Correspondence
Medical Education — Professionalism
N Engl J Med 2007; 356:639-641February 8, 2007
- Article
To the Editor:
It is gratifying to see the subject of medical professionalism considered in the review article by Stern and Papadakis (Oct. 26 issue).1 However, the article fails to meaningfully address the reality that physicians are increasingly employed by or dependent on organizations with a business ethic that is indifferent and occasionally hostile to the values and behaviors of professionalism. Medical practitioners are expected to placate profit-driven employers and insurance carriers, for example, while remaining loyal to the highest standards of medical professionalism. The educational imperative should be not only to teach the values of medical professionalism but also to provide practical instruction for their implementation.
1 ReferencesTimothy Howland, M.D.
Lourdes Hospital, Binghamton, NY 13905
thowland@lourdes.com 1
Stern DT ,Papadakis M . The developing physician -- becoming a professional. N Engl J Med 2006;355:1794-1799
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To the Editor:
Stern and Papadakis underscore the importance of instilling a sense of professionalism again in physicians and students, and they warn us about what medicine stands to lose if we do not do so. However, they leave out something crucially important that was identified by the sociologist Talcott Parsons more than 50 years ago: “The `ideology' of the profession lays great emphasis on the obligation of the physician to put the `welfare of the patient' above his personal interests, and regards `commercialism' as the most serious and insidious evil with which it has to contend.”1 In 1995, George Lundberg, then editor-in-chief of the Journal of the American Medical Association, repeated this admonishment: “The fundamental purpose of a business is to make money. . . . On the other hand, the fundamental purpose of a profession is to provide a service that reflects commitment to a worthy cause that transcends self-interest.”2 Specialty hospitals, boutique care at a price, and a range of other practices threaten the core of trust on which our profession stands. We need to teach our students — and model for them in our own practices — that commercialism has no place in the profession of medicine.
2 ReferencesDonald A. Barr, M.D., Ph.D.
Stanford University, Stanford, CA 94305
barr@stanford.edu 1
Parsons T. The social system. Glencoe, IL: Free Press, 1951:435.
2
Lundberg GD . The failure of organized health system reform -- now what? Caveat aeger -- let the patient beware. JAMA 1995;273:1539-1541
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To the Editor:
The article by Stern and Papadakis on becoming a medical professional rightly stresses the humanistic aspects of professionalism and ethical obligations. The outcome measures in this model of professionalism assess behaviors that reflect appropriate value systems. However, the definition of a professional also includes asymmetries of knowledge between the client and the professional.1 To satisfy this criterion of professionalism, the physician must deliberately reflect2 on potential knowledge gaps vis-à-vis the changing evidence base for practice. At the core of a “seasoned clinician” is the knowledge that will provide the best available options for the patient3 and a commitment to maintain this edge. A comprehensive and balanced program of professional development should encourage physicians to seek out this knowledge. Such a program would ensure that the professional will be in a position to practice safely and to advise patients about options for the best clinical outcomes on the basis of current knowledge. In this model of professionalism, outcome measures reflect the view that the maintenance of current clinical and scientific knowledge is paramount, but these measures are also integrated with previous experience and sustained by a value system that is in line with societal expectations.
3 ReferencesJohn I. Balla, F.R.A.C.P.
Melbourne University, Geelong 3220, Australia1
Freidson E. Profession of medicine: a study of the sociology of applied knowledge. New York: Dodd, Mead, 1970.
2
Ericsson KA . Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79:Suppl:S70-S81
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Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-based medicine: how to practice and teach EBM. 3rd ed. Edinburgh: Elsevier Churchill Livingstone, 2005.
To the Editor:
In their otherwise informative article on professionalism, Stern and Papadakis suggest that “it is now possible to reliably predict interpersonal and communication skills with the use of multiple, brief standardized interpersonal interactions.” This could be exciting news for the admissions committees of medical schools. However, the authors cite only one reference regarding this topic.1 A careful review of this reference suggests that readers should be cautious in drawing definitive conclusions because of the lack of predictive validity data. Preliminary results of a single study are not a sufficient reason to incorporate the multiple medical interview into such an important decision as whether to admit a candidate to medical school.
1 ReferencesRobert Knopp, M.D.
Regions Hospital, St. Paul, MN 55105
knopp003@umn.edu 1
Eva KW ,Rosenfeld J ,Reiter HI ,Norman GR . An admissions OSCE: the multiple mini-interview. Med Educ 2004;38:314-326
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Author/Editor Response
Howland and Barr reflect on the challenges that doctors face when confronted with the practice settings, health care systems, and commercial interests that test our professional resolve. It is here that we must not only aspire to the principles of professionalism but also wisely apply them. Medical practice cannot be insulated from an otherwise commercial world, and financial solvency is a necessity. Rather than condemn all forms of commercial interest, we encourage our students to engage in the development of regulatory policies and systems that benefit patients and are concordant with our values. Advocacy at the local, national, and international levels is critical to such engagement.1
Professionalism is demonstrated through a foundation of clinical competence, communication skills, and ethical understanding. The aspiration to and wise application of the principles of professionalism — excellence, humanism, accountability, and altruism — are built on this foundation.2 Although our article focuses on these latter principles of professionalism, Balla rightly identifies the foundational element of knowledge without which a doctor would be a communicative, compassionate charlatan.
Selecting students with the aspiration for and ability to wisely apply the principles of professionalism is a long-standing challenge for medical educators. If, before they entered medical school, we could identify those most likely to behave professionally in most situations, we would be doing both the public and the profession a great service. As Knopp suggests, the multiple medical interview is a potentially groundbreaking innovation that deserves further investigation. A growing amount of literature on the multiple medical interview, including data on its validity,3 provides support for our contention that this assessment method should have a role in the medical school–admissions process.
3 ReferencesDavid T. Stern, M.D., Ph.D.
University of Michigan Medical School, Ann Arbor, MI 48109
dstern@umich.edu Maxine Papadakis, M.D.
University of California, San Francisco, San Francisco, CA 941431
Gruen RL ,Pearson SD ,Brennan TA . Physician-citizens -- public roles and professional obligations. JAMA 2004;291:94-98
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Arnold L, Stern DT. What is professionalism? In: Stern DT, ed. Measuring medical professionalism. New York: Oxford University Press, 2005:15-37.
3
Eva KW ,Reiter HI ,Rosenfeld J ,Norman GR . The ability of the Multiple Mini-Interview to predict preclerkship performance in medical school. Acad Med 2004;79:Suppl:S40-S42
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