to provide encouragement and keep individuals from abandoning the goal of altruism altogether.
Just as professionalism is difficult to accurately define, different individuals may also perceive it different ways. Brownell et al looked at senior resident physicians’ views on the meaning of professionalism.9 The authors surveyed 533 residents with a response rate of 48.4% (258 residents). Competence (50%), respect for others (48%), and empathy (39%) were the most commonly named attributes. Altruism, which is at the core of the definition of professionalism, was only named by a small minority (2.3%) of respondents.9
Other important attributes of professionalism that were listed by a minority of the 258 respondents included: responsibility (24%), confidentiality (19%), ethical behavior (17%), devotion (7.3%), justice (6.2%), and humility (3.9%).9 The majority of medical ethics and professionalism’s core values were not identified by the respondents in this study, and this underlines the need for renewed efforts in the teaching of professionalism. Negative role model clinical educators were felt to be less important in learning the tenets of professionalism (44%).9 This same group felt that informal discussions were the dominant vehicle for teaching (76% of the time), while course work (28%) and teaching rounds (26%) were judged to be less important.7
The need for more emphasis on the teaching of professionalism is highlighted by the importance assigned to professionalism by the American College of Graduate Medical Education (ACGME).4 Other authors have proposed innovative ways to approach both the teaching and evaluation of professionalism to medical students and residents.12,13 Most of the qualities that define professionalism are virtues that are universal and inherent in the human condition. It is generally unknown how difficult or successful formal teaching of these virtues will be, especially to adult learners. Educators have struggled with the didactic presentation of virtue and ethics for centuries, which is illustrated as early as the first Greek philosophers:
"Can you tell me, Socrates, is virtue something that can be taught? Or does it come by practice? Or is it neither teaching nor practice that gives it to a man, but natural aptitude or something else?"14
Pelligrino and Thomasma believe that medical virtues can and must be taught to medical professionals.15 Admittedly, medical students arrive with their own value systems and faiths that are unlikely to be altered. However, medical faculties still have a responsibility to teach those virtues inherent in becoming a physician. Even as early as the medical school admissions process, faculty members should focus on obtaining students with values concurrent with the practice of medicine. Teaching ethics and virtue as a discipline is a vital first step, but teaching by example also is essential. To quote Pelligrino and Thomasma, "The power of a faculty model to shape behavior for good or evil is enormous. It far exceeds the power of a lecture or course on ethics."15 Those involved in the medical education process are responsible, in at least some part, for both the virtuous and abusive physicians they have trained.
History
The three traditional professions have been defined as law, clergy, and medicine. A profession has been called "a way of life with a moral value," a definition that distinguishes a profession as being a calling rather than just an occupation. In Studs Terkel’s book Working, which reviewed multiple occupations, medicine was not listed .16 The author’s reasoning was that physicians work for more than just a salary. This is more than just an academic distinction. Physicians’ voices on medical and social issues often are well received by the public, especially when they speak for patient advocacy. To quote Steven Brint: "Without a strong sense of the public and social purposes served by professional knowledge, professionals tend to lose their distinctive voice in public debate."17 When physicians declare concern about rising malpractice rates and lack of tort reform because of exorbitant overhead costs, the public has little empathy. However, when these same alarms are sounded over a possible loss of physicians in certain states or specialties, affecting the public’s access to quality medical care, the public is much more sympathetic.
To understand current medical ethics, it is necessary to briefly review the history of professionalism in medicine. The obligations of medicine as a profession go back to ancient times, and are embodied in the Hippocratic Oath. The statements "I will keep them from harm and injustice," "I will come for the benefit of the sick," and "In purity and holiness I will guard my life and my art," certainly were at the core of professionalism remain so then and now. The struggle between self-interest and patient interest is as old as medicine itself.18
From the Middle Ages to the 1700s, medicine was perceived more as a trade than a profession in the Western world. During the 1700s, the practice of medicine was competitive and market-based. Training was obtained through unregulated apprenticeships. It was during this time that the modern beginnings of professionalism were articulated by Dr. John Gregory of Scotland, who argued that the physician should be the fiduciary of the patient.19,20 Dr. Thomas Percival, who in 1805 wrote a seminal code of medical ethics, felt that there are three primary obligations in the fiduciary relationship. The first is an adherence to clinical competence, the second an elevation of the patients’ interests above that of the physician, and the third to maintain a "confidence that a life of service to patients will result in adequate remuneration."21
In the 1800s, the advent of formal training and medical schools advanced the cause of professionalism greatly. There was significant resistance to the idea of regulation of medical training and degrees by the status quo. At that time, Yale and Harvard universities had a great deal of political influence and were successful in promoting formal training through medical schools. The American Medical Association formally published its first code of ethics in 1847. Society, in turn, recognized medicine as a profession, allowing physicians to regulate themselves, which is an important distinction between a profession and a trade.
