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PROFESSIONALISM CONFERENCE 2002
Professor John Luce Address
John M. Luce, M.D. Professor of Medicine and Anaesthesia
University of California, San Francisco
Associate Director, Medical-Surgical Intensive Care Unit
San Francisco General Hospital
FUNDAMENTALS AND FIRST PRINCIPLES OF PROFESSIONALISM IN A MODERN HEALTH SYSTEM
IntroductionIt is a great pleasure to participate in this conference on professionalism. I do so as a physician involved in clinical practice, health services and biomedical ethics research, and hospital administration at San Francisco General Hospital. San Francisco General differs from most American hospitals in that it is a public facility, owned and operated by the City and County of San Francisco. At the same time, we are staffed by medical faculty from the University of California, San Francisco, under contract with the City and County.
As a public facility, we serve as a trauma center for San Francisco and as a community hospital for the poor. We have approximately 17,000 admissions, 60,000 emergency department visits, and 535,000 visits to our clinics and a half-dozen clinics based in the community. Approximately half of our patients have no insurance; those who do are covered largely by Medi-Cal, our state version of Medicaid.
The hospital is chronically underfunded, and our medical professionals struggle daily with the free market, in that many of our patients are denied care at other local hospitals because they are unsponsored, and with the state, in that we are at its mercy in maintaining our role in health care.
I have alluded to San Francisco General in my remarks to give you a better sense of who I am and where I come from, and to remind you that we are all professionals and all under siege. Over the next few minutes, I hope to expand on the nature of our predicament and how we can make the most of it. But before I do, I need to define several terms that will be focused on today.
Professionalism
The first term, profession, means, in its broadest sense, "a principal calling, vocation, or employment," according to Webster's Third New International Dictionary 1. In its broadest sense, this definition reflects the common use of the term "profession" to describe almost any occupation. But, in its narrow sense, the term "profession" separates those in the learned professions-historically limited to theology, medicine, and law, and perhaps also including engineering and university teaching-from other lines of work. The best dictionary definition I have found of "profession" in its narrow sense comes again from Webster's Third New International Dictionary:
"A calling requiring specialized knowledge and often long and intensive preparation including instruction in skills and methods as well as in the scientific, historical, or scholarly principles underlying such skill and methods, maintaining by force of organization or concerted opinion high standards of achievement and conduct, and committing its members to continued study and to a kind of work which has as its prime purpose the rendering of a public service."
In keeping with this narrow definition of "profession", Webster's defines a "professional" as
one who belongs to one of the learned professions or is in an occupation requiring a high level of training and
proficiency 1.
Hence, "professionalism" is defined as
the conduct, aims, or qualities that characterize or mark a profession or a professional person 1.
This definition of "professionalism" is far from complete, as we shall see, but it will serve to introduce the concept of professionalism for now.
Medical Professionalism
What are the qualities-or virtues-that we can attribute to a professional? The American Board of Internal Medicine (ABIM), which writes qualifying examinations for voluntary certification in Internal Medicine and its subspecialities and is also concerned with improving the qualities and qualifications of internists in the U.S., launched an enterprise called Project Professionalism in the 1990s that was and is intended
to enhance the evaluation of professionalism as a component of clinical competence and to promote the integrity of internal medicine. In large part, the project was motivated by changes, inside and outside the educational environment, eroding professional standards.
Among its other objectives, Project Professionalism sought to define the characteristics that mark the ideal internist. As spelled out in a publication 2 describing the project, they are:
Altruism-putting the interests of patients first;
Accountability-to patients for fulfilling the implied contract governing the patient/physician relationship, to society for addressing the health needs of the public, and to their profession for adhering to its time-honored ethical precepts;
Excellence-a commitment to exceeding ordinary expectations and engaging in life-long learning;
Duty-to patients, professional organizations, and society;
Honor and integrity-the consistent regard for the highest standards of behavior and refusal to violate personal and professional codes; and
Respect for others-patients, their families, fellow physicians, and other professional colleagues.
