Professionalism in medicine (part I)

“It is dangerous to be right in matters on which

the established authorities are wrong”
~Voltaire

In the recent orthopaedic press, the topic of professionalism has been brought up. The AAOS has put out new standards for professionalism on two topics, Advertising by Orthopaedic Surgeons and Orthopaedist-Industry Conflicts of Interest. This made me ask several questions. First, what is the definition of professionalism; even more important, what is medical professionalism? Second, have these views of professionalism changed and are they effected by the current changes in residencies today? The first question will be addressed in this post.

Most would say that professionalism should be inherently understood in medicine. It is clearly stated in the Hippocratic oath we take when we graduate medical school. But, most medical schools don't take the original Hippocratic oath; they take the abridged version. There are some that feel Hippocratic Oath is inadequate to address the realities of a medical world that has witnessed huge scientific, economic, political, and social changes, a world of legalized abortion, physician-assisted suicide, and pestilences unheard of in Hippocrates' time.

Hippocratic Oath -- Classical Version

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfil according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943.

Now compare this with the modern oath.

Hippocratic Oath—Modern Version

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.

Truly times have changed since the original oath was written. How have we adjusted things so that they fit modern days? This is yet to be seen.

So, what is considered a profession? One basic definition of a profession is an occupation, especially one which requires an advanced education. One more fitting for the medical profession itself is:

an occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.

Cruess, S.R, Johnston, S. and Cruess, R.L. ‘Profession’: A working definition for medical educators. Teaching and Learning in Medicine, 2004; 16: 74-76.

With this understanding of what the profession is, then what would the definition of professionalism be? Many would agree that humanistic values such as honesty and integrity, caring and compassion, altruism and empathy, respect for others, and trustworthiness, should be at the core of medical professionalism. The humanistic values are not a requisite to professional behavior, but the practice of medicine is a human endeavor. In an article by Swick titled Toward a normative definition of medical professionalism (Academic Medicine, 2000; 75: 612-616.), there was an attempt to put into words what should be a general understanding of what is considered to be professionalism. In this article, a number of points were made.

• Physicians subordinate their own interests to the interests of others;
• Physicians adhere to high ethical and moral standards:
• Physicians respond to societal needs, and their behaviors reflect a social contract with the communities served;
• Physicians evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for self, patients, peers, attendings, nurses, and other health care professionals;
• Physicians exercise accountability for themselves and for their colleagues;
• Physicians recognize when there is a conflict of interest to themselves, their patients, their practice
• Physicians demonstrate a continuing commitment to excellence;
• Physicians exhibit a commitment to scholarship and to advancing their field;
• Physicians must (are able to) deal effectively with high levels of complexity and uncertainty;
• Physicians reflect critically upon their actions and decisions and strive for IMPROVEMENT in all aspects of their work
• Professionalism incorporates the concept of one’s moral development
• The profession of medicine is a “self regulating” profession, dependent on the professional actions and moral development of its members; this concept includes one’s responsibility to the profession as a healer
• Professionalism includes receiving and responding to critiques from peers, students, colleagues, superiors
• Physicians must demonstrate sensitivity to multiple cultures
• Physicians must maintain competence in the body of knowledge for which they are responsible; they must have a commitment to life long learning

A document titled Medical Professionalism in the New Millennium: A Physician Charter (Ann Intern Med. 2002;136:243-246) set forth what they termed a set of commitments. This was put out by the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine and in this they stated there are three fundamental principles set the stage for the heart of the charter. In its preamble, they state that

Professionalism is the basis of medicine’s contract with society.

The three principles that make up this charter are:

1. Principle of primacy of patient welfare.
2. Principle of patient autonomy.
3. Principle of social justice.

Thcharter also sets forth some basic professional responsibilities.

• Commitment to professional competence.
• Commitment to honesty with patients.
• Commitment to patient confidentiality.
• Commitment to maintaining appropriate relations with patients.
• Commitment to improving quality of care.
• Commitment to improving access to care.
• Commitment to a just distribution of finite resources.
• Commitment to scientific knowledge.
• Commitment to maintaining trust by managing conflicts of interest.
• Commitment to professional responsibilities.

The summary of this document states:

The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges center on increasing disparities among the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform health care systems, and the temptation for physicians to forsake their traditional commitment to the privacy of patients’ interests. To maintain the fidelity of medicine’s social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an action agenda for the profession of medicine that is universal in scope and purpose.

The gauntlet has been set forth and the powers have established some rules of what should be considered professionalism. Do these hold up in our current times? Do the new generations of residents feel the same calling to medicine and dedication to their patients? Have our eyes been so clouded by the thoughts of work hour restrictions, CMS payment schedules, and increase in malpractice cases that we have forgotten our social obligation to our patients? The Hippocratic oath that we took upon our graduation, although it may not completely apply to todays medical climate, gives us some of the basic tenets under which we should practice. I don't have all the answers. We all are born in different eras and trained under different guidelines. We listen to different music and have different beliefs. But, we are all physicians. That we have in common. A common purpose to provide appropriate care to our patients with in the realm of our current knowledge. A common purpose to be professional.

