Measuring medical professionalism

328 Pages·2006·15.88 MB·English

by  David Thomas Stern

Measuring Medical Professionalism
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MEASURING MEDICAL
PROFESSIONALISM
David Thomas Stern, Editor
OXTORD
UNIVERSITY PRESS
2006
OXFORD
UNIVERSITY PRESS
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Library of Congress Cataloging-in-Publication Data
Measuring medical professionalism / David Thomas Stern, editor.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-19-517226-3
ISBN-10: 0-19-517226-4
1. Medicine—Ability testing. 2. Physicians—Rating of. 3. Physicians—Professional
ethics. 4. Clinical competence—Evaluation. 5. Medical care—Quality control—
Measurement. I. Stern, David Thomas. [DNLM: 1. Physician's Role. 2. Evaluation
Studies. 3. Professional Competence—standards. 4. Professional Practice—standards.
W 21 M484 2005]
R837.A2M43 2005
610.69—dc22 2005007759
9 8 7 6 5 4 3 21
Printed in the United States of America
on acid-free paper
Foreword
Jordan Cohen
When I was dean of the medical school at SUNY Stony Brook, we
had a vice president for buildings and grounds who had spent most
of his earlier career in the military. He had a tough job supervis-
ing a large group of mainly unskilled laborers, but the physical
condition of the campus under his watch was the best I've ever
seen. The grass was always well kempt, graffiti was scrubbed clean
as soon as it appeared, broken windows were replaced almost im-
mediately, and dormitory floors were spotless. I asked him once
how he managed to maintain such high standards among his work-
ers. His answer taught me one of the most valuable lessons I've
ever learned about the importance of evaluation. His secret, he
said, was contained in a simple principle: "They don't respect what
you expect; they respect what you inspect" He made it a point to
rigorously evaluate the outcomes of the work his employees
performed against the high standards he established. It didn't
take long for the appearance of the whole campus to reflect the
wisdom of this assessment-driven, outcomes-oriented approach to
superior performance.
vi Foreword
This book attempts to apply that principle to a task far more im-
portant than maintaining an immaculate university campus. Ensur-
ing that students of medicine at all levels not only acquire but con-
sistently demonstrate the attributes of medical professionalism is
arguably the most important task facing medical educators here at
the beginning of the twenty-first century. As noted in detail in chap-
ter 2, many previous attempts have been made to define profes-
sionalism, and despite some differences in emphasis and scope, lit-
tle substantive disagreement exists about the qualities of mind and
standards of behavior that constitute this quintessential feature of
the complete physician. Thus, we have a good understanding of what
to expect in this arena. We have much less understanding, however,
of how to inspect for its presence. And that is why the present volume
is so welcomed. What it adds is a much-needed examination of the
methods available to assess whether an individual actually manifests
the attributes of professionalism.
Why is it so important to ensure that physicians not only un-
derstand the core values of professionalism but also conduct them-
selves in accordance with its precepts in their everyday professional
dealings, especially with their patients? Another way of posing that
question is to ask, Why is it important to maintain the medical pro-
fession's implicit contract with society? For it is professionalism that
is the medium though which individual physicians fulfill the lofty ex-
pectations that society has of medicine. If norms of physician be-
havior fall short of the responsibilities called for by medical profes-
sionalism, both presumed signatories to the social contract—the
profession and the public—are destined to suffer irreparable harm.
For the medical profession, what's at stake is a set of very special
privileges that we too often take for granted. Those privileges include
(1) the ability to self-regulate, to set our own standards (e.g., medical
school admission criteria, licensure requirements, qualifications for
board certification, credentials needed for hospital privileges, accred-
itation standards for medical schools, hospitals, residency programs,
and continuing medical education providers); (2) a degree of auton-
omy in our interactions with patients that is virtually unheard of in
any other sector of society; (3) a level of public esteem that surpasses
virtually all other lines of work; and (4) an enviable measure of secu-
rity as evidenced by unparalleled opportunities for well-compensated
employment. These exceptional privileges are not birthrights to which
doctors are entitled just because they have an MD degree; they are
tenuous accommodations granted by society, in return for which so-
Foreword vii
ciety has legitimate expectations. Failing to deliver on those expecta-
tions, that is, falling short on the responsibilities of professionalism,
will surely result in a withdrawal of the tremendous advantages that
now accompany our profession's status.
But as high as the stakes are for the profession, they are much
higher still for the public. What medical professionalism affords the
public (and individual patients) is of profound and inestimable
value, albeit not widely acknowledged. Having a physician imbued
with professionalism offers patients by far the best hope for experi-
encing a beneficial outcome when encountering our increasingly so-
phisticated and inherently risky health care system. Nothing can sub-
stitute for having a trustworthy physician to safeguard a patient's
interest: not laws, not regulations, not a patient's bill of rights, not