In the early 1900s, professionalism continued to advance. In 1914, the New York Supreme Court gave a landmark ruling regarding patient autonomy. From 1940 to the 1960s, the Nuremburg and Helsinki declarations expanded that autonomy in the area of human research. This expansion of patient’s rights was affirmed in 1948 as the World Medical Association echoed much of the tenets of the Hippocratic Oath in their Declaration of Geneva Physician’s Oath. The oath was also born in response to atrocities committed by doctors in Nazi Germany and adopted near the same time as the United Nations Universal Declaration of Human Rights in 1948. The oath is applicable to all medical professionals and states that the adoptee "will practice [their] profession with conscience and dignity; the health of [their] patient will be [their] first consideration." The oath further states: "I will maintain the utmost respect for human life from the time of conception, even under threat. I will not use my medical knowledge contrary to the laws of humanity."22
At this same time, unprecedented scientific and technological breakthroughs expanded the scope, as well as the cost, of medicine. This increase in medical costs also increased physician remuneration. This, together with concurrent sweeping social changes in America, caused professionalism to be questioned in the 1960s.
As medical costs continued to escalate during the next several decades, business joined government in an attempt to regulate costs. The managed care environment that subsequently emerged posed its own set of dangers to professionalism, felt by many to be more profound than that of the fee-for-service era.7,23,24 The challenge to remain primarily a patient advocate in a cost limiting environment seemed to threaten the very core of physician professionalism. Physicians by definition and tradition were formerly charged with placing a patient’s interests ahead of their own. In a managed care atmosphere physicians also are forced to place patients’ interests ahead of the payer’s interests, who might then hold providers economically accountable. This choice becomes even more ethically difficult when the physician is a direct employee of the managed care organization.
Alternatively, managed care also may regarded as a steward for finite health care resources. Physicians should have a societal duty in the in management of dwindling health care resources and in containing medical costs. It has been argued that clinical fidelity and societal responsibilities are not mutually exclusive, and each must be mediated in a case-by-case method.25 Furthermore, there is an ethical value to clinical work occurring on behalf of socially desirable ends, but for the medical professional the privileged position of clinical fidelity must first be acknowledged.25
Dr. Bulger, in his book, Quest for Mercy, points out the dangers of a health care system that uses a core principle of financial incentives for limiting expenditures for medical care. In addition, there are potential concomitant dangers to restrictions placed on a physician’s time. He writes, "Those caregivers whose time is excessively restricted may well lose altogether the time it takes to develop the trust that in turn empowers patients to enter into their own healing."26 On the other hand, Dr. Puma, in a series of essays entitled "Managed Care Ethics," challenges physicians and managed care organizations to practice cooperatively in an ethical, patient-centered environment. These essays highlight many of the dilemmas facing the managed care physician, the patient, and the managed care institutions. It is felt that unless all, or at least the majority, of physicians act in concert on the vital issues surrounding patient advocacy it will become difficult to make a substantive difference.27
It should not be assumed that the present crisis in professionalism is solely due to the advent of managed care. The concern regarding the decline of professionalism also is shared in the United Kingdom and Europe, where government-based, single-payer systems are the rule. "Medical Professionalism in the New Millennium: A Physician Charter" was a joint effort of the ABIM and the European Federation of Internal Medicine (EFIM) to illuminate a variety of professional issues.3 The recent concern regarding the decline in medical professionalism appears to be largely universal and multifactorial, and cannot be specifically linked to a single medical or insurance system.
Components of Professionalism
The role of medical professionalism in patient care has been expanded and adapted over the past century and also served in developing the modern version of professionalism. However, despite the many changes in medicine, the principles of patient advocacy and altruism remain at the core of modern day professionalism. As previously discussed, medical professionalism has been difficult concept to accurately define. However, the qualities and behaviors closely associated with professionalism often are much easier to describe. These components are helpful in eliciting a more complete picture of what professionalism means in the twenty-first century.
