Virtual Mentor. July 2006, Volume 8, Number 7: 459-463.

Journal Discussion

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For What Ends Do We Promote Medical Professionalism?

Two researchers argue in favor of training physicians to better understand and practice the tenets of medical professionalism.

Nathan A. Bostick, MA, MPP

Cruess R, Cruess S. Teaching medicine as a profession in the service of healing. Acad Med. 1997;72:941-952.

Introduction
In their article “Teaching Medicine as a Profession in the Service of Healing,” authors Richard and Sylvia Cruess argue in favor of training physicians to better understand and abide by the tenets of medical professionalism. In preparing this argument, the authors examine the dual roles of contemporary physicians, which they refer to as those of the “physician healer” and the “physician professional” [1]. Citing recent criticisms levied against the profession, the authors conclude that physicians must better understand those roles and concurrent duties if they wish to effectively satisfy the public’s demands and maintain the benefit of professional autonomy.

The authors define a profession as a vocation characterized by the possession of a specialized body of knowledge and by commitment to service, often formalized through agreed-upon values or a code of ethics. Having delved into literature from social sciences and humanities, they identify several privileges and duties afforded to members of the medical profession. For example, physicians must act collectively to promote the public good while acting individually to promote patients’ welfare and to fulfill the fiduciary duties ascribed by the patient-physician relationship. In return, society rewards the medical profession with elevated status within the community and the ability to self-regulate [2].

The authors acknowledge that this reciprocal relationship between society and the medical profession has become increasingly strained within the last few decades. Their research suggests that the public has become skeptical of the individual physician’s ability to balance the altruistic goals of medicine against his or her own self-interests. Cruess and Cruess hypothesize that the public perceives that the collective profession is similarly guilty of remaining inactive on issues of societal concern, while instead engaging in activities that serve to protect the status and income of physicians [3]. The authors speculate that this loss of public trust has diminished the profession’s ability to self-regulate. The privilege of professional autonomy has been further curtailed by changing market forces and increasing governmental intervention.

The authors conclude that the medical profession must undertake positive steps to re-establish public trust and thereby maintain the privilege to self-regulate [4]. They recommend that the profession actively educate physicians about the historical origins of professionalism and its present definition and accordant public responsibilities. Ultimately, this educational process should encourage the moral growth of medical students and physicians by establishing strong aspirational standards of individual conduct [5].

Why should physicians be educated about professional
values and obligations?
Although this article provides an interesting perspective on the origins and development of our current conceptions of professionalism, some questions remain as to the proper ideological imperatives for educating physicians about professionalism. The authors build the case that educating physicians about the values and obligations of professionalism represents an endeavor essential to the retention of professional autonomy and self-regulation. However, their emphasis on maintaining professional autonomy as an end-goal appears to contradict the long-established goals of medical practice, including the promotion of health and societal well-being.

Proponents of continued self-regulation argue that the possession of specialized knowledge renders the profession better qualified than the lay public to determine the proper application of this knowledge [6]. This particular justification for the right to professional self-regulation, however, appears largely dated. Although physicians may have historically enjoyed a monopolistic hold upon medical information, that knowledge no longer remains under the exclusive control of the medical profession.

The advancement of medical knowledge has now emerged as a multidisciplinary endeavor. Moreover, current thought suggests that allowing nonprofessionals to access and even contribute to the body of available medical information effectively promotes societal welfare. Evidence indicates that the autonomous actions of physicians have resulted in the provision of divergent treatments for like medical conditions based on differences in the training and practice styles of individual physicians [7]. These deviations have led to systemwide variations in the use of medical services, medical expenses and patient outcomes [8]. In response, the involvement of nonphysicians, such as biostatisticians, economists and epidemiologists, in medical research has provided the profession with evidence-based practice guidelines that now enhance the safety and efficacy of medical care [9].

The singular pursuit of professional autonomy as an end unto itself does not necessarily enhance patients’ welfare. It is the promotion of safe and efficacious care, and not the outright preservation of professional autonomy, that should be the impetus for promoting professionalism among physicians. There are two important reasons why this is so. The first derives from the reciprocal relationship between the medical professions and society, which has invested heavily into individual physicians by the time they have joined the medical profession. In return for the funding of medical education and the granting of exclusive rights to practice medicine, the medical profession ostensibly owes society certain positive obligations [10]. The profession also owes a similar debt to patients who have volunteered the use of their bodies in teaching hospitals and have offered intimate accounts of their medical histories for the purposes of educating new physicians [11]. The fulfillment of these responsibilities to patients and society should supersede such self-serving goals as the enhancement of professional autonomy.

