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PROFESSIONALISM IN A MODERN HEALTH SYSTEM
ISSUE 5 JUNE 2003
Introduction
by Dr David Galler ASMS National President
For many senior doctors and dentists it is hard enough keeping up with the advances in one's own field, let alone keeping an eye on the machinations of government officials and how their policies might affect the provision of care to our patients. Although initially and primarily an industrial organisation, this has become part of the core work for the Association of Salaried Medical Specialists (ASMS).
In April 2002 the ASMS, The Minister of Health and Ministry of Health jointly sponsored a one-day meeting entitled
PROFESSIONALISM: Its nature and role in the health system.
So much has happened since then that begs the following questions:
- Have the insights and fine words from that meeting become blurred or forgotten, lost in the tumult of the day to day?
- What new insights have we taken on board to help us help our patients?
- Have we entered a brave new world where professionalism in medicine has been reaffirmed or have we simply returned to more of the same old same old?
For many of us, nothing will have changed, partly because there is so much to change, but also because there remains considerable resistance to change. For many in the Auckland region thanks, to the attitudes and comments of the Auckland District Health Board chairperson and for many in South Canterbury bruised by an unfortunate management style, there will be a sense of having gone backwards.
To date the 'do-as-I-say' managerialism and the fiscal bottom line seem to be firmly in the ascendancy, leaving the professional model yet to score.
However, there have been some signs of progress. The Ministry of Health documents on Reportable Events and Sentinel Event Reporting (www.moh.govt.nz) and the acknowledgement by some officials of the urgent need to tackle the systemic nature of error in medicine, are big advances.
On the other hand, the day to day struggle to improve patient care and the ongoing financial woes of the district health boards are profoundly depressing and demoralising. With the change of government in late 1999, there was some hope of respite in the daily struggle to improve public access to the health system and the quality of care they receive in it. This hope has not been fully realised. Life has never been tougher and the financial environment never tighter. On a practical level this means investment in new initiatives are less likely, progress made in the past is not taken advantage of, the morale of the workforce deteriorates, we become more cynical, depressed and disillusioned, some of us burnout and some just leave.
To add another dimension, government proposed legislation ostensibly aimed to assure the public that registered health practitioners are competent to practise, risks further eroding medical professionalism in New Zealand by imposing more external controls on the profession as opposed to promoting rigorous internal regulation.
Given the good sense expressed in Ministry of Health documents relating to event reporting on the one hand, and so far, the failure to protect key quality assurance activities in proposed legislation on the other, one might assume that one arm of government doesn't know what the other arm is doing. Alas not so lucky! This is not the result of poor communication; it reflects a genuine difference in belief between enlightened and less enlightened groups within various government departments.
With all of those matters in mind, it might be useful at this point to reflect on the key messages from the April 2002 Professionalism Conference, to remind us again what this was all about and how we as a profession might move forward.
This conference arose out of a growing realisation that professionalism in medicine was on the wane. For government and management, the business model in health had been paramount; for our resident medical officer colleagues, the so-called 'industrial model' appears to be more relevant; however for the ASMS, the Minister and some in the Ministry, the value of Professionalism in Medicine remains valuable and in need of affirmation.
As it happened, medical staff in other parts of the world felt the same way. The professionalism movement in the United Kingdom and in the United States was already on a roll.
The Minister of Health, the Hon Annette King, opened the Professionalism Conference. I remember her specifically saying:
I am keen to see that the values of professionalism are the core driving force for doctors, nurses and other health professionals working and making decisions in DHBs. DHBs will not achieve their objectives without winning the hearts and minds of motivated, confident senior doctors.
The keynote speaker at the meeting was Professor John Luce from San Francisco. A person of considerable clinical experience and wisdom, he eloquently developed a definition of professionalism and discussed its attributes and challenges.
His definition spoke of a calling with a sense of responsibility, ethics and morality. A calling characterised by specialised knowledge, long and intensive preparation, maintenance of 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.
He drew our attention to the Physician's Charter (www.professionalism.org). Born out of a growing sense of disenfranchisement from essential decision making, the Project Professionalism Group published a set of fundamental principles of professionalism in the February 2002 editions of The Annals of Internal Medicine and The Lancet. (http://pdf.thelancet.com/pdfdownload?uid=llan.359.9305.editorial_and_review.19405.1&x=x.pdf).