Dr. Herbert Swick published a normative definition of medical professionalism, which he divided into the nine behaviors listed in Table1.5 Dr. Swick proposes that this definition encompasses both the nature of the profession as well as the nature of the physicians’ work.5 Dr. Cruess published a list of the characteristics defining professions and professionals. (See Table 2.) This list addresses the professions as a whole, but its tenets remain in the context of medical professionalism.2
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ABIM commissioned a medical professionalism project involving ABIM, the American College of Physicians (ACP), American Society of Internal Medicine (ASIM) Foundation, and the European Federation of Internal Medicine. The preamble states that, "Professionalism is the basis of medicine’s contract with society, and demands placing the interests of patients above those of physicians, setting and maintaining standards of competence and integrity in providing expert advice to society in matters of health."3
The fundamental principles on which ABIM’s charter was based are the principles of primacy of patient welfare, patient autonomy, and social justice.3 The ABIM charter then follows these principles with a set of professional responsibilities. These responsibilities are defined as commitments to the responsibilities listed in Table 3.
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Although a list of responsibilities like the one in Table 3 may seem straightforward, in practice professionalism can be thought of as more of an art than a science. After sufficient contact, it is possible to recognize specific actions and demeanors that embody the highest level of professionalism. Attempting to measure or evaluate professionalism often is based on subjective qualitative reports. One example of an attempt to measure professionalism is a scale developed by Arnold et al.29 The scale is based on physician responses to a questionnaire measuring the perceived overall environment of professionalism at their institution. Barry et al developed a physician survey instrument using six clinical scenarios designed to assess physician satisfaction with their training in professionalism.6 An investigator panel judged the most appropriate response for the clinical scenarios noted a range of acceptable answers in 12-86% of scenarios. Most (73%) of the respondents reported having 10 or fewer hours of formal training in professionalism.
As eluded to earlier, much of the decline in professionalism has occurred due to an overemphasis of business and economic culture in medicine. The covenantal relationship that has been at the core of the physician-patient relationship is clearly in danger.7 Pelligrino has accurately described the physician-patient relationship as a covenant.15 A covenant implies an overall aura of fidelity and trust. These qualities stand in sharp contradistinction to the business contract, for which the adages "Look out for No. 1" and "Let the buyer beware" have been applied. Yet, even current common medical terminology reflects the influence of the business culture. Physicians are commonly referred to as "health care providers" and patients as "clients" or "customers." Use of this language demeans the patient-physician relationship to the level of that of a business selling a product or service to a customer. Ruth Malone writes, "The product-market metaphor for [health care] policy implies that our moral capacity toward others is something up for sale."30 Physicians are the most qualified to advocate for patients, and this must supercede whatever responsibilities they have to payers.
Another factor in the decline of professionalism is physicians who become victims of their own technology. Physicians now are able to make diagnoses and affect cures that were unheard of in the 1940s and 1950s. Dr. Bulger refers to physicians as "scientific healers," and feels that modern physicians have embraced too much the role of scientist and largely neglected the role of healer.27 Bulger also points out the devotion to the reductionist, biomolecular orientation in medicine, which leaves little room for the "healer" role. If a scientific cure for a disease cannot be offered, physicians may either be reluctant or unable to offer their advice, presence, counsel, and empathy.
Bulger defines illness as disease plus suffering. Many diseases, such as diabetes, are chronic, but diabetics are only considered to be ill when their disease causes suffering. Suffering goes beyond physical pain and includes a fear of death, a loss of control, the dread of abandonment, and the loss of self-esteem. He points out that our society tends to shun suffering, and many physicians do the same.26 Perhaps many of the physicians in older eras were perceived as being more professional because they effectively addressed suffering. What these physicians lacked in scientific armamentarium of modern medicine may have been replaced by increased patient communication and compassion.
Professionalism in Organized Medicine
Professionalism is a responsibility that goes beyond the individual physician and is transferred to the medical profession as a whole. This is particularly true of professional associations. The first level of professionalism must be individual. The second should be collective. These associations historically have led the professional field in developing codes of ethics, that guide conduct. There always has been a tension between self and ethical obligations.18 In an era when economic reimbursements are an enormous concern, this becomes a much larger issue. Peligrino and Railman call upon medical professional organizations to "reaffirm the ethical commitment to ground physician authenticity" and set forth six guidelines to help professional associations retain their professionalism.18 (See Table 4.)