Secondary to any potential positive obligations that may or may not be owed to society, few would reject the virtue-based ethic that the medical profession is bound to promote the well-being of patients. Since Hippocratic times, the paramount purpose of medicine has been the promotion of health and alleviation of suffering [12]. Many aspects of the proposed professional curriculum enumerated by Cruess and Cruess will help physicians attain this goal. They suggest that the ideals of altruism and the promotion of patients’ welfare should be emphasized within the profession and that physicians should be aware of relevant codes of professional conduct [13]. However, other goals such as the promotion of more transparent self-regulation and the reinforcement of the link between professional status and obligations to society make clear that the proposed curriculum is primarily intended to foster the public’s trust in the medical profession, rather than a patient’s trust in his or her own physician.

The trust between patient and physician must not be underemphasized when educating physicians about professionalism as it is fundamental to physicians’ ability to promote patients’ well-being [14]. Trust is essential to the patient-physician relationship insofar as patients must rely upon physicians for the information necessary to make an informed decision, just as physicians must rely on patients to honestly disclose deeply personal medical information so that a proper diagnosis can be rendered [14]. In practice, higher levels of trust between patients and their physicians are associated with improved treatment adherence, better health outcomes and higher levels of patient satisfaction [15-17]. Should this element of the patient-physician relationship be neglected, diminished levels of trust are then correlated with reduced and poorer continuity of care, less patient compliance and reductions in patients’ overall health status [18].

In summary, there is a direct link between the maintenance of patients’ trust in their physicians and the fulfillment of the profession’s ethical obligations. The curriculum proposed by Cruess and Cruess should therefore be augmented by modules that teach physicians how to establish and maintain trust within the patient-physician relationship. To this end, physicians should be taught to embrace patient-centered communication practices, respect patient autonomy and effectively manage any conflicts of interest that might undermine the patient-physician relationship. Through these methods, physicians may better serve patients, engender trust within society and perhaps even maintain the privilege of professional self-regulation.

References

1. Cruess R, Cruess S., Teaching medicine as a profession in the service of healing. Acad Med. 1997;72:941-952.
2. Cruess R, Cruess S., 944.
3. Cruess R, Cruess S., 948-949.
4. Cruess R, Cruess S., 950.
5. Cruess R, Cruess S., 950.
6. Good WJ. The theoretical limits of professionalism. In: Etzioni A, ed. The Semi-Professions and their Organization: Teachers, Nurses, Social Workers. New York, NY: Free Press; 1969:266-313.
7. Wennberg JE, Barnes BA, Zubkoff M. Professional uncertainty and the problem of supplier-induced demand. Soc Sci Med. 1982;16:811-824.
8. Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998;280:1000-1005.
9. Garber AM. Evidence-based guidelines as foundation for performance incentives. Health Aff. 2005;24:174-179.
10. McCurdy L, Goode LD, Inui TS, et al. Fulfilling the social contract between medical schools and the public. Acad Med. 1997;72:1063-1070.
11. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. New York, NY: Oxford University Press; 2001:174-175.
12. Beauchamp TL, McCullough LB. Medical Ethics: The Moral Responsibilities of Physicians. Englewood Cliffs, NJ: Prentice Hall, Inc; 1984:13-19.
13. Cruess R, Cruess S. Teaching medicine as a profession in the service of healing. Acad Med. 1997;72:949-950.
14. American Medical Association Council on Ethical and Judicial Affairs. Fundamental elements of the patient-physician relationship. JAMA. 1990;262:3133.
15. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152:1423-1433.
16. Kaplan SH, Greenfield S, Gandek B, Rogers WH, Ware JE Jr. Characteristics of physicians with participatory decision-making styles. Ann Intern Med. 1996;124:497-504.
17. Mechanic D. The functions and limitations of trust in the provision of medical care. J Health Polit Policy Law. 1998;23:661-686.
18. Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects on physician-patient interactions on the outcomes of chronic disease. Med Care. 1989;27:S110-S127.

Nathan A. Bostick, MA, MPP, is a senior research assistant for the Council on Ethical and Judicial Affairs at the American Medical Association in Chicago, Ill.