Professionalism is an overused word in the medical industry. What exactly is meant by professionalism, and what should it mean to hospitalists? Wikipedia notes that a professional is one who earns a living from a specified activity that has standards of education and training that prepare members of the profession with the knowledge and skills necessary to perform the role required. In addition, professionals are subject to strict codes of conduct enshrining rigorous ethical and moral obligations.
Physicians are the consummate professionals; over centuries, we have been afforded the reputation of being one of the “highest-ranking” professionals within societies, along with divinity and law. We are held to very high standards, both in and out of the workplace, including arduous and rigorous standards of education and training. We are in one of the only professions that take the Hippocratic Oath at graduation. This oath requires us to swear to uphold specific ethical standards. Being a professional means we always act within our professional standards and advocate for our patients in all circumstances.1
Threats to Professionalism?
Over the past several decades, concern has been growing about a widespread decline in professionalism among physicians, a decline that extends beyond a single generation. There are many purported reasons for this erosion of professionalism; we need to first understand the threats to professionalism in order to guard against its erosion in ourselves and in the next generation of physicians.1
One major issue is that we do not have a common understanding of the nature of professionalism; the definition is both overused and misused. We often refer to professionalism by what it isn’t, rather than understanding what it is. For example, there are scores of definitions for “unprofessional” conduct in the medical industry, many of which refer to physician behaviors. These include actions that intimidate, berate, or bully others, regardless of the rationale or intent, and encompass any form of physical or psychological harm. The actions of the “disruptive physician” are often thought of as synonymous with unprofessional behavior. But professionalism is so much more than the absence of disruptive behavior. So part of the erosion of professionalism is an oversimplification of what it isn’t, rather than what it is.
Another issue with upholding professionalism over time is that many physicians forget their professional standards, because there are few “booster sessions” to remind us of why we practice medicine. Once we enter the workforce, we are confronted with so many obstacles to delivering good care to patients that we often feel overwhelmed or incapable of removing the real barriers to good care, and therefore incapable of fulfilling our mission. There are no regular “revivals” or checkpoints to refresh our memory of what we went into medicine to accomplish.
Although our ultimate goal is to take good care of patients, another threat to professionalism is that doing this often requires physicians to operate outside their “trained” knowledge and skill sets. It requires us to act on behalf of patients as an advocate in all aspects of their life, not just as a “diagnoser” or “prescriber.” As a result, maintaining the ideals of professionalism has become ever more complex, because the social determinants of health have a major impact on patient well-being and health, including access to food, housing, and transportation. Many times, diagnosing and prescribing have little impact on the patient’s outcome; these social determinants of disease take sole precedence. A patient’s education, income, and home environment have a much greater impact in determining their health outcomes than does access to prescription medications. This means that advocating for patient health and well-being extends far beyond the walls of a hospital or emergency room, a role in which most hospitalists are incapable and/or uncomfortable.1
Another major catalyst in the erosion of professionalism is the complex issue of money and income. Many physicians, including hospitalists, are “judged” by their relative value units, an indicator of the quantity and complexity of patients seen. Services not “billable” are generally delegated to others, or they go undone. Such services include communicating tirelessly with all the stakeholders in the patients’ care, including family members, primary care physicians, other physician specialists, and other disciplines. Untoward behaviors, such as “upcoding,” selecting funded patients for care, creating patient streams for highly lucrative services, and under-resourcing care provisions that “lose money”—regardless of the value to the patient—are inadvertently incentivized on individual and system levels to enhance revenue. Many hospitalists are strapped with student loans early in their careers, requiring them to earn enough to pay back these loans in a timely fashion. These perverse incentives can and often do confound our ability to act solely on behalf of our patients.2
How Do We Overcome These Threats?
The first step in reviving professionalism is to define it by what it is, not by what it isn’t. Professionalism is not the absence of bad behavior. Professionalism is the “commitment to carrying out professional responsibilities and an adherence to ethical principles.”3 Professionalism is the pursuit of the tenets of the Hippocratic Oath. As a litmus test, read and reread the oath, and honestly reflect upon your practice.
Another step is to continuously work in multidisciplinary teams, a skill that comes naturally to most hospitalists. In order to fulfill the oath, you should not work as a social worker, but you should advocate for your patients’ social work needs. You need a plethora of other disciplines to help you fulfill your role as a patient advocate. Know and respect the roles that your team members are playing, all of which are invaluable to you and your patients.
An additional step in helping you fulfill your role as a professional is to get the education and skills you need to function effectively within the complex systems in which we currently work. You should incorporate business and management education into your continuing medical education so that you can help patients traverse a system that is complex. You should know and understand the general concepts of value-based payment, insurance exchanges, federal-state-private insurances, and the basic tenets of health systems. You should know how to recognize and reduce waste and unnecessary variation in the system, and know how to measure and improve upon processes.
In the words of Emanuel Ezekiel, MD, PhD, “Learning clinical medicine is necessary for making patient well-being the physician’s primary obligation. But it is not sufficient. To promote professionalism and all that it entails (reducing errors; ensuring safe, consistent, high-quality, and convenient care; removing unnecessary services; and improving the efficiency in the delivery of services), physicians must develop better management skills … Becoming better managers will make physicians better medical professionals”.2
For those entering medical school, nine core competencies can predict success in medical school and later in practice; we should all commit to excellence in these, which go beyond clinical knowledge:
- ethical responsibility to self and others;
- reliability and dependability;
- service orientation;
- social skills;
- capacity for improvement;
- resilience and adaptability;
- cultural competence;
- oral communication; and
Lastly, a critical step in preventing the erosion of professionalism in medicine is self-regulation. External regulation comes to those who refuse or are unwilling to regulate themselves. Professionalism is a set of skills that can be taught, learned, and modeled. As a new specialty, we all own the success or failure of the reputation of hospitalists as consummate professionals.1