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Physician Arrogance
Many of the attributes of professionalism have been discussed and at times individuals may demonstrate behaviors that are the very opposite of professionalism. Chief among these is arrogance. Arrogance among physicians may be felt to be so commonplace as to scarcely seem worthy of mention. However, this is likely another factor that has also contributed to the decline of professionalism. In the past, physicians assumed a paternalistic role, being held in great esteem by the public and rarely having their authority or knowledge questioned.31 Today patients represent a more involved and educated population, often requiring autonomous control of their decisions. In addition to physicians’ propensity to be impressed with their own knowledge and skills, the increasing impersonalization of medicine is epitomized in the managed care environment.31 As pointed out earlier, many physicians are more comfortable with their role as scientists than as healers. To truly relate to suffering, however, one cannot be arrogant or detached. Most physicians who themselves become patients experiencing significant suffering gain great insights into the true patient-physician relationship.31
The Abusive Physician
Much of the discussion thus far has centered on the relationship of the physician to the patient, which is at the core of a physician’s identity. It also is vitally important to explore how physicians relate to each other and to other heath care workers. The abusive physician is the extreme offshoot of the arrogant physician, and is the antithesis of the professional. This type of physician behavior, unfortunately, is addressed primarily in the nursing literature with very little or no mention found in the medical literature.32,33 This is regrettable, but understandable, as nurses probably are the most common victims of the abusive physicians’ behavior. They are not, however, the only recipients. Rare is the emergency physician who has not had to endure an abusive tirade from a primary care or specialist colleague. Residents and medical students in all fields are particularly vulnerable, as they may be dependent on an abusive physician for an evaluation of their competence and performance. Allied health care personnel also are frequent victims of inappropriate physician behavior.
The immediate problem may appear to be between the abusive physician and his/her victim, but in reality, it is a problem for all physicians. As there are ethical obligations of professional organizations, there are similar obligations for medical staff members within institutions. Professionalism not only includes physician monitoring of peers’ clinical competence, but their behavior as well. Physicians should be at the forefront of implementing institutional policies to address the abusive physician. There are many policies already in existence that are easily accessible through the literature (primarily nursing or hospital literature).33,34 The AMA Code of Medical Ethics recommends instituting such a policy for each medical staff and includes guidelines for such a policy.35
Relationships with the Pharmaceutical Industry
The role of professionalism in the relationship with the pharmaceutical industry also deserves discussion. The full breadth of this topic is beyond the scope of this article, but the way in which a physician interacts with the biomedical industry has far-reaching implications for patients, peers, and any physicians in training he/she may be in contact with. Honesty, integrity, altruism, and trustworthiness are virtues inherent in professionalism, and all must be considered carefully in a physician’s dealings with the pharmaceutical industry
The biomedical industry is involved in three major categories of interaction: 1) Company-funded clinical trials; 2) Company-sponsored CME; and 3) Gifts and information on products.36 Guidelines dealing with the first category can be found in the AMA Code of Medical Ethics.35
The AMA guidelines on gifts from industry represent a good reference for an often nebulous topic. Gifts accepted should entail a benefit to patients and should not be of substantial value. Textbooks, modest meals, and other gifts are appropriate if they serve a genuine educational function. Cash is never appropriate. Individual gifts of minimal value are permissible as long as the gifts are related to the physicians’ work (i.e., pens or note pads).35
Additional guidelines for physician relationships with pharmaceutical companies concern themselves with conferences, meetings, and CME. The AMA defines a legitimate conference as having "objective scientific and educational activities and discourse" as well as the "main incentive for bringing attendees together is to further their knowledge on the topic." Subsidies from industry for CME are allowable as long as the monies go to the sponsoring organization and not to the individual physician. Subsidies for travel, lodging, or personal expenses of participating physicians are prohibited. Funds may be given for medical students to attend conferences as long as the funds are administered by the academic institution and used only for meetings of merit. No gifts should be accepted if there are strings attached.35
In general these guidelines are well thought out and provide a good starting point for individual decisions. However, the influence that drug companies prevail on prescribing patterns is well documented. Forty-six percent of physicians report that drug representatives are moderately to very important in influencing their prescribing habits,37 and one-third of medical residents report that they change their practice based on information provided by drug representatives.38 Drug companies spent an estimated $15.7 billion on promotion and distributed $7.2 billion worth of free samples in 2000.39 Pharmaceutical industries remain the most profitable businesses in America, posting median profits of 18% of revenue in 2001. For the remainder of Fortune 500 companies, median profits were 3.5%.40
Case Discussions
Case No. 1. A recalcitrant 51-year-old male is coerced by his wife to come to the ED for an evaluation of chest pain that is now resolved. He is initially very resistant to answering any questions or agreeing to have any tests performed. The emergency physician spends a lengthy time establishing a rapport with the man and his wife to convince the patient of the need for further testing. He is refusing hospitalization because of economic issues unless it is definitive that "he is having a heart attack." After a negative ECG is performed, the EP suspects the patient’s pain is probably secondary to reflux esophagitis and discharges him with an order for an outpatient stress test later that week. Upon discharge, the patient and his wife thank the EP for his care. The patient states, "I really trust you, Doc, and generally I don’t like doctors." Several hours later and 15 minutes before the physician’s shift ends, the patient returns specifically asking for the EP to evaluate him again as his chest pain has returned.
