Beyond Professionalism

I am worried about the future of the profession of medicine in general, and of psychiatry in particular. Behind my anxiety is a series of 3 disturbing occurrences—the subject of this column—in which I sense a gradual but palpable shift in the identity of physicians, both those in training and those in practice.

Several times a year, I teach a seminar in public health ethics for fourth-year medical students in which we discuss the myriad of ethical dilemmas associated with pandemic flu. Among the most debated is what ethicists call the "duty to care," which is the obligation for physicians and other health care providers to risk their health and even lives to serve and save the sick. I ask the students whether they believe they would come to work during a pandemic, and in some classes almost no one raises their hand.¹ While their reasons reflect important values—the need to care for a partner or children, or fear of dying and depriving their family of livelihood—their choices are the reverse of what has historically been expected of medicine. True, there were cowardly physicians who fled to the relatively safe country during the black plague, but there were many more clergy and doctors who perished while tending to the dying. Similar heroic examples from our own day occurred during the severe acute respiratory syndrome (SARS) outbreak.¹

This change in conceptualization was also reflected in the comment of one of my most respected colleagues, who told me that he had 2 sons and that he would do anything he could to dissuade them from becoming physicians because medicine was no longer a profession but a business.

In the final disturbing incident, more than two thirds of the residents in my own academic institution, the University of New Mexico, voted to unionize. Many of the most idealistic trainees who supported the union believe it is paradoxically the last bastion of professionalism. Others would say more pragmatically that the business of medicine is a fait accompli and that unions represent the most fair means of obtaining humane working conditions, which will, in turn, safeguard the quality of patient care from being reduced to the lowest economic denominator. Far better ethicists than I have held that unionization is not consonant with the historic understanding of a profession.²

At this point, it is important to stop and remind ourselves of the definition of a profession, so that we can better judge what actions and attitudes threaten and support the concept. While there is considerable debate about the exact contours of the definition, the basic shape of a profession has retained the lineaments of Flexner's formulation during the reformation of American medical education. A contemporary statement is that of Arnold and Stern: "Professionalism is demonstrated through a foundation of clinical competence, communication skills, and ethical and legal understanding, upon which is built the aspiration to and wise application of the principles of professionalism: excellence, humanism, accountability, and altruism."³

Almost everyone would agree that this is not a description of a business but of something qualitatively in a different moral universe. This is not to say that businesses cannot adhere to the highest ethical standards of their respective domains, nor even that some corporations are not engaged in the public form of altruism, philanthropy, or are not organizationally accountable to the environment and their own employees and customers. This is only to say that the sine qua non of a business is profit and production for those who have invested in it and own it--not the service of others beyond all other interests, which has been the goal of medicine since Hippocrates. In fact, the Hippocratic school began as a protest against the commercialism of health care practitioners of the period and amounted to a moral revolution in the practice of medicine that was reflected in the ideals of the famous oath.⁴

It would be illogical and presumptuous to claim that doctors could not provide competent, even dedicated, treatment of illness and injury as employees or managers. Many of the most progressive initiatives in health care delivery are derived from business, such as performance improvement, quality assurance, and systems analysis.⁵ There are health care entities operating today whose leadership and staff understand and present themselves as the "health care industry," and many patients, including psychiatric patients, actually prefer the moniker "consumer." Policy analysts and economists have argued that the comprehensive transformation of medicine into a business is the only means of controlling cost, ensuring equitable access, and maintaining high standards. From the ethical perspective, if medicine were to become a business and not a profession, it would resolve a number of pressing and thorny conflicts of interest, especially for psychiatry, such as the role of the pharmaceutical industry in education and research, self-referral to imaging facilities, and the perennial struggle with government funding.^6,7

If medicine continues on its present path and evolves, or I should say devolves, into a business, it will represent the first time since the Hippocratic revolution that those entrusted with the care of the sick and weak are not members of a profession with all the virtues and values this implies. However effective and even equitable the future business of medicine might become, the authentic practice of medicine as a healing art will no longer be possible, since the essence of doctoring is the exercise of compassion in the relief of suffering. As Eric Cassell writes in one of the most important books in the postmodern history of medicine: "Suffering is personal and medicine is a personal profession—one doctor and one patient—each incomplete without the other. All medicine—all care and caregivers, all medical science and technology—rests on that special relationship. . . . Current descriptions of physician and patient as adversaries struggling over a commodity called medical care bear no relation to the actual care of sick persons because of this special connection."⁸

