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