Should the EP: A) Stay over to care for him as he already has established rapport with this difficult patient; B) Instruct the nurse to relay to the patient that he is off shift and on his way home; C) Go into the patient’s room with the relieving physician and help take the initial history while introducing his partner.
The first alternative is the most altruistic and meets the highest standards of professionalism. The second option is clearly suboptimal. The third choice might be a reasonable compromise to meet fiduciary obligations to the patient without compromising physician wellness.
Case No. 2. A physician is invited to a golf outing with dinner at an exclusive local country club. All expenses are paid by a pharmaceutical company, as there is a presentation during dinner regarding a new antibiotic. The physician participates and enjoys a cordial evening with other local physicians.
The physician is also a member of her hospital’s Pharmacy and Therapeutics Committee. A few weeks later she receives a visit from the same pharmaceutical representative asking that she consider approving this antibiotic for use on the hospital’s formulary. The representative asks if she enjoyed the golf outing, thanks her for coming, and then makes his pitch.
Should the physician A) Tell him, remembering his largesse, she will do her best to get the drug on the hospital’s formulary; B) Tell him the golf outing has nothing to do with the hospital’s formulary and then terminate the conversation; C) Listen to what the representative has to say, remaining non-committal.
Choice A is obviously a clear violation of medical ethics and professionalism. Alternatives B and C are more acceptable, but any choice in this scenario contains the taint of influence. It is exceedingly difficult to deny the pharmaceutical representative had any persuasion upon the physician from the evening of CME and entertainment. Even if the physician does not feel personally compromised, the appearance of influence is undeniable.
Case No. 3. An EP is working in the ED when a patient with abdominal pain highly suspicious for appendicitis presents. After making a tentative diagnosis, the EP calls the attending surgeon who agrees to come to the ED to evaluate the patient. After he arrives, the nurse comes to the EP and says she smells alcohol on the surgeon’s breath. The emergency physician observes him from afar and notes the surgeon’s gait and mannerisms appear normal.
The EP should: A) Tell the nurse it is not his problem, the surgeon is here to assume care of the patient; B) Take the surgeon aside and ask him if he has been drinking alcohol; C) Investigate further by making small talk with the surgeon to observe any smell of alcohol.
Option A obviously abrogates the physician’s responsibility to the patient. Choice C, while appearing to be a reasonable step, is equivocating, as a brief conversation cannot guarantee sobriety. Option B is the correct professionalism choice, but it is considerably more intimidating in real life.
Case No. 4. An EP working at a teaching hospital supervising resident physicians is caring for a complicated patient that requires the presence of the consultant. The resident calls the consultant, who arrives in ill humor and subsequently degrades the resident liberally with verbally abusive and profane language. The EP overhears this, but none of the comments are directed at her.
The EP’s options are A) Tell the resident he needs to develop a "thick skin" and not to let it bother him; B) Intervene and take the consultant aside and tell him this is inappropriate behavior and ask for an apology to the resident; C) Make herself busy charting and pretend not to hear the conversation.
