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Viewpoint: The Elephant in Medical Professionalism???s Kitchen
Abstract
The rise of the corporation within health care during the 1980s and early 1990s was met by organized medicine with a deluge of editorials, articles, and books that identified a singular enemy--commercialism--and depicted it as corrosive of, and antithetical to, medical professionalism. Medicine's ire proved prognostic as scores of highly publicized corporate-medical scandals began to crater the landscape of a rapidly emerging "medical marketplace." Medicine's main weapon in this counteroffensive was a renewed call to medical professionalism. Numerous organizations hosted conferences and underwrote initiatives to define, measure, and ultimately inculcate professionalism as a core medical competency. Nonetheless, an examination of medicine's overall response to the threat of commercialism reveals inconsistencies and schisms between these praiseworthy efforts and a parallel absence of action at the community practitioner and peer-review levels. The most recent salvo in this war on commercialism is a policy proposal by influential medical leaders who call for an end to the market incentives linking academic health centers and medical schools with industry. These forthright proposals nevertheless appear once again not to address the heartbeat of professional social control: community-based peer review, including a vigorous and proactive role by state medical boards. The author concludes by examining the implications of a professionalism bereft of peer review and explores the societal-level responsibilities of organized medicine to protect, nurture, and expand the role of the physician to maintain the values and ideals of professionalism against the countervailing social forces of the free market and bureaucracy.
... During our conversations two issues in particular suggested the latter: the increasing relevance that lifestyle and personal morality seem to play in the professional behavior of medical students and medical residents (e.g., Rippe, 1999;Wear & Castellani, 2002), and the extent to which the professionalism of practicing physicians seems to be infused with an "entrepreneurial" spirit (e.g. Hafferty, 2005). It appeared to us that both of these factors were not just diminishing the current discourse on professionalism, but seemed to be the basis for entirely new ways of practicing professionalism. ...
... What changed in the 1980s was Wall Street's discovery of clinical medicine as a profit center, which reinvigorated an ethic of commercialism in the examination and operating rooms of clinical medicine, legitimating the desire of a significant number of physicians to ground their professionalism in the ethics of business. And so was born entrepreneurial professionalism (e.g., Hafferty, 2004Hafferty, , 2005. ...
... Entrepreneurial professionalism is comprised of physicians from just about every area of medicine, ranging from physicians who started their own specialty surgery or imaging centers to those practicing boutique and retainer medicine, to those performing vanity plastic surgery or selling Amway products in their offices (e.g., Hafferty, 2005). Despite these differences, the theme of this cluster is consistent. ...
Efforts within organized medicine over the last twenty years to reestablish an ethic of professionalism have obscured the fact that currently there are several competing clusters or types of medical professionalism, each of which represents a unique approach to medical work. Stated differently, the "professionalism" that has emerged within the academic medical journals, conferences, debates, and discussions over the past twenty years is a highly selective and privileged narrative, developed and delivered by one, possibly two, particular strata within the organizational structure of medicine. We call this strata the ruling class of medicine, and we refer to its medical professionalism as nostalgic. The other clusters of medical professionalism that we empirically "discovered" include entrepreneurial, empirical, lifestyle, unreflective, academic, and activist professionalism. The development of this seven-cluster system of medical professionalism was by no means an accident. Instead, it was the direct result of our involvement in the new science of complexity (e.g., Axelrod, 1997; Bak, 1999; Capra, 1996; Cilliers, 1998; Holland, 1998). Specifically, we are in the process of developing our own theoretical and methodological framework, which we applied to the current study. The purpose of this chapter is to introduce readers to a more "complex" medical professionalism. To do so, we begin with a quick overview of the theory and method we developed, along with the historical archive we used to conduct our empirical analyses. Next, we review the five important ways the theory and method helped us to recognize, discover, analyze and assemble medical professionalism as a complex social system, including a thick description of the seven clusters we discovered. We conclude by putting the complex social system of medical professionalism together, reflecting on the insights our results have for the future teaching and evaluation of professionalism.
