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Indian Pediatr 2018;55: 193-195

Beneath the White Coat

 

Santosh T Soans

National President, Indian Academy of Pediatrics, 2018.
Email: drsoans62@gmail.com


T
he White Coat that each of us learned to wear while at medical school is the unmistakable symbol of the doctor’s profession. It was introduced as part of our professional attire sometime in the late 1800’s as a symbol of cleanliness. That was the time when modern medicine was gaining respect as a scientific discipline, and there was a great need to distinguish it from quackery and mysticism. Hence to emphasize the transition to the more scientific approach practiced in modern medicine, physicians sought to represent themselves as scientists, and began to wear the most recognizable symbol of the scientist – the white laboratory coat. Today it is the distinctive dress of physicians and surgeons, which often stereotyped in representing our profession in popular culture ranging from cinema to advertising.

However, wearing the white coat itself in no way makes us into better practitioners of our profession than for that matter, merely possessing the relevant university degree. Indeed, the standards that determine our professionalism run much deeper than the external markers. So what are these precious elements that mark us out as professionals? And what is it that we can all do to make ourselves into true professionals?

Defining Professionalism

The dictionary defines professionalism as "the practicing of an activity by professional rather than amateur players." Yet another definition goes on to say that "professionalism is skill or behavior that goes beyond what an ordinary person would have or behaving in a more formal or business-like manner." In ordinary parlance, we understand professionalism as the act of extending an expert service in exchange for a financial consideration. In short, we are paid for rendering our expertise within business-like settings. However, relying on dictionary definitions to determine our professional conduct would be to skim the surface. Such definitions should only serve as an overall framework for us to lead to a better understanding of the subject.

A Historical Perspective

In exploring the subject, we might be tempted to view ourselves as products of a modern era, and that the idea of professionalism is the outcome of 20th century thinking. Yet, the very first thing we do on entering the profession lays bare the historical depths in which this concept is rooted. The Hippocratic Oath that we commit ourselves to, which can be dated to as far back as the 3rd century BC, is one of the first declarations of the professional aspirations of the healing science.

Similarly, the unique concept of mentoring of juniors by the more experienced seniors of the profession, the evolution of protocol-based treatment regimen, the practice of continuing medical education and the proliferation of knowledge through peer-reviewed academic literature are some of the other means by which medicine has tried to establish professional formats that seek to ensure standardized delivery of healthcare at the applied level and present medical science as an integrated discipline before the patient community.

Professionalism vs. Ethics

While it is easy to confuse the one for the other, the moot question to ask is: are they in fact one and the same? From a practical perspective, ethics can be considered as guidelines for individuals, which clearly state the dos and don’ts. Ethics exists in many contexts and pertains more to acceptable and unacceptable behaviors in individual situations. Professionalism, on the other hand, refers to the skills, the competency levels and the conduct displayed by an individual within the larger context of a certain profession. Thus professionalism is a wider umbrella within which ethics also operates. In order to be professional, one should also be ethical; but being ethical alone does not increase one’s professionalism. Hence for the purpose of this article, let us focus only on professionalism; the question of ethics is something that I hope to touch upon at a future juncture.

The Four Pillars of Professionalism

The Indian Academy of Pediatrics in its mission statement professes to "provide and promote ethical and professional standards among the members." The American Board of Pediatrics (ABP) endorses the Physician Charter, also known as the Charter on Medical Professionalism. Quoting ‘Medical Professionalism in the New Millennium: A Physician Charter’ on the theme, it states that "Professionalism is the basis of medicine’s contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health [1]."

I consider the following as four pillars of professionalism that every medical professional should follow:

1. Trustability and Reliability: The foundation for doctor-patient relationship is personal trust. When compared to other professions, medicine is considered to be one of the trusted professions. But this notion is taking a beating these days. In an article published in The New York Times on January 23, 2018 entitled ‘Do You Trust the Medical Profession?’, Dhruv Khullar writes: "In 1966, more than three-fourths of Americans had great confidence in medical leaders; today, only 34 percent do. Compared with people in other developed countries, Americans are considerably less likely to trust doctors, and only a quarter express confidence in the health system [2]."