The Group recognises three broad principles of professional care:
Primacy of the patient
Principle of patient autonomy
Principle of social justice
These principles have been embodied into the Charter in the form of 10 professional commitments:
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
Professional responsibilities
Whilst that might be a long and hard list for many to remember, for the vast majority of members of our Association, these commitments will be the way they behave with every patient everyday.
However, as well as keeping those commitments, even more is required of us. The word profession is from the Latin, to speak forth, implying that merely holding a personal belief in these principles is not enough; one must profess those beliefs and values publicly. I don't think that we do that enough. Since the Cartwright inquiry of the late 1980s, the medical profession as a group, seem to have gone into a huddle and haven't come out. Well, we need to come out and we need to come out now.
Medicine is about relationships and at its core is the sanctity of the doctor patient relationship. But we must not forget that medicine is also about a wider relationship, one with the public at large. Despite the many mutually satisfactory interactions between individual medical staff and individual patients, at a macro level the nature of this relationship between the medical profession and the public is better characterised as a mutual 'culture of suspicion'. What I am sure both parties want is a culture of trust.
Whether we like it or not, we as a profession, and the wider public, are part of a dynamic social contract in which each party needs to have a balanced understanding of, and respect for, the values and beliefs of the other party. Making this relationship work will bring us all great rewards.
For the public and the profession, there are huge advantages in effectively dealing with the massive and costly problem of medical error. We need to move beyond the naming and blaming and learn the lessons so effectively put into practice by the airline industry.
Both parties need to take part in decision making at all levels of health care planning with the expertise of the professions and the aspirations of the public key elements to ensure that these decisions deliver desirable outcomes.
For this to happen we, in the medical profession, need to get involved, to speak forth, individually and through our professional associations. The ASMS is proud to publish Professor Luce's address to the Professionalism Conference in order to further facilitate this discussion along with the introductory address from the Minister of Health, the Hon Annette King.
PROFESSIONALISM: ITS NATURE AND ROLE IN THE HEALTH SYSTEM
Opening Remarks from Hon Annette King Minister of Health
Firstly, I would like to welcome everyone to this important conference, and to congratulate the Association of Salaried Medical Specialists and the Ministry of Health for jointly sponsoring the event.
I feel honoured that I have been asked to co-chair the conference, along with Dr Peter Roberts, and I will spend as much time here today as I can.
The list of people attending and participating in this conference represents a strong who's who of the medical profession. If this group cannot come up with solutions and ideas about ways in which we should be applying the principles and values of professionalism, particularly in our District Health Boards, then I doubt if any group in this country would be capable of doing so.
Very shortly we will be starting on the main business of the day with the address by Professor John Luce, from the University of California. Like everyone else here, I am looking forward to hearing what he has to say, but one perk of being a co-chair is that before the professor speaks, I have the chance to pass on a few thoughts of my own. The first of those thoughts is that it is essential to acknowledge the complexity of some of the issues with which you will be grappling. The words health and complexity tend to go together, in fact. Because we all have different jobs, we all tend to view the complexities or the problems slightly differently. That makes it even more important to try to find balanced solutions.
Professionalism in health is about ensuring people are adequately trained and equipped to appreciate and respond to the complex issues and problems that arise in their daily work.
The reason for that is straightforward, even if it is sometimes forgotten. Health professionals, and the wider health workforce, are the crucial ingredients in providing safe and effective services.
Hospital walls and the equipment within them do not protect patients. The people who work within those walls and use the equipment do that.
To return to the word balance that I just mentioned. For this event to be successful today, people here have to acknowledge that achieving balance while still maintaining the highest professional standards is not an easy or straightforward task. Everyone has a contribution to make. No individual or group, no matter how senior, has an exclusive insight into professionalism.
It is no bad thing that we have four themes today to help focus our thinking. Those themes deserve reiterating through the day. They are:
How professionalism can improve the effectiveness of the system?
Why is it important to empower health professionals?
What is the role of management in working with health professionals?
And what is the role and importance of culture in DHBs?
I think it is important to point out that a desire to improve things doesn't mean things are not working well. Things are working well. The vast majority of New Zealanders continue to receive high quality, professional care from our public health system. We should not lose sight of this fact. What we want is to do better still.
It is interesting, to try to put our health service in some sort of perspective, to reflect on a new report, released this week, from the Commonwealth Fund. It reveals that more than one of five Americans, or some 8.1 million households, report that they or a family member have experienced a medical or prescription drug error that turned out to be a serious problem.