“We often refuse to accept an idea merely because the tone of voice in which it has been expressed is unsympathetic to us.”
~ Friedrich Nietzsche

NEXT: Professionalism in medicine (part II)
Have these views of professionalism changed and are they effected by the current changes in residencies today?

"... there were horses, and a man on fire, and I killed a guy with a trident."

“When you have to kill a man it costs nothing to be polite.”

~Winston Churchill

I had some interesting comments on a previous post. A post that I didn't think would get anyone upset. OK, maybe one or two radiologists. It is all in fun. It was a bit of a rant or may be even a vent. Anyone who has worked in a hospital has had an experience where a service was being difficult. Patients being on your service instead of a more appropriate service. Orthopaedics is definitely one of the offending services. As a resident, I always appreciated when an attending went to bat for me. That was the basis of the post and not the actual argument.

For the young physicians, I do believe that those who are above them should take their side. Sometimes it feels like a war. Attendings are the leaders with residents and medical students being their soldiers. It got me thinking. The hospital is like a little war ground. Every service is fighting for their little piece of the pie. With that thought, I started another blog. Basically, it is a story about the battles between services. I call it the University Hospital Crusades. For anyone who is interested please visit and make suggestions of where you think these stories should go. It is an evolving story that will include all specialties. So for those who are not in orthopaedics, your suggestions will definitely be helpful to deter some of my surgery bias.

“I am prepared to die, but there is no cause for which I am prepared to kill.”

~Mahatma Gandhi

I still hate call ...

"Amor Fati – 'Love Your Fate', which is in fact your life.”

~Friedrich Nietzsche

After a long day in the OR, my chief resident asked me who was on call as we finish up or last case. As usual, I had no idea who was on call. I look down at my Motorola Q and check my calendar. July 25th Call. Damn. I inform my resident that I am on call. He informs me of a case in the ER. It is only 530pm so we should be able to get that done and I will be out of the OR and off to home for R&R.

We complete the case. I say to my anesthesiologist, I'll see you when you get back from vacation. I made the bad assumption that I would not have to come back tonight. Sniffle, I think I am getting a cold. I get dressed and grab my keys from the office. There are a ton of papers on my desk. I'll get to that tomorrow.

I start walking down the stairs to my car. I send a text my wife to grab me something from San Sai. Then, my phone rings. Dr. F. Why is he calling me? I am not on adult call.

Dr. F says, Yeah, Dr. P, there is an open ...

aaaaarrrrggghhh, I guess I can't push that off until the morning.

I got a coke and back to the OR.

I hate call. No matter how long I do it. Being called in never gets any easier, it may even get hard the older you get. Well, at least I didn't get called in right after I started to fall asleep. There are worse things in the world.

“Through humor, you can soften some of the worst blows that life delivers. And once you find laughter, no matter how painful your situation might be, you can survive it.”

~Bill Cosby

Imjussayin ...

As I have proposed previously, I think that there should be the additions the Webster's dictionary. Words such as FFT (fan-f#%k!n-tastic) and EFT (enter-f#%k!n-taining) should have their place in Websters. I can see I have a chance of making Webster's seeing that the word ginormous has just made it into the new dictionary. My next push will be for Imjussayin. Jump on the bandwagon now. We are about to make history.

PE's .... How do we know?

I ran across this post on Jerwin's ER about PE role out criteria. Although these criteria may not make it as standard here in the US. I thought it was applicable to orthopaedic surgeons.

The main goal of Pulmonary Embolism Rule-out Criteria (PERC) is to minimize unnecessary testing in PE, which is another way of saying, to prevent unnecessary ordering of D-dimer.

Please be aware that most of our guidelines for the prophylaxis and treatment of DVT and PE's comes from the American Academy of Chest Surgeons.

What do we do now?

“Real education must ultimately be limited to men

who insist on knowing, the rest is mere sheep-herding.”
~Ezra Pound

My son is here this week with is girlfriend. They are a cute couple. I wonder sometimes what she sees in him but I guess love is blind. Speaking with him last night I came to the realization that training residence is in someways like trying to lead you older children towards on path and away from another. Trying to keep them from making the same errors, misguided judgments, and just plain ole' stupid mistakes. You know the old mantra, "It seemed like a good idea at the time."

I am a bold face teacher. Sometimes I add in italics, but for the most part bold face. What is bold print teaching? I try to ask questions, referred to lovingly by med students and residents as pimping, that are helpful in guiding their learning, relevant to patient care, and commonly tested. Most of the questions I ask are in bold face in the text book. I will concede that sometimes my question is not as precise as I would like (the what am I thinking question), but for the most part I do OK.