... The rise of commercialism in healthcare and the formation of a healthcare marketplace is not reserved for dentistry, but has been noted in other fields. As an example, Hafferty [116] described the pervasiveness of medical commercialism by stating that "medicine's traditional 'one or two bad apples' has morphed into a megaorchard of physician clinicians and researchers, brimming with commercial proclivities, penchants, and practices" [116]. Such developments clearly pose a threat to the survival of the core professional privileges, which include discretionary decision making, occupational autonomy and the right to control recruitment, training and credentialing of new professionals. ...
... The rise of commercialism in healthcare and the formation of a healthcare marketplace is not reserved for dentistry, but has been noted in other fields. As an example, Hafferty [116] described the pervasiveness of medical commercialism by stating that "medicine's traditional 'one or two bad apples' has morphed into a megaorchard of physician clinicians and researchers, brimming with commercial proclivities, penchants, and practices" [116]. Such developments clearly pose a threat to the survival of the core professional privileges, which include discretionary decision making, occupational autonomy and the right to control recruitment, training and credentialing of new professionals. ...
... Noting that the heart of what professionalism must defend is the economic privilege that follows from professionalism's monopoly over its knowledge base, Freidson [117] predicted that unless current trends are opposed, the professionals are on a course of changing into neutral technical experts serving the needs of state and capital, which will increasingly gain control over performance and costs. Both Hafferty [116] and Freidson [117] noted how the "conspicuous absence of activities conscientiously enforcing professional codes of ethics" has contributed to the vulnerability of the healthcare professions to attacks, and they conclude that the core of professionalism is the devotion to use disciplined knowledge for the public good. ...
This aim of this paper is to spur a discussion of the direction of caries-lesion detection activities in clinical dental practice. It is argued that since the dental clinician's caries-related decision making is a script-matching enterprise in which clinical decisions are made on the basis of 'this-lesion-needs-this-kind-of-treatment' reasoning, the methods and strategies employed for caries lesion detection should accommodate this fact. This may be done by employing a clinical visual-tactile method for caries lesion detection that evaluates the two aspects that are crucial for appropriate caries management: lesion activity and surface integrity. The use of diagnostic methods that do not assess these features directly but involve assumptions about activity status and surface integrity should be avoided. This includes the use of bite-wing radiography for the detection of approximal caries lesions, as it may be shown that plain reliance on radiographs leads to considerable overtreatment. If clinical dentistry is to retain its status as a profession committed to doing good, changes in diagnostic practices along these lines are warranted.
... Over the last century health care systems worldwide have transformed from a servicefocused profession to a commercialised industry (Hafferty, 2006), and Vietnam is no exception. In 1986 the Vietnamese Government introduced the economic reform known as Doi Moi, which transformed the Vietnamese economy from a socialist, predominantly subsidised economy to a market economy (Beresford, 2008;Ladinsky, Nguyen, & Volk, 2000;Segall et al., 2002;Witter, 1996). ...
... For instance, there is now a greater emphasis on the professional and personal development of physicians (Hatem, 2003), and an increased importance on financial reward and monetary incentives (Reynolds, 1994;Swick, Bryan, & Longo, 2006). Most of these changes have been seen as undermining the very essence of medical professional values (Hafferty, 2006;Relman, 1998;Swick et al., 2006), creating a fear that physicians will no longer place patient and society needs above their own (Hilton & Slotnick, 2005). For example, physician prescribing habits and professional behaviour have been found to be influenced by physician's interactions with pharmaceutical companies (Chew et al., 2000;Lexchin, 1993;Orlowski & Wateska, 1992;Wazana, 2000). ...
