When I was 22 I was camping in the Pacific Northwest and broke my arm. I was a student with no health insurance and no money. I went to a couple of emergency rooms in the small towns in the area and all of them told me they couldn't treat me. Finally I found a physician—not an orthopedic surgeon—probably an internist—who would see me. We both scanned a book about fractures to see how to set my arm. When asked by his office staff how to code the bill, he said code it “H” for humanitarian.
This one example of medical professionalism was a defining moment for me. It led me to medical school. The combination of independence, intellectual curiosity and a higher purpose that this one physician exemplified was enough for me. It was why I became a physician. It was also one of the best examples of medical professionalism I've experienced in my decades' long career.
Often, the term physician professionalism is used to describe the motivations behind physician behavior—a physician's unique ability to see beyond personal self-interest or comfort—and do what is right for their patient and their community. Professionalism has at its heart a fundamental core—the idea that physicians are led by an intrinsic motivation to do their best for their patients.
On the flipside of the generous doctor noted above, all of us who practice medicine have seen the other side of the coin. Physicians who deride colleagues, who perform impaired, who lack the cognitive skills necessary to practice. These transgressions—or “unprofessional” behavior—undermine our ability to deliver on our promise to our patients and our communities. As a profession—have we done enough to address these shortcomings? Have we done enough to train physicians live up to the ideals embodied in the Hippocratic oath? Have we codified behaviors that are unacceptable?
What has characterized the definitions of professionalism in the past century was that it was defined, and controlled by the profession itself, primarily through its professional associations. Many outside the profession, however, have little understanding of the term. Some have dismissed the concept as a shield for physicians against criticism and action. They are concerned that professionalism equals “just trust us.” In some ways, those worries are well-founded. We all know of shocking lapses in reporting and sanctioning of impaired colleagues—which get dismissed as “unprofessional behavior” and not remediated. These are the kinds of shortcomings that made even the term “professionalism” subject to suspicion from those outside the profession.
Attempts to codify the term—and bring into focus the core responsibilities of medical professionalism—were undertaken by a triumvirate of physician organizations in 2001: the ABIM Foundation, American College of Physicians Foundation, and the European Federation of Internal Medicine. Medical Professionalism in the New Millennium: A Physician Charter was written to provide affirmative expectations of professionalism—a definition if you will. While initiated by internists, the Physician Charter was endorsed by every specialty, and by medical organizations throughout the world.
The Charter remains alive more than a decade later and has spawned a rich and growing literature examining the meaning of this modern concept of professionalism. The Charter's impact in the contemporary practice of medicine is its usefulness for patients and for physicians in establishing a clear social contract needed in the twenty-first century. New realities in health care include expectations of transparency about errors and gaps in quality of care, expectations of patient experience as a key aspect to defining quality of care and of the patient voice as an essential one at every table. These new definitions of professionalism don't change the fundamental principle of devotion to the patient's well-being. But they reshape professionalism as embracing a full understanding of the patient's values, of the responsibility to make information available more broadly to consumers and purchasers, and the demand for continuous improvement.
In some ways the Charter is the proud father of this book. But this book takes the concept further than the Charter ever could.
There is growing awareness that institutions and organizations can create environments that foster professionalism, or they can create barriers to professional behavior. For organizations that want to improve quality of care, that want to create teams, that want to provide high value care, while reducing waste—professionalism can be an effectively lever for change. We have seen this with the national Choosing Wisely® campaign where leaders in medical specialties have called out tests and procedures that may be unnecessary—potentially undercutting reimbursements in the process. Their commitment to their patients and the health care system overrides their self-interest. Their professionalism drives this important effort.
With the growing emphasis on the value of systems in coordinating care, it is vitally important for health care organizations to consider their policies and their culture as key to advancing and supporting positive motivations of the professionals who work within their frameworks. This book is the first to place so firmly this responsibility with institutional leaders, and to include key practical considerations within every chapter.
In this past decade, scholarship on the topic of professionalism has expanded exponentially. But it is hard for the student, resident or fellow, or anyone in a busy practice to review this extensive literature and easily understand its implications for how they practice every day. In addition, health system leaders do not yet understand the link between physician leadership and professionalism and quality improvements.
Levinson and her colleagues have provided an extraordinary service to the profession, to health system leaders, to patients, and to society, in creating this important book. While built on the deep scholarship of philosophers and sociologists, and integrated with evidence on motivation, behavior, and learning it is accessible and actionable and focuses ultimately on what matters most to physicians—how to deliver the highest quality care possible.
President and CEO, National Quality Forum
Immediate Past President and CEO,
American Board of Internal Medicine and ABIM Foundation