In its publication on Project Professionalism, the ABIM did not define "professionalism" per se, other than stating that it "requires the physician to serve the intents of the patient above his or her self-interest" and outlining the elements of professionalism in the qualities outlines above. Nevertheless, the Board did spell out its idea of the fundamental principles of professionalism, which I will adopt for the duration of this talk. These are contained in a document called Medical professionalism in the new millennium: a physician charter, which was developed with the American College of Physicians and American Society of Internal Medicine and the European Federation of Internal Medicine and published in the Annals of Internal Medicine this year 3. The principles are:
Primacy of patient welfare-based on a dedication of serving the interests of the patients;
Principle of patient autonomy-being honest with patients, empowering them to make informed decisions; and
Principle of social justice-promoting a fair distribution of health care resources.
Accompanying these fundamental principles in the physician charter are the following ten professional commitments, which represent a sort of ten commandments to the profession:
Professional competence,
Honesty with patients,
Patient confidentiality,
Maintaining appropriate relationships with patients,
Improving quality of care,
Improving access to care,
Just distribution of finite resources,
Scientific knowledge,
Maintaining trust by managing conflicts of interest, and
Professional responsibilities 3.
The physician charter is a unique document both in its explicit presentation of professional virtues and in its acknowledgement that "changes in the health care delivery systems in countries throughout the industrialized world threaten the values of professionalism." Harold Sox, editor of the Annals of Internal Medicine, was recently interviewed in the Journal of the American Medical Association about why the charter was published now. His response speaks to the sense among physicians, in the U.S. and elsewhere, that not only their professional ethics but also their way of life are being challenged.
Physicians are under a great deal of stress because of things that are beyond their control. The charter reminds physicians that satisfying in full the expectations of a medical professional is still within their control 4.
Dr. Sox's concern that physicians are losing control reminds us that professionalism is more than a set of qualities, fundamental principles, and commitments. Indeed professionalism, also is an organizational model. Today this model is threatened like never before, if it is not already extinct. As a result, physicians are trying to retain what has been called their "professional autonomy" and "guild power".
Eliot Freidson, a sociologist then at New York University, published one of the most important works on professionalism, Profession of Medicine: A Study of the Sociology of Applied Knowledge, (1975) 5. In this seminal work, Freidson points out that for physicians, professionalism has always been not just a set of virtues or moral imperatives but also a means of organizing themselves as an occupation with monopoly power granted through an implicit social contract with the state. According to Freidson, physicians have served their own self interests while at the same time serving the interests of their patients.
Consciously or not, they have sought and protected their own professional autonomy, which in essence gives them control over their own work.
In a more recent publication, Professionalism Reborn 6, Freidson provides a discussion of professionalism that allows expansion of the definition I have used earlier in this talk to include the concept of professionalism as an organizational model. In his words;
Professionalism, like the free market and bureaucracy, represents a method of organizing the performance of work. It differs from the free market and from bureaucracy in that it revolves around the central principle that the members of a specialized occupation control their own work. By control, I mean that the members of the occupation determine the content of the work they do 6.
Absolute control presupposes controlling the goals, terms, and conditions of work as well as the criteria by which it can be legitimately evaluated.
By contrast, in the free market, consumer demand and the free competition of workers for consumer choice determine what work will be done, who shall do what work, how, and for how much pay. In bureaucracy, the market for labor and its products is institutionalized by rational-legal methods: the executives of organizations decide what product will be made or service offered, who shall make it, by what methods, and how it shall be offered to consumers 6.
As indicated by the above quotation, Freidson believes that, as an organizational model, medical professionalism increasingly is competing with the models of the free market and of corporate or state bureaucracies. Of the goals of these rational-legal bureaucracies, he writes that;
the spirit of these organizations is to reduce everything to the predictable and calculable so as to gain a stated set of ends with the greatest possible efficacy. The structure and practices of such rational-legal bureaucracy express that spirit of formal rationality. In the case of private commercial organizations, we might not be too far off the mark to say that the end is the production of saleable goods and services at the lowest possible cost so as either to increase profits or sustain growth. In the case of public or state organizations, the end is the production of politically acceptable goods or services at the lowest possible cost to the Treasury 6.