Physician values influence a physician's clinical practice and level of medical professionalism. Currently, there is no psychometrically valid scale to assess physician values in Vietnam. This study assessed the initial validity and reliability of the Vietnamese Physician Professional Values Scale (VPPVS). Hartung's original Physician Values in Practice Scale (PVIPS) was translated from English into Vietnamese and adapted to reflect the cultural values of Vietnamese physicians. A sample of clinical experts reviewed the VPPVS to ensure face and content validity of the scale, resulting in a draft 37-item measure. A cross-sectional survey of 1086 physicians from Hanoi, Hue and Ho Chi Minh City completed a self-report survey, which included the draft of the VPPVS. Exploratory Factor Analysis was used to assess construct validity, resulting in 35 items assessing physician's professional values across five main factors: lifestyle, professionalism, prestige, management and finance. The final five-factor scale illustrated acceptable internal consistency, with Cronbach's alpha coefficients ranging from 0.73 to 0.86 and all item-total correlations >0.2. Limited floor or ceiling effects were found. This study supports the application of the VPPVS to measure medical professional values of Vietnamese physicians. Future studies should further assess the psychometric properties of the VPPVS using large samples.
... In the extensive literature on professionalism, there is a sociological critique of the concept's tendency to nostalgia (Erde 2008;Hafferty 2006b;Hafferty and Levinson 2008), but critical attention has not been paid to social contract theory as a philosophical source for our understanding of the place of medicine in society. In this article, I describe how educators and clinicians use the concept of a social contract as a heuristic to promote reflection on social expectations of the profession. ...
... (The list of bargained goods is longer in other writings of the Cruesses, extending to lifestyle considerations and financial remuneration, and the number of "contracts" multiplies as various stakeholders are distinguished; Cruess and Cruess 2008). Some have praised the potential of this framework to situate professionalism in terms of the relationship between medicine and society (Hafferty 2006b).The idea of the social contract takes the profession beyond an individualistic conception of professionalism, and brings to the fore questions of social context and social responsibility.The way it construes social responsibility, however, carries a specific history of bargaining for professional autonomy: the public rejected that bargain in the political sphere, but the idea of a bargaining stance vis-à-vis society reemerged in the final CanMEDS competency profile. ...
Conceptions of professionalism in medicine draw on social contract theory; its strengths and weaknesses play out in how we reason about professionalism. The social contract metaphor may be a heuristic device prompting reflection on social responsibility, and as such is appealing: it encourages reasoning about privilege and responsibility, the broader context and consequences of action, and diverse perspectives on medical practice. However, when this metaphor is elevated to the status of a theory, it has well-known limits: the assumed subject position of contractors engenders blind spots about privilege, not critical reflection; its tendency to dress up the status quo in the trappings of a theoretical agreement may limit social negotiation; its attempted reconciliation of social obligation and self-interest fosters the view that ethics and self-interest should coincide; it sets up false expectations by identifying appearance and reality in morality; and its construal of prima facie duties as conditional misdirects ethical attention in particular situations from current needs to supposed past agreements or reciprocities. Using philosophical ideas as heuristic devices in medical ethics is inevitable, but we should be conscious of their limitations. When they limit the ethical scope of debate, we should seek new metaphors.
... Practice of medicine is something which requires skill and knowledge. Medicine is a field where there should be no bias based on the treatment given to a patient with respect to (1) political, legal or materialistic influence. The Hippocratic Oath, which goes by to do no harm to the patient at any stage from in-utero to natural death has now become irrelevant as the profession itself has lost its nobility and thus proves to be an utter business. ...
... Practice of medicine is something which requires skill and knowledge. Medicine is a field where there should be no bias based on the treatment given to a patient with respect to (1) political, legal or materialistic influence. The Hippocratic Oath, which goes by to do no harm to the patient at any stage from in-utero to natural death has now become irrelevant as the profession itself has lost its nobility and thus proves to be an utter business. ...
Ethical standards are the underpinning of medical practice and practising it is considered to be devotional. 21 century marks the oppressed period for health practitioners as many of them face challenges in day-to-day practice. And as a result, these doctors are facing tension against the ill treatment towards them. These days, health practitioners face threat from many strata of individuals asking them to modify or even change certain data so as to benefit the said person. Such unethical practices have made the public lose trust in them. In order to overcome such issues, the health care professionals need to be given ample amount of rest period so as to relax their body and mind through strategic approach. Along with this, proper government rules should be passed in order to stop such deceitful practices with no loopholes available. The management of stress shall drastically decrease with the above two measure along with which good leadership skills and strategic interventions are needed for the same. The managerial tools shall be taken into consideration by various doctors and thereby channelize them into making good. This review mainly focuses on the effectiveness of measures implemented to reduce tension and how to endure it.