Both choices A and C tolerate and even encourage disruptive behavior and give the impression that it is acceptable. These choices also damage a teacher/student relationship between the attending and resident physician, and neglects the attending physician’s responsibility to the resident physician. Option B is the hard but correct choice.
Case No. 5. The administration of a hospital does a retrospective chart review of their ED. They are interested in physician productivity, as well as the frequency of tests ordered for several diagnoses. The EPs are told that their reimbursement will reflect both their productivity (patients per hour) as well as their cost per diagnosis. One physician is subsequently told he is in the bottom 20% of productivity category and the top 20% of the cost category. What should be his response?
This is a more difficult scenario than the two prior cases, as there may be unnecessary tests that the physician is ordering as well as decreased patient care efficiency. However, the physician also might feel he is being asked to lower his standard of care simply for economic reasons. It may be necessary for the physician to spend more time with the patient than other emergency physicians in the group because he feels it is important to establish trust in the physician/patient relationship. Unfortunately there is no right answer to this scenario. However, it is a breech of professionalism to order fewer tests and care for more patients per hour if the physician feels it compromises his standard of care.
Conclusion
Professionalism is at the core of physician identity. The threat of economic and sociological pressures transforming the profession into simply another trade is very real and possible. Professionalism not only defines physicians, it also defines the physician-patient relationship. If physicians recommit themselves as medical professionals and act as patient advocates they can continue to count on the public’s trust and confidence in their ability to regulate themselves. If physicians travel further on the path of service merchants (health care providers), they will lose public trust and the right to self-regulation. If this occurs, both the physicians as well as their patients will be the losers.
References
1. Adams J. An argument for professionalism. Society for Academic Emergency Medicine web site. Available at http://www.saem.org/inform/adams.htm. Accessed May 2003.
2. Cruess RL, Cruess SR, Johnston SE. Renewing professionalism: An opportunity for medicine. Academic Medicine 1999;74: 878-884.
3. Medical Professionalism Project. Medical professionalism in the new millennium. Ann Intern Med 2002;136:243-246.
4. ACGME Outcome Project, General Competencies accessed at www.acgme.org/outcomes/comp/compfull.asp. Accessed Aug. 2003.
5. Swick HM. Toward a normative definition of medical professionalism. Academic Medicine 2000;75:612-616.
6. Barry D, Cyran E, Anderson RJ. Common issues in medical professionalism. Am J Med 2000;108:136-140.
7. Sullivan WM. What is left of professionalism after managed care? Hastings Center Report, March-April 1999:7-13.
8. Hensel WA., Dickey NW. Teaching professionalism: Passing the torch. Academic Medicine 1998;73:865-870.
9. Brownell AK, Côté L. Senior residents’ views on the meaning of professionalism and how they learn about it. Academic Medicine 2001;75:734-737.
10. Finkel MA, James G. Ethical issues in emergency medicine. Emerg Med Clin North Am 1999:17:1-8
11. Ludmerer KM. Instilling professionalism in medical education. JAMA 1999;282: 881-882.
12. Wear D, Castellani B. The development of professionalism: Curriculum matters. Academic Medicine 2000;75:602-611.
13. Larkin GL. Evaluating professionalism in emergency medicine: Clinical ethical competence. Acad Emerg Med 1999;6: 302-311.
14. Plato. Meno 70a, p1-5
15. Pelligrino ED, Thomasma DC. The Virtues in Medical Practice. New York: Oxford University Press; 1993.
16 Turkel S. Working. New York: Random House; 1974.
17 Brint S. In an Age of Experts: The Changing Role of Professionals in Politics and Public Life. Princeton: Princeton University Press; 1994.
18. Pelligrino ED, Relman AS. Professional medical associations ethical and practical guidelines. JAMA 1999;282: 984-986.
19. Chervenak FA, McCullough LB. Professionalism and justice: Ethical management guidelines for leaders of academic medical centers. Academic Medicine 2002;77:45-47.
20. McCullough LB. John Gregory and the Invention of Professional Medical Ethics and the Profession of Medicine. Dordrecht, The Netherlands: Kluwar Academic Publishers; 1998.
21. Pelligrino ED. "Foreward: Thomas Percival, The Ethics beneath the Etiquette" Medical Ethics, or a Code of Institutions and Precepts Adapted to the Conduct of Physicians and Surgeons, Thomas Percival, MD {Reprinted from the 1805 version} Birmingham, AL: Classics of Medicine Library; 1985: 1-65.
