From the Department of the Maximally Self-Righteous comes this delightful little piece of scholarship, a letter to the Journal of the American Medical Association (JAMA) that describes a survey of internal medicine interns on the subject of professionalism. In it, participants were asked to rate their participation in and perception of “unprofessional behaviors” related to residency. The survey* was created based on the input of third-year medical students, residents, and faculty, and was administered in the first three months of the subjects’ intern years.
Among behaviors rated as most unprofessional by the participating interns were: discussing patient information in public spaces (yeah, that’s a no-brainer); falsification of patient records (illegal, and bad medicine); reporting patient information as normal when uncertain of true results (dumb); not alerting the patient that the individual [made] an error (not always helpful, especially if it didn’t result in harm, but certainly ethically reasonable); making fun of patients to colleagues (poor form, indee–wait, what?).
I mean, WHAT?
In my most recent encounter with “unprofessionalism,” the word seemed to be usable interchangeably with “being human.” The JAMA survey only confirms my sense that professionalism in medicine has come to represent a romantic fantasy–and worse, that we’ve invented that fantasy, ourselves.
The Accreditation Council for Graduate Medical Education–the people who accredit residency programs–now has requirements for residency programs based around six “core competencies,” one of which is professionalism. In this competency, they mandate, residents should be able to demonstrate the following:
1) compassion, integrity, and respect for others;
2) responsiveness to patient needs that supersedes self-interest;
3) respect for patient privacy and autonomy;
4) accountability to patients, society and the profession; and,
5) sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.
Sounds mostly reasonable, right? Except for that pesky item two, which suggests that to be a good doctor, I need to routinely prioritize patients’ needs above my own. With this as our model, is it any wonder physician burnout is a problem? What other profession–other than maybe the priesthood–would willfully submit to this?
After my unfortunate experience a month ago, I felt certain that the unrealistic model of medical professionalism was the responsibility of several vocal, unreasonably demanding patient advocates. As customers, I was certain, they felt they were always right–and since no one ever told them otherwise, they became right by default.
On the fringes of the JAMA study lurks a different story, however: we have unreasonable expectations of ourselves. Perhaps we even enter the medical profession because of those unreasonable expectations: if we become everything we dream of being, after all, we will be suprahuman–we will be gods.
The truth is, it’s hard, and not much fun, to be suprahuman while still being an actual human. Actual human residents see a patient population that is incredibly dysfunctional and often abusive of the medical system and its employees. At times, there is only one way to really unpack the madness that accumulates after taking a few blows: judging harshly, while snickering, over beers. The day I am told that’s unprofessional by anyone who’s been in practice longer than three months is the day I poke a motherfucker in the eye.
Venting about the people that make-a you crazy is part of being a functional person. So is prioritizing your own needs over those of a patient. It is possible to be a compassionate, meticulous, attentive doctor while doing those things, but I’m not sure how possible it is to be a functional human without doing them.
*I’ve got some issues with the survey (especially the boy-girl stuff: why is “unprofessional dress” equivalent to “sexy and provocative” for women and “messy” for men? What is it, 1950?), but we can fight about that at another time.