... Curriculum is a set of influences that operates at institutional structure and culture (Hafferty, 1998) that manipulates learners in instructional process. In education, learners go through the process of identity construction as they adapt to institutional environment (Hafferty, 2006). When the learners adjust themselves with the environment that leads to the formation of their habitus, which serves as a social capital for them (Bourdieu, 1991). ...
Curriculum provides specific kinds of exposure to learners in a continuous process and determines learners' abilities. According to different educational policies, developing an integrated curriculum in primary education is one way of balancing content exposures for all learners across socioeconomic classes. However, schools within the country vary greatly in terms of curriculum and its delivery. Curriculum variations lead to disparities in educational content. This study explores the nature of variations in the English curriculum used in different types of schools since there are different school systems in the country. The study explores reasons for disparities in curriculum across socially stratified schools in Pakistan with a specific focus on the English language instruction. The study uses phenomenological methods to gather data through interviews, demographic information and analysis of the fifth class English textbooks across 30 different schools. Results show how and why curriculum differs across low, middle and high cost schools and elaborate on how teachers can improve instructions to minimize the differences.
... [7][8][9] It traverses the formal curriculum and spills into our hallways, cafeterias, lounges, and offices. 10,11 Since 1999, professionalism has been formally considered a medical education competency by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties; in 2013, the Association of American Medical Colleges adopted related professionalism competencies. 12,13 Given the lack of a universally accepted definition of the concept, however, it is not surprising that assessing lapses in professional behavior remains challenging. ...
Professionalism lapses by trainees can be addressed productively if viewed through a lens of medical error, drawing on “just culture” principles. With this approach, educators can promote a formative learning environment while fairly addressing problematic behaviors.
... The recognition of the doctor's work, mainly by the way of the remuneration as well as the general society that seem to recognize those who prosper is not good. Lack of recognition of the clinical work of doctors has been shown to be a major challenge for those who want to concentrate on caring for the patient (13,17) because in some institutions , publication and research form part of what administration uses for promotion of personnel. This is the same in our set up though the recognition talked of in our study was more of the societal recognition as well as remuneration. ...
Background: Professionalism in medicine is a social contract between society and the medical personnel. Challenges in the practice has been raised worldwide. Since it concerns values that change from time to time and from culture to culture, the concern and challenges are expected to be difference from culture to culture. Our aim was to explore the challenges to inculcation and practice of professionalism as viewed by those who are involved in the surgical teaching environment in Kenya. Methodology: A sequential mixed methods study was conducted among faculty, registrars, medical students and auxiliary clinical staff at University of Nairobi Department of Surgery, Kenyatta National Hospital surgical wards. The data were collected through focus group discussions and individual interviews, then analyzed using grounded theory. Views expressed were used to construct a questionnaire used in the survey for validation of the challenges mentioned. The survey was analysed using Statistical Package for Social Sciences (SPSS) version 20(Chicago, Illinois) Results: The majority of the participants felt that the most challenging issue was character as reflected in the poor attitude towards patient and lack of resources that makes it difficult to give professional services. This then leads to the physicians participating more in private practice leading unavailability in the employment place. The two challenges were then confirmed in the survey with 85.1% and 85.6% agreeing respectively. Conclusion: The predominant challenges according to the view of those in the surgical community in the setting of University of Nairobi in so far as professionalism is concerned are character and financial resources. An appreciation of these challenges should lead to changes in the curriculum and practical changes to the teaching and practice environment.