More than any other branch of medicine, the profession of psychiatry is unable to coexist with business because the suffering of mentally ill persons is deeper and darker and more pervasive and powerful than any other form of human anguish, whether biological or social. The 17-year-old girl with anorexia who weighs 78 lb and is on the verge of metabolic failure, whose bloated delusion in the mirror forces her to exercise 3 hours per day and eat only one meager meal, knows a pain beyond the most traumatic physical injury. The tortured combat veteran who wrestles nightly, like Jacob with the angel, with fallen comrades and enemies while he battles the demons of substance abuse would gladly give up his leg or arm to have a whole mind. The patient with bipolar disorder who, despite a fist full of daily pills, can hold no job, keep no relationship, and cannot endure for a year without hospitalization, has an illness that is at once acute and chronic and far too often terminal. Such intensity of suffering existentially demands and morally warrants the response of humanism and altruism that belongs not to doing a job but to being a member of a profession.

I welcome the new breed of physician who has a life outside medicine and the influx of women who seek to balance family and career, all of whom are barometers of our own improved self-care that we as psychiatrists know is essential for enduring empathy toward patients. None of these salutary developments contradict physicians' identities as professionals or prevent them from making the moral commitment to valuing the good of patients above all other claims. Professionalism does not require total self-abnegation--which, if one looks at the history of monasticism, only fed the ego with pride—but recognition that true compassion in the service of healing involves inconvenience, stress, disappointment, and a measure of self-sacrifice. To those critics who say this asks too much of physicians or that it is a supererogatory standard, I would respond with the words of my mentor—"Compared to the refugees in Darfur, we have nothing to complain about. "No matter what becomes of "managed care," the wealth and power of the average physician surpasses that of 99% of the people on this planet.

A more thoughtful objection is that the current economic climate and political landscape have created an environment in which the professionalism of prior generations is no longer enough to safeguard the integrity of medicine and the welfare of patients. Unless some form of universal health care, including parity for mental health, comes soon (which is doubtful), psychiatry may need to go beyond being a profession to become a vocation, to be responsive to what Robert Coles spoke of as The Call of Service,⁹ if it is to stand by the addicted and afflicted.

Several months ago I spoke to a small church group on end-of-life issues. Naturally, I used examples from my experience as an ethics consultant. At the close of the discussion, one elderly couple asked me, "How are you able to continue to do this kind of work without losing hope?" Without even thinking I answered, "It is not a job to me but a vocation. I can't always hold onto that vision, especially when I am too tired and feel I have failed, but without that spiritual dimension, I would be so overwhelmed with suffering I could help no one."

References:

References

1.

Ruderman C, Tracy CS, Bensimon CM, et al. On pandemics and the duty to care: whose duty? who cares?

BMC Med Ethics.

2006;7:E5.

2.

Sulmasy DP.

The Rebirth of the Clinic: An Introduction to Spirituality in Health Care.

Washington, DC: Georgetown University Press; 2006.

3.

Arnold L. What is medical professionalism? In: Stern DT, ed.

Measuring Medical Professionalism.

New York: Oxford University Press; 2005:19.

4.

Edelstein L.

Ancient Medicine: Selected Papers of Ludwig Edelstein.

Baltimore: Johns Hopkins University Press; 1967.

5.

Liebler JG, McConnell CR.

Management Principles for Health Professionals.

4th ed. Boston: Jones and Bartlett; 2004.

6.

Geppert CM. Medical education and the pharmaceutical industry: a review of ethical guidelines and their implications for psychiatric training.

Acad Psychiatry.

2007;31:32-39.

7.

Carlat DJ. Conflict of interest in psychiatry: how much disclosure is necessary.

Psychiatric Times.

2006;23 (13):1.

8.

Cassell EJ.

The Nature of Suffering and the Goals of Medicine.

New York: Oxford University Press; 1991.

9.

Coles R.

The Call of Service: A Witness to Idealism.

Boston: Houghton Mifflin; 1993.