watchdog federal agencies, not fine print in an insurance contract.
Nothing. And it is professionalism that is the foundation of trust—
trust between the medical profession and society, and trust between
doctor and patient. Only by adhering to the fundamental precepts
of professionalism can physicians establish the requisite trust that
both sustains medicine as a moral enterprise and assures patients
that their interests are always of paramount concern.
Why is the task of inculcating and sustaining professionalism
such a challenge? Why have medical educators been urged so
strongly in recent years to address professionalism in their curricula
and to mount effective evaluations of their students' professional at-
tributes? Why must we worry about whether students are being well
armed to withstand the threats to professionalism? The answer to
these questions is rooted both in certain timeless realities and in the
peculiarities of this moment in medicine's history. Among the time-
less challenges to sustaining professionalism's behavioral norms, the
most basic is human nature itself. All of us have been hard-wired by
eons of evolution to look out first for number one. Self-protection
is the hallmark of survival. Self-interest, the antithesis of profession-
alism, is a powerful instinct to overcome. Compounding the innate
tendency to serve one's own interests are the innumerable oppor-
tunities that physicians have—and always have had—to yield to temp-
tation. Operating in the unwitnessed privacy of the examining room
and with the presumed authority of their exclusive knowledge, physi-
cians have always been in a virtually unique position to exploit rou-
tine encounters to extract private gain. Few have the inherent con-
flicts of interest that physicians are forced to contend with on a daily
basis. Yet another abiding challenge to professionalism is pressure
viii Foreword
from physician peers. When many of one's colleagues are seen to ab-
rogate their professional responsibilities, as appears regrettably to be
an increasing problem in the present era, the difficulty of sustaining
one's commitment to professionalism is understandably intensified.
As if these classic challenges to professionalism were not enough
to worry about, we have the added burden of living at a time when
medicine finds itself inundated by a wave of commercialism. Whether
by intent or otherwise, our country has chosen to rely on the com-
mercial marketplace in an effort to control the escalating costs of
health care. As a consequence, medicine is increasingly being viewed
by policy makers and others as no different from any other com-
mercial entity. In their view, medicine is just another business. Wit-
ness the terminology that has crept into common usage: doctors are
commonly referred to as providers; patients, as consumers; health
care services, as commodities. As a salient reminder of the funda-
mental difference between commercialism and professionalism, con-
sider their starkly contrasting mottos. Commercialism's is caveat emp-
tor, buyer beware. Medicine's is primum non nocere, first do no harm.
The health care system has learned some very important lessons
from the world of commerce, and these lessons must be acknowl-
edged. For example, over the past few decades medicine has become
more attentive to wasteful effort and expenditures, to sound back-
office business procedures, and to the need to systematize routine
care. The danger posed by commercialism lies not in medicine's
adopting its business-like processes but in medicine's adopting its
core ideology. Self-interest, the dominant paradigm of the market-
place, is the very antithesis of the self-sacrifice called for by medi-
cine's commitment to the primacy of our patients' interests. And that
is where professionalism enters the picture. For it is the mandates of
professionalism that serve to keep self-interest in check; profession-
alism is the bulwark that prevents physicians' unavoidable conflicts
of interest from corrupting the patient-physician relationship and
dissipating trust. The last thing most people want is to be distrustful
of their physician's motives.
For this reason, measuring medical professionalism in students
at all levels should be a top priority of medical educators. We still
have much to learn about how to make such measurements as reli-
able as those we depend upon to evaluate other aspects of physician
performance. But the techniques are improving steadily, and those
who digest this book will be in the best position to lead this critical
field forward.
Acknowledgments
For at least a thousand years, physicians have worked to maintain the
highest standards of behavior for this profession. In the last 20 years,
medical educators have ventured into the area of assessing profes-
sional behavior with the intent of ensuring that physicians exhibit
the excellence, humanism, accountability, and altruism that are ex-
pected of today's doctors. This exploration has not been a solitary
one, but rather a group effort, with a vigorous, open dialogue in the
community of medical educators. This book marks a point in time
where we can now begin to assert that measuring professional be-
havior is possible. While there is still a great deal of work to be done,
the ideas in this book form the foundation of what is likely to be a
more comprehensive assessment of professionalism in physicians for
the future.
The ideas in this book derive not only from the authors' indi-
vidual work but also from the discussions we have had together at
meetings and conferences over the years. The Association of Amer-
ican Medical Colleges has dedicated time to research professional-
ism at meetings for many years, and our dialogue at these meetings