... As already described, the notions of responsibility and competence are each addressed by large bodies of literature. Some identity issues appear in the currently very prominent professionalism literature (Brainard & Brislen, 2007;Cruess & Cruess, 2006;Cruess, Cruess, & Steinert, 2010;Hafferty, 2006;Hafferty & Castellani, 2010;Hafferty & Levinson, 2008;Whitcomb, 2005aWhitcomb, , 2005b. Others are addressed through medical socialization literature (Becker, 1961;Bloom, 1963;Bonner, 1995; Different aspects of this extremely wide array of literature relate at different points and in varying ways to the discourses of the good doctor. ...
... Medical sociologist Eliot Freidson (2001) viewed professional groups dedicated to upholding transcendent values as a countervailing force to both the free market and bureaucratic managers. Following Freidson, Hafferty (2006) characterized the combination of commercialism and bureaucracy as an " elephant in medical professionalism's kitchen " (p. 906), that tramples what the American Medical Association (2003) designated in the subtitle of a recent declaration as " Medicine's Social Contract with Humanity. ...
An approach analogous to the military concept of “conduct unbecoming an officer” is increasingly evident in the attempted management of physicians' personal behavior by medical licensing entities—even when such behavior bears little or no relation to medical practice. This article surveys the genesis of this approach, the social and professional forces that have encouraged attempts to regulate extra-medical activities, and the current status of pertinent guild rules and other professional guidelines. Two reported case examples are reviewed with critical commentary.
... If we add the rising demands for "efficiency,"seeing a larger number of patients with fewer resources, and the increase in the workload and responsibilities of health care providers in general, -we will find fertile ground not only for disruptive behaviors but also for the identity crisis of modern medical practice as exemplified by the rise of commercialism against values such as altruism and compassion. 2,31 Philip Zimbardo, in his book The Lucifer Effect: Understanding How Good People Turn Evil, states that situational forces can induce good people to depart from ethical paths via mechanisms such as obedience to authority, deindividuation, self-justification, and rationalization, all of which are remarkably common in the learning of medicine. 32 He argues that leaders must share the responsibility for the occurrence of unethical behaviors (and their consequences) within their institutions. ...
The exposure to unethical and unprofessional behavior is thought to play a major role in the declining empathy experienced by medical students during their training. We reflect on the reasons why medical schools are tolerant of unethical behavior of faculty. First, there are barriers to reporting unprofessional behavior within medical schools including fear of retaliation and lack of mechanisms to ensure anonymity. Second, deans and directors do not want to look for unethical behavior in their colleagues. Third, most of us have learned to take disrespectful circumstances in health care institutions for granted. Fourth, the accreditation of medical schools around the world does not usually cover the processes or outcomes associated with fostering ethical behavior in students. Several initiatives promise to change that picture.
© 2015 Annals of Family Medicine, Inc.
... As a corollary, unprofessional behavior in medical schools is associated with subsequent disciplinary action by the state medical boards (Papadakis et al. 2004). In the spate of public criticism against commercialization of medicine, medical schools all over the world have begun to address the issue of developing professionalism among young medicos (Hafferty 2006). Unfortunately, the issues such as 'what constitutes good professional behavior' and how to inculcate these qualities among young medical students have been subjected to perennial debate (Whitcomb 2005;. ...
Professionalism has emerged as a core competency for the medical professionals globally. However, few studies have been reported from the Gulf region to assess the situation and take steps to promote professionalism.
To elicit the views of final year medical students, interns, and residents to explore what professionalism meant to them, what problems they encountered, and what can be done to promote professionalism.
We adopted qualitative approach including 10 focus group discussions. The proceedings were tape-recorded, transcribed, and analyzed independently by two researchers.
The respondents admitted that that they were deficient in the acquisition of professional values. According to them, professionalism was not taught or assessed. They followed "hidden curriculum". They considered very few teachers as positive role models. The deficiencies could be attributed to negative role modeling by the faculty or deficiencies in the curriculum such as lack of rich clinical experiences, limited interaction with health team, and absence of feedback besides organizational issues.