In India too, we are witnessing a drastic decline in public confidence in doctors. We have only ourselves to blame for this sad outcome. With rampant commercialization of the profession, we have become unwitting contributors to people’s negative perception of us. It is about time we regained lost ground and earned the trust before it gets forfeited forever. For this to happen, we should take pains to ensure that the patient sees us as having their interest foremost at heart. In India, fortunately the referral system is still the basis for the initial doctor-patient contact. So we are already starting on a positive note. It is up to us to take it forward from there. Exhibiting personal integrity, practicing truthful communication, and displaying sensitivity to patient needs and sensibilities plays a great role in this regard. Treat patient trust as sacrosanct, and do everything it takes to honor it.

2. Competence and Excellence: Patients seek us out for rendering our services primarily because they see us as experts in our respective domains. So it is imperative that we live up to this promise by keeping ourselves updated on our knowledge, which should be the latest and the best. Excellence is a fast moving target and we need to keep pace with it through continuous endeavor at updating our knowledge and skill base. Wide clinical exposure, constant reading and participating in CMEs, academic interaction with peers, and insightful engagement with patients are the means by which our competence gets sharpened in real time. Failure to do so would prove disastrous to our professional standing in the long run.

3. Appearance and Demeanor: There was a time not long along when intellectual arrogance was considered fashionable even among the medical community. A doctor could get away with acting busy or even verbally abusing patients who are annoying or not likeable. Today the tables are reversed, and it is considered unprofessional to be unfriendly with patients. That the demand is more so for pediatricians who deal with children goes without saying. Being well groomed and maintaining friendly and approachable demeanor is vital to the equation. Cultivating patience, civility and basic good manners go with the job today. So is keeping a professional distance, and remaining open, yet non-intrusive. Striking this balance between being personal and being professional at the same time is a huge challenge. But then the patient is with us out of choice and this position is inviolable.

4. Organization and Accountability: This has more to do with the logistics of maintaining one’s practice. Having the right secretarial assistance to see that appointments are met and that the documentation maintained is available at the press of a button serves to highlight one’s professional decorum. Neat and clean premises, confidence-building ambience, comforts in the waiting room plus clinically and socially well trained human assistance are the essentials of the doctor’s eco-system. The ability to explain a clinical decision when called for, and the humility to accept when one is at fault add to one’s paradigm of accountability in the profession.

Role of Medical Education

With the idea of medical professionalism getting deeply embedded in the contemporary social environment, it would be a grave mistake not to instill this in the upcoming generation of healthcare professionals. It is only in the last two decades or so that the subject of medical professionalism is getting some sort of mention in the medical education system. The focus so far had only been on developing technical competency among the medical students, and professionalism was something that one had to learn on the job. While the curriculum these days does touch upon cultivating professionalism, the effort in this regard is simply not enough.

As Shrank, et al. [3] commented: "Unfortunately, the culture of academic medical centers and the behaviors that faculty model are often incongruent with our image of professionalism." Authors further proposed that "the incentive structure be adjusted to reward professional behavior in both students and faculty" and that "the next critical step is the assessment of professionalism and the construction of incentives that demonstrate that the profession truly values these qualities [3]."

In the final analysis, professionalism is not just a set of commitments but more so an attitude. But as David H. Maister, a former Harvard Business School professor and management expert implies, the proof of the pudding is in the eating. Says he in his book ‘True Professionalism’: "Professional is not a label you give yourself. It’s a description you hope others will apply to you. You do the best you can as a matter of self-respect. Having self-respect is the key to earning respect and trust from others. If you want to be trusted and respected you have to earn it. These behaviors lead to job fulfillment [4]."

Professionals take pride in their work. Be proud to be a doctor and a pediatrician.

References

1. The American Board of Pediatrics. Medical Professionalism. Available from: https://www.abp.org/content/medical-professionalism. Accessed February 15, 2018.

2. Khullar D. Do You Trust the Medical Profession? The New York Times, January 23, 2018. Available from: https://www.nytimes.com/2018/01/23/upshot/do-you-trust-the-medical-profession.html. Accessed February 15, 2018.

3. Shrank WH, Reed VA, Jernstedt GC. Fostering professionalism in medical education: A call for improved assessment and meaningful incentives. J Gen Intern Med. 2004;19:887-92.

4. Maister DH. True Professionalism: The Courage to Care about Your People, Your Clients, and Your Career. New York: Simon & Schuster, 1997.

 

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