We should remind ourselves that major mistakes that give rise to questions about the professionalism of the system here are rare, despite the publicity they almost invariably attract. Yet it remains vitally important to try to learn from mistakes when they do occur.
As Commonwealth Fund senior vice-president Stephen Schoenbaum says: "A good relationship between doctor and patient characterised by open and trusting communication is a critical component of high quality health care."
We should not feel threatened by the public's determination to talk more openly about the performance of medical professionals and safety in health. It is a matter of finding a balance between patients' rights and ensuring they receive the quality care they justifiably expect, and safeguarding the interests of medical professionals who need to be able to work without fear of harassment.
Safety is only one aspect of achieving professionalism. Maintaining professionalism across the whole system is a far more complex and challenging task.
I believe there are four key components to doing this: balance, trust, reliability and effective relationships. B, T, R. and E. Add another "e" and a "t", and you have what we are aiming for, something "BETTER".
As I mentioned in my opening remarks, balance is essential because health is a complex area. The tension of managing within resource constraints and providing the treatment options we want will always exist regardless of policies or the economic and political environment. We cannot deal with these elements in isolation from each other. The crucial issue is identifying processes and structures, and cultures that allow us to negotiate a path through the tensions. The policy setting of the past decade was not always good at doing this.
This Government has instituted a number of changes that should make the difficult task of achieving balance somewhat easier. These changes are based on admitting that imposing change is not good enough. There has to be cultural change if new structures are to work.
The admission that central government no longer has all the answers is central to this process. So is every opportunity to allow groups like medical professionals, who have extensive expertise to contribute, to have a role in decision-making. I know some DHBs are exploring ways in which they can help this happen.
The three-year funding package and long-term commitment to the District Health Board structure are particularly important in this regard.
Both are designed to provide certainty to assist decision-making, a greater sense of partnership with communities, and to build on the good working relationships that already exist between the different groups making up the health workforce. In some cases, these groups may need to prove to each other that they have a constructive contribution to make to this process.
Doing things better will also require re-establishing the sense of trust that many feel has been eroded in recent years. The challenge is to facilitate the development of good relationships, and for health professionals the ambit of relationships is wide indeed.
It stretches from the patient-doctor relationship to a relationship with other health professionals to a relationship with the public, and how the latter relates to public expectations about how professionals perform.
Relationships are tenuous in nature. In the past decade or so there was an emphasis on contractual relationships, probably to our cost. It is necessary to return to a more basic, if also more complex, interpretation of the nature of relationships.
These are only brief thoughts, but I hope they reflect some of the ways you have been thinking about the issues we are here to discuss.
During the day I certainly look forward to learning more about what you are thinking. And what better way will there be to start that process than by listening to Professor Luce.
Fundamentals and First Principles of Professionalism in a Modern Health System
Keynote Address by Professor John M Luce MD
Professor of Medicine and Anaesthesia
University of California San Francisco
Associate Director
Medical-Surgical Intensive Care Unit
San Francisco General Hospital
It 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.
The first term, profession, means, in its broadest sense, "a principal calling, vocation, or employment," according to Webster's Third New International Dictionary1. 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 specialised 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 organisation 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.
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 publication2 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 organisations, 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 organisational 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 organisational 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 specialised 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 institutionalised by rational-legal methods: the executives of organisations 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 organisational 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 organisations 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 organisations, 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 organisations, 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 specialised 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 organisational 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 organisational 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 organisation 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 house-officers, belong to unions or are organized in a viable fashion. Collective bargaining by non-salaried 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 organisations.
Encroachments on control of the medical workplace also are manifest. Whereas many American hospitals once were run by physicians, they and managed care organisations increasingly are directed by non-physician 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 organisations 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 organisational 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 organisational 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 organisations devoted to maximizing profits or growth by minimizing production costs, or publicly supported organisations 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
1. Webster's Third New International Dictionary, Merriam-Webster, 1993.
2. American Board of Internal Medicine, Project Professionalism, 1995.
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.
4. Vastay B. Annals of Internal Medicine's Harold Sox, MD, discusses 'Physician Charter of Professionalism'. JAMA 2001;286:3065-3066.
5. Freidson E. Professor of Medicine: A Study of the Sociology of Applied Knowledge. Dodd, Mead and Company, 1975.
6. Freidson E. Professionalism Reborn. University of Chicago Press, 1994.
7. Krause EA. Death of the Guilds. Yale University Press, 1996.