The students' views should be tallied with other sources of evidences. Nevertheless, they have policy implications on faculty recruitment, development, curriculum reform, and an organizational culture that supports professionalism.
... groups have made struggles to categorize a physician's proficient principles, social promises, and individual objectives in oaths, testimonies, agreements, strategies, and work proclamations (The Prayer of Maimonides, 1918;Crawshaw and Link, 1996). These statements range from the least proficiencies required of all physicians to the highest expectations and morals of the model physician (The Prayer of Maimonides, 1918, Hafferty 2006. Now, the medical professionalism is challenged by advances in technology, varying market forces, managed care, other business arrangements in health care, bioterrorism, globalization and a rising sense of the attrition of public trust in the medical profession (Swick 1998, Ludmerer, 1999. ...
Professionalism with high moral character should be developed from the
schooling time of the students. The objective of this study was to explore the
professionalism of medical students. It was a cross-sectional study conducted
on 108 year-I and year-II medical students of session 2012-2013 selected
conveniently at UniSZA, Malaysia. Data was collected using a mixed type of
validated instrument and analyzed using SPSS. Year-I and year-II were 86%
and 98% respectively. Only 27% respondents were male and 73% were female.
Mean professionalism scores for year-I and year-II were 175.20 and 172.91,
while for male and female were 172.31 and 174.58 respectively. No significant
differences observed between gender (p=0.536) and study-year (p=0.484).
However, 34% year-I and 19% year-II students defined professionalism
diversely while 18% and 9% were un-responded. Professionalism is a braodconcept;
a burning issue worldwide. Teachers should emphasis on core
elements of professionalism which are unique for all professions.
... groups have made struggles to categorize a physician's proficient principles, social promises, and individual objectives in oaths, testimonies, agreements, strategies, and work proclamations (The Prayer of Maimonides, 1918;Crawshaw and Link, 1996). These statements range from the least proficiencies required of all physicians to the highest expectations and morals of the model physician (The Prayer of Maimonides, 1918, Hafferty 2006. Now, the medical professionalism is challenged by advances in technology, varying market forces, managed care, other business arrangements in health care, bioterrorism, globalization and a rising sense of the attrition of public trust in the medical profession (Swick 1998, Ludmerer, 1999. ...
Professionalism with high moral character should be developed from the
schooling time of the students. The objective of this study was to explore the
professionalism of medical students. It was a cross-sectional study conducted
on 108 year-I and year-II medical students of session 2012-2013 selected
conveniently at UniSZA, Malaysia. Data was collected using a mixed type of
validated instrument and analyzed using SPSS. Year-I and year-II were 86%
and 98% respectively. Only 27% respondents were male and 73% were female.
Mean professionalism scores for year-I and year-II were 175.20 and 172.91,
while for male and female were 172.31 and 174.58 respectively. No significant
differences observed between gender (p=0.536) and study-year (p=0.484).
However, 34% year-I and 19% year-II students defined professionalism
diversely while 18% and 9% were un-responded. Professionalism is a braodconcept;
a burning issue worldwide. Teachers should emphasis on core
elements of professionalism which are unique for all professions.
... The hidden curriculum is classically defined as ‘a set of influences that function at the level of organisational structure and culture’,8 which manipulate teachers and learners in the context of both the formal and informal curricula. During clinical training, students undergo a process of professional identity formation9 as they learn the ‘rules’ of the new community of practice they are joining.10 This process of situated learning, widely recognised as a key element of learning professionalism,11,12 is heavily influenced by the often non-overt attitudes and behaviours of peers and teachers. ...
CONTEXT Major influences on learning about medical professionalism come from the hidden curriculum. These influences can contribute positively or negatively towards the professional enculturation of clinical students. The fact that there is no validated method for identifying the components of the hidden curriculum poses problems for educators considering professionalism. The aim of this study was to analyse whether a cultural web, adapted from a business context, might assist in the identification of elements of the hidden curriculum at a UK veterinary school.