Regarding how bureaucracies achieve their goals, Freidson notes that;
the structure of a rational-legal bureaucracy is designed to create an efficient division of labor, modes of supervision that can effectively control and coordinate a complex variety of specialized tasks, and channels that freely and fully transmit commands, appeals, and information up and down the hierarchy 6.
Elliott Krause, a sociologist from Northeastern University, equates the "professional autonomy" explored by Freidson to what he calls "guild power" in a work entitled Death of the Guilds: Professions, States, and the Advance of Capitalism 7. As with professional autonomy or professionalism, guild power is an organizational model. According to Krause
a model of guild power-any model-has to be abstracted out of the complex reality from which the guilds, with their tremendous variation, arose. The model, as I propose it, should have the following dimensions: power and control over the association, the workplace, the market, and the relation to the state. These dimensions are interrelated, and the degree of power and control can vary widely 7.
Like Freidson, Krause believes that professionalism as an organizational model is a fight with capitalism (in the sense of the free market) and the state for control of the health care marketplace. However, whereas Freidson asserts that physicians remain dominant even while in employee status, Krause considers them an increasingly marginalized group. In his words;
but what may not be obvious is that in considering how workplace activity relates to a profession's organization and professional groups, to the role of market factors, and to the role of states and capitalism, I am not saying, even as a hypothesis, that any given profession 'dies'. What I do suggest is that guild power-the control of these factors by professions-is declining as state power and capitalist power encroach upon it 7.
The encroachments on guild power alluded to by Krause are increasingly evident in the U.S. Fewer than 50% of American physicians belong to the American Medical Association (AMA), which for over 150 years has been their major political and economic lobbying group. Whereas the AMA once determined the numbers and characteristics of medical students through its influence in medical schools, these factors are now determined by government funding. Few American physicians, other than houseofficers, belong to unions or are organized in a viable fashion. Collective bargaining by nonsalaried physicians is not allowed by the U.S. Federal Trade Commission, making it difficult for independent physicians, even when organized in groups, to dictate terms to managed care organizations.
Encroachments on control of the medical workplace also are manifest. Whereas many American hospitals once were run by physicians, they and managed care organizations increasingly are directed by nonphysician managers. American medicine once was dominated by solo physician practitioners who functioned as small businessmen (and, rarely, businesswomen), but today most physicians work in groups, and more than 50% are salaried. Other practitioners, including nurses, are licensed just as physicians are and no longer have to work under their supervision. Alternative medicine is rampant in the U.S., and chiropractic, once the bane of the AMA, is now paid for by Medicare and Medicaid.
With reference to encroachments on control of the market, fee-for-service reimbursement has been replaced by capitalism in many, if not most, parts of the U.S. Direct-to-consumer marketing of drugs and high-technology screening tests such as total body computerized tomographic scans is commonplace. Following a U.S. Supreme Court decision several years ago, American physicians are allowed to advertise, sell products, and openly compete against one another. The profession is vulnerable to governmental and corporate cost controls, risk assumption when physicians take on capitated patients, and malpractice suits in which physicians testify against one another as expert witnesses.
Finally, I offer several examples of encroachments on control of the profession's relation to the states. The government, through Medicare and Medicaid, is the major purchaser of health services in the U.S., even though the country still lacks national health insurance. Public and private reimbursement schedules are increasingly parsimonious; they also are burdensome in that they require large amounts of paperwork and bureaucratic oversight. Physician decisions regarding Medicare patients are scrutinized by professional review organizations paid for by the government. And government and commercially-sponsored research has changed medical schools from simple training grounds for tomorrow's doctors to more complex centers at the hub of the U.S. healthcare industry.
