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.
- Log in to post comments
The questions raised by your posting have often troubled me. I want to be a doctor in order to help people, but it seems to me that if a balance is not struck between taking care of others and taking care of oneself, to what what degree can one realistically be capable of caring for others in the best possible manner? If a doctor is not as well rested as needed, or has not taken time out for themselves or their family, how can they be focused adequately on the patient? The fact that surgery residents, who have been on call the prior 24 hours, are performing potentially life-saving operations when they are not at their best scares the shit out of me! Coming to the OR with bags under your bloodshot eyes in a cranky mood likely instills little confidence in the patients and their families regarding the care they are about to receive. I understand that residency is an education, but if medicine TRULY is about helping the patient and minimizing harm, post-graduate programs should take initiative to keep their doctors in the best possible shape (physically and mentally) so that they are able to meet the expectations of top-notch care. Putting your work ahead of your own well-being on a regular basis may result in colleagues praising your work ethic and dedication, but it will likely result in bad medical practice as well, and that defeats the whole purpose of being a doctor.
I'm sure that these so called data are purely anecdotal, have identified a few bad actors and could not possibly be indicative of a systematic problem. I read doctor blogs, you see, and they assure me that all is well. These authors must have simply been jealous or had some axe to grind or perhaps just have personality defects.
HTH, HAND.
"What other profession would willfully..."?
Answer: Nursing!
Word. Yeah, you guys are at least as crazy as we are. Less pay, and more getting kicked around (and not just during training). At least you actually get to spend some time with patients.
Professionalism is like pornography. You know it when you see it. And it is so nebulous, so it's easy to criticize people for being "unprofessional" which turns into "doing something I don't like." You magically become "professional" when you graduate from residency.
"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."
I wonder if we can get this on the scienceblogs portal page...
Thanks for the thought, moneduloides, but I have no control over what goes on the portal page. Also, I'm not sure how thrilled the overlords would be with showcasing my pottymouth.
In the legal profession, the ethical requirement is not that one prioritize one's client's needs above one's own. Rather, the requirement is that one not make decisions relating to the client's representation on bases that are based on the attorney's own self interest. What troubles me--and I think you--is the "responsiveness" language. Attorneys and physicians should not make decisions about their representation/treatment of their clients/patients on any basis other than the best interest of the clients/patients. But, other than in emergent situations, I agree that professionals should not owe their clients/patients a duty of "responsiveness" that rises to a level beyond "reasonable". And "superseding self interest" goes beyond reasonable.
Medical professionalism, as defined by the ACGME, is unattainable. I think it would be fun to do a survey of our own of other docs and ask them to define professionalism. Wouldn't that be eye-opening.
Thanks for posting this.
I am glad you recognized her dread about pronouncement as something more than paperwork. One part of my residency I loved was the once a week the hospital chaplain/counselor/ethics professor would round with us.
Word. Yeah, you guys are at least as crazy as we are. Less pay, and more getting kicked around (and not just during training). At least you actually get to spend some time with patients.
I understand that residency is an education, but if medicine TRULY is about helping the patient and minimizing I read doctor blogs, you see, and they assure me that all is well.
I understand that residency is an education, but if medicine TRULY is about helping the patient and minimizing I read doctor blogs, you see, and they assure me that all is well.