This past week my partner was out of town, so I did a majority of the procedures this week. The residents were with me all week. It was kind of exhausting for me. I was running from place to place, clinic to clinic, OR to OR. The residents double teamed me. It just doesn't seem fair. Luckily this year it wasn't as busy as it was in the previous years. I was able to do a bit more teaching. Because I had a captive audience, I was able to teach en masse. It was busy and fun, at least for me.

Over dinner yesterday with my son and his girlfriend, it reminded me of the past 2 weeks. Asking what the future holds, trying to guide him down paths and not having much success. He may have considered my questions similar to pimping. For him, there were no bold face answers. Life is different. It is very much like a "box of chocolates." The thing that reminded me of this week wasn't the questioning; it was the blank look on his face. You know what I mean. It is that, I have no idea and if I stall long enough may be he will ask someone else or just tell me.

This week was a plethora of learning and growth this week. Because I was the only one there most of the time, I was able to teach 2-3 of the residents at the same time. I could actually feel the learning. It was great. Doing cases this week, I think my residents realized that it is not as easy as it sometimes looks and that you can't learn everything from the book. As I have said before, I feel like a conductor. My role is to guide them, to give them the tools and the knowledge for future practice. I can't give them all the answers. They will have to learn that over time. I watched them struggle this week. Case after case, I found myself bailing them out of different situations. They made no real errors; they were just having difficulty making it "look easy." They kept giving me that blank look. The "what do we do now" look.

In medicine and in life, I don't think I know any more than the next person. There are some people who know more and others who know less. I am sure of one thing, I know what I know. I understand the limits of my knowledge base and my experience. I try to pass on to my residents my clinical experience and to my son my life experience in order to keep them from making the same mistakes and errors I have made. There are times I succeed and other times I fail. I just hope that one day their faces will be filled with the all the answers.

“I never teach my pupils; I only attempt to provide
the conditions in which they can learn.”
~Albert Einstein

Why does radiology have to be difficult?

“When angry, count to four. When very angry, swear.”
~Mark Twain

With orthopaedics being a high volume user of radiology, you would think that they wouldn't give you such a hard time when ordering studies. I understand that I am in an academic center and other services have residents calling for studies without an attending even seeing the patient. But, that is not how I roll. So, today I had to lay the smack down on a attending radiologist. When another service disrespects my residents, it makes me go volcano. So, here's the brief story.

I was minding my own business when 2 dudes ... oh sorry, that's a trauma story. Let me start again.

I am in clinic seeing my usual Monday morning 35 patients. I have a patient come in with a complaint of one foot problem (foot turning in) and we find another problem (probable PFFD). The mom is a poor historian and we have no charts from the outside hospital. On clinical exam, the patient just doesn't look right. He had dysmorphic facies and lower extremity anomalies. Something just wasn't right with this kid. We obtain the x-rays and realize that the other leg, which mom is not complaining about, has no hip. I further questioned the mother about his past medical history without any more information gathered. I thought about it and thought well how do I further evaluate this hip. I could do and MRI, Arthrogram, or an Ultrasound. Probably the least expensive and risky procedure would be an ultrasound. I ordered it and asked my nurse to see if it could be done today. I didn't think it would be such a big deal. Do the ultrasound and send the patient home with follow-up. Yeah, but no such luck.

As I go in and out of rooms, I hear my nurse trying to get things set up. There is some kind of back and forth. Then I hear they want to talk to the doctor. I said, OK; but my resident said he was all over is. I went into the next room. I come out again and my resident and nurse are saying how they don't want to do it because the kid is to old and they won't be able to see anything and yada yada yada. He gave one excuse after another. My resident said well Dr. P would like this done because it would be the most helpful and repeated what I had told him (this was confirmed by 2 others in the room at the time of the conversation). The radiologist said well I don't care what he wants, so forth and so on. (pause) "Oh no he didn't."

So, I walk over to radiology clinic. I walk into the reading area where 2 radiologists are reading films. I can't say everything I said. But, let's say if it was on TV it would have been bleeped out. I chewed him out for being rude to both my nurse and resident and for being a general @ss&*!#. The other radiologist got scatter from the fray as he tried to chime in on the case. I asked the just to do their f#%k!ng job and stop trying to act as if they are actually providing useful patient care. They should do the procedures they are asked to do like good technicians. In the end, I got my point across and the proper test was done.

Radiologists are like shadow merchants offering one expensive procedure after another and waffling on every diagnosis. They are like pathologists who need just one more stain or immunofluorescence to make the waffle diagnosis. Have some balls, make the call, and stop giving those who actually are taking care of the patients such a hard time.

"Anger is never without a reason, but seldom with a good one”
~Benjamin Franklin

PS. I actually have a lot of love for my radiology and pathology colleagues.