METHODS A qualitative approach was used. Seven focus groups consisting of three staff groups and four student groups were organised. Questioning was framed using the cultural web, which is a model used by business owners to assess their environment and consider how it affects their employees and customers. The focus group discussions were recorded, transcribed and analysed thematically using a combination of a priori and emergent themes.
RESULTS The cultural web identified elements of the hidden curriculum for both students and staff. These included: core assumptions; routines; rituals; control systems; organisational factors; power structures, and symbols. Discussions occurred about how and where these issues may affect students’ professional identity development.
CONCLUSIONS The cultural web framework functioned well to help participants identify elements of the hidden curriculum. These aspects aligned broadly with previously described factors such as role models and institutional slang. The influence of these issues on a student’s development of a professional identity requires discussion amongst faculty staff, and could be used to develop learning opportunities for students. The framework is promising for the analysis of the hidden curriculum and could be developed as an instrument for implementation in other clinical teaching environments.
... Furthermore, the backbone of medicine's professionalism discourse was a particular version of professionalism -something sociologists would come to label "nostalgic professionalism" (Castellani and Hafferty 2006). This particular framing, with its emphasis on altruism and personal sacrifice, would not sit well with students and would form the basis of a subcultural backlash against something (professionalism) students felt was being "crammed down our throats" (see below; Hafferty 2002Hafferty , 2006aHafferty , 2008Humphrey et al. 2007). ...
In 1959, the novelist and physicist C. P. Snow, delivered his famous lecture on ‘Two Cultures’ at the University of Cambridge. Snow argued that while the humanities and the sciences (in particular, the natural sciences)
form the two great cultural traditions humans use to make sense of their lives, these domains of knowing remain strangers
to one another. Like ships passing in the night, science and art reflect a cultural divide for which no easy rapprochement
exists.
... 15,32 This study adds a cross-cultural perspective to this tension and urges us to consider dimensions of the hidden curriculum that have not been well explored in the existing literature. 33 We found the most influential role models to be alumni residents, rather than attending physician, as reported elsewhere. 34 In addition to role models, our study suggests that other domains of the hidden curriculum, such as 'cultural norms', deserve attention as these norms may not be in harmony with the principles articulated in globalised formal curricula. ...
Medical educators internationally are faced with the challenge of teaching and assessing professionalism in their students. Some studies have drawn attention to contextual factors that influence students' responses to professional dilemmas. Although culture is a significant contextual factor, no research has examined student responses to professional dilemmas across different cultures.
Semi-structured interviews inquiring into reactions towards, and reasoning about, five video clips depicting students facing professional dilemmas were conducted with 24 final-year medical students in Taiwan. The interviews were transcribed and analysed according to the theoretical framework used in prior Canadian studies using the same videos and interview questions.
The framework from previous Canadian research, including the components of principles, affect and implications, was generally applicable to the decision making of Taiwanese students, with some distinctions. Taiwanese students cited a few more avowed principles. Taiwanese students emphasised an additional unavowed principle that pertained to following the advice of more senior trainees. In addition to implications for patients, team members or themselves, Taiwanese students considered the impact of their responses on multiple relationships, including those with patients' families and alumni residents. Cultural norms were also cited by Taiwanese students.
Medical educators must acknowledge students' reasoning in professionally challenging situations and guide students to balance considerations of principles, implications, affects and cultural norms. The prominence of Confucian relationalism in this study, exhibited by students' considerations of the rippling effects of their behaviours on all their social relationships, calls for further cross-cultural studies on medical professionalism to move the field beyond a Western individualist focus.
... Very few others have written about the effects of elephants or organizational silence in health care. Hafferty has addressed the familiar silence around the tension between medical professionalism and commercialism 16 while Hart and Hazlegrove have used the term "cultural censorship" to describe a deceptive side of health service organizations-a side where problematic events are simultaneously recognized yet hidden. 9 Their description aligns with that of Sherriff who points out that "one of the central features of cultural silence is that it tends to be, in rather paradoxical terms, simultaneously recognized and concealed." ...
To study the types, causes, and consequences of academic health center (AHC) "elephants," which the authors define as