Certainly some of the changes I have described as encroachments may have a salutary effect on health care, if not on the medical profession. But the basic question remains of whether the free market model or the bureaucratic organizational model are superior to the professionalism model and therefore appropriate replacements for it. I do not believe that the free market model is entirely relevant to health care because it presupposes that patients are well-informed and emotionally neutral consumers who can decide between physicians and other competing "products". The free-market model also emphasizes cost to the possible detriment of quality, and the market restrains access to care because some patients are not profitable.
To care for the bureaucratic model, on the other hand, values conformity and efficiency but places little emphases on knowledge and innovation, and in its haste to reduce costs, it may consider quality and consumer interests only as afterthoughts.
In contrast, the professionalism model, which values collegiality and consumer trust, promotes patient autonomy and welfare more than the other two models do. It also is better suited to expanding access to health services, insofar as physicians subscribe to the principle of social justice. These and other advantages apparently have led Freidson, who once was highly skeptical of professionalism as an organizational model, to espouse it in his more recent writings. As he notes in Professionalism Reborn:
I believe that the overall strategy of social policy should be aimed at keeping the professional model at the center of health care and other business services while checking and correcting the vices of its practitioners by carefully chosen elements of the other models 6.
The professional shortcomings or vices that Freidson cites includes arrogance, sanctimoniousness, insularism, suspicion of other practitioners, and an aversion to self-regulation and unwillingness to be regulated by others. He presumably would feel better about physicians, and about the ability of professionalism to survive, if we were to embrace the fundamental principles and ten commitments articulated by the ABIM.
In place of the ABIM's ten commitments, I offer ten responsibilities. Half of these are responsibilities of physicians: to strengthen our ties with patients by being their advocates; to enhance peer review of ourselves; to share power with other practitioners, including nurses; to advance knowledge, including evidence-based medicine when evidence is available; and to improve the quality of care.
To the free market and the state, I assign five responsibilities: to appreciate the unique nature of professionalism and the medical profession; to allow physicians to manage ourselves when possible; to support the quality initiatives we bring forward; to prevent professional frustration with the work environment; and, as corollary, to let physicians do good work.
Regarding the last point, I close with the words of Eliot Freidson, whose writings have informed so many of my thoughts. Freidson believes that work, and control of it, is the goal of any professional, and that because work is so important to them, professionals cannot function professionally unless their work and its conditions are good. As he states;
whether they work in private organizations devoted to maximizing profits or growth by minimizing production costs, or publicly supported organizations required to maximize production with minimal resources in order to keep taxes and political pressures low, an overwhelming caseload combined with a poverty of resources by which to handle it will at least discourage if not destroy both the inclination and the capacity to do good work 6.
References
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1 |
Webster's Third New International Dictionary, Merriam-Webster, 1993. |
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2 |
American Board of Internal Medicine, Project Professionalism, 1995. |
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3 |
ABIM Foundation, ACP-ASIM Foundation, and European Federation of Internal Medicine. 'Medical professionalism in the new millennium: a physician charter". Ann Intern Med 2002;136:243-246. |
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4 |
Vastay B. Annals of Internal Medicine's Harold Sox, MD, discusses 'Physician Charter of Professionalism'. JAMA 2001;286:3065-3066. |
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5 |
Freidson E. Professor of Medicine: A Study of the Sociology of Applied Knowledge. Dodd, Mead and Company, 1975. |
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6 |
Freidson E. Professionalism Reborn. University of Chicago Press, 1994. |
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7 |
Krause EA. Death of the Guilds. Yale University Press, 1996. |
Address inquiries to
Dr. Luce at: Division of Pulmonary and Critical Care Medicine
San Francisco General Hospital
1001 Potrero Avenue, Room 5K1
San Francisco, CA 94110
Telephone: 415-206-8289
FAX: 415-695-1551
john_luce@sfgh.org