22. Declaration of Geneva (1948). Adopted by the General Assembly of World Medical Association at Geneva Switzerland, September 1948.
23. Kuttner R. Managed care and medical education. N Eng J Med 1999;341:1092-1096.
24. Larkin GL. Evaluating professionalism in emergency medicine: Clinical ethical competence. Acad Emerg Med 1999;6: 302-311.
25. Bloche MG. Clinical loyalties and the social purposes of medicine. JAMA 1999; 281:268-274.
26. Bulger RJ. The quest for mercy: The forgotten ingredient in health care reform. Part I. West J Med 1997;167: 361-373.
27. Puma JL. Managed Care Ethics: Essays on the Impact of Managed Care on Traditional Medical Ethics. New York: Hatherleigh Press; 1998.
28. Irvine D. The performance of doctors: The new professionalism. Lancet 1999;353: 1174-1177.
29. Arnold EL, Blank LL, Race K et al. Can professionalism be measured? The development of a scale for use in the medical environment. Academic Medicine 1998;73: 119-1121.
30. Malone RE. Policy as product: Morality and metaphor in health policy discourse. Hastings Cent Rep 1999;29:16-22.
31. Berger AS. Arrogance among physicians.
Academic Medicine 2002;77:145-147.
32. Rosenstein AH. Nurse physician relationships: Impact on nurse satisfaction and retention. AJN 2002;102:26-34.
33. Barnsteiner JH, Madigan C, Spray T. Instituting a disruptive conduct policy for medical staff. AACN 2001;12: 378-382.
34. Neff K. Understanding and managing physicians with disruptive behavior. In: Ransom SB, et al., ed. Enhancing Physician Performance: Advanced Principles of Medical Management. Tampa (FL), American College of Physician Executives: 2000;45-72.
35. American Medical Association. AMA Code of Medical Ethics: Current Opinions with Annotations. Chicago; AMA Press: 2002-2003 Edition.
36. Lechin J. Interactions between physicians and the pharmaceutical industry: What does the literature say? Can Med Assoc 1993;149: 1401-1406.
37. Avorn J, Chen M, Hartley R. Scientific versus commercial sources of influence on the prescribing behavior of physicians. Am J Med 1982;73:4-8.
38. Lurie N, Rich EC, Simpson DE, et al. Pharmaceutical representatives in academic medical centers: Interaction with faculty and housestaff. J Gen Int Med 1990;5: 240-243.
39. IMS HEALTH Global Services; www.ims-global.com/index.html. Accessed Sept 2003.
40. Profiting from Pain: Where Prescription Drug Dollars Go. Families USA Publication No. 02-105 Families USA,Washington, DC 2002.
CME Objectives
After completing the program, participants will be able to:
- Define medical professionalism and describe its historical development;
- Illustrate behaviors of professionals and characteristics of medical professionalism;
- Understand the responsibilities of the medical professional; and
- Delineate modern threats to medical professionalism.
Physician CME Questions
1. Professionalism is defined simply as:
A. medical competence and professional demeanor.
B. board certification in a medical specialty.
C. placing the patient’s interest ahead of physician’s interest.
D. adherence to the Hippocratic Oath.
2. In his survey of senior residents, Brownel found which attribute of professionalism
was listed the most frequently?
A. Altruism
B. Ethical behavior
C. Confidentiality
D. Competence
E. Empathy
3. Which of the
following terms is not synonymous with a business culture?
A. Customer
B. Health care provider
C. Product
D. Covenant
4. According to the AMA guidelines, which of the following gifts from the pharmaceutical
industry is not acceptable?
A. Modest meals
B. Cash for the physician’s time
C. Textbooks
D. Contributions to a general scholarship fund
5. Which of the following statements about professionalism is
false?
A. Professionalism is presently under attack.
B. Professionalism and medical ethics are inseparable.
C. There are no real conflicts with professionalism and managed care.
D. Professionalism is one of six key competencies in residency training.
Answer Key
1. C; 2. D; 3. D; 4. B; 5. C
Emergency physicians (EPs), and physicians in general, have faced enormous tests of their core professionalism and ethical values in recent years. The unionization of resident physicians, the financial pressures of a managed care environment, and the thorny role of the pharmaceutical industry have presented new and difficult challenges for medicine.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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