The Professionalism Paradigm: Physician Conduct and Patient Care in Changing Times

by
  • Matevosian, Rima, MD
| Jan 09, 2012

A colleague recently shared her experience about undergoing a routine procedure at a local surgical center. She joked that her anesthesiologist spent only brief moments with her prior to the procedure and went on to describe how the anesthesiologist appeared in the operating room only moments before the case began: their interaction was limited to being instructed to count backwards from ten. Conspicuously absent from her description was a pre-procedure examination and interview, or anything approaching a follow-up to ensure that her recovery was on schedule, and that there were no complications from the operation.

My initial reaction of surprise quickly yielded to sadness—for me, the critical, perioperative care our specialty provides is amongst the most satisfying—and important—aspects of being an anesthesiologist. Moreover, the opportunity to interact with and comfort a patient in their time of greatest need is the very meaning of being a physician.

“I still don’t know his name,” she quipped, letting the words linger in the air, even as she left to scrub in for her next case, leaving me to consider the meaning of professionalism, patient care and the implications for the future.

As physicians, we are justifiably held to a high standard by the society we serve, afforded considerable privileges and autonomy in exchange for performing our duties diligently, and with the best interests of the patient—and the public—at heart. This “social contract” provides the foundation and context for professionalism and professional conduct.

In this respect, professionalism is the means by which physicians honor and maintain their contract with society, having as its hallmarks compassion, respect, integrity, accountability, and a commitment to excellence and duty. In practice, the application of these values will necessarily differ from one setting to another—available resources, clinical conditions, and the characteristics of the patient population being served influences the specific ways in which doctors manifest their commitment to professionalism, but the underlying principles remain the same.

Recognizing the importance of this understanding to the continued prominence of medicine and medical training, the Accreditation Council for Graduate Medical Education (ACGME) introduced professionalism as one of its six general competencies that must be imparted during clinical training or residency. That same year, a collaborative Medical Professionalism Project defined three key concepts of professionalism—the primacy of patient welfare, shared decision-making, and an emphasis on social justice and the fair distribution of (limited) health-care resources. The Charter continues to describe ten categories of responsibility essential to professional conduct in medicine, ranging from advanced scientific knowledge and a commitment to fulfilling the obligations imposed by the profession, to more abstract concepts such as honesty, respect for confidentiality, and dedication to improving both the availability and quality of care.

The challenge of translating these lofty ideals and concepts into actionable, measurable elements of clinical practice is significant. Professionalism necessarily speaks to values and behaviors, not technical skills or clinical knowledge—as a consequence, providing meaningful feedback to newly-minted physicians, medical students and interns can prove challenging, if not intimidating. The natural reluctance to comment disparagingly on a student or colleague’s values is in stark contrast to the constant evaluation and critique of technical skills. Likewise, behaviors cannot be described as deficient with the same empirical certainty as clinical knowledge or acumen, and as a result, deviations from best practices are seldom brought to light barring a medical error—and by then, it’s too late to take corrective measures.

My colleague’s recent experience is illustrative—while the technical skills and quality of clinical care were satisfactory, the behaviors exhibited during her case were decidedly inconsistent with the hallmarks of professional conduct.

Taking the time to perform a thorough examination and interview of the patient accomplishes several critical functions, including identification of potential complications or extenuating circumstances, vital to assessing a patient and recommending a suitable plan of action. The pre-operative assessment serves to establish patient rapport that cannot be replicated through telephone conversations or chart review. As physicians entrusted with the care and well-being of our patients, this responsibility is solemn and cannot be overlooked for the sake of expediency, or because “it’s a routine procedure.”

In a similar spirit, providing diligent follow-up and aftercare affirms the continued engagement of the physician in providing treatment, provides a forum to ask any questions that may have arisen, and enables the physician to make further recommendations on care. The active engagement of the physician throughout the entire continuum of care effectively “closes the loop” on an operative case, and can have a significant impact limiting liability while enabling the early identification of surgical site infections or other complications. Most importantly, diligent follow-through imparts a sense of comfort to the patient, through the knowledge that their well-being has been and continues to be under the management of a trained expert.

By taking ownership of a case well before a patient is wheeled into the operating room, anesthesiologists can provide a significant added value in patient care, but also demonstrate the role of our specialty to the broader community of our hospitals or medical groups, helping to debunk the widely-held and outrageous opinion that the role of the anesthesiologist is limited to the administration of anesthesia.

These considerations require no particular clinical expertise, advanced medical knowledge or experience, yet are perhaps more important than the technical acumen we apply for the benefit of our patients. With the changing landscape of medical practice and the promise of further changes in the near future, the challenges to providing patient-centered care are increasingly diverse, insidious and pronounced. As physicians, we must conceive, adopt and apply a new professionalism with compassion, integrity, and an unwavering commitment to patient care as its hallmarks. By recalling that the origin of professionalism is the profession itself, and never losing sight of the special role that physicians play in our society, we serve to remind ourselves of the profound trust and responsibility instilled in us, and the promise of service and duty to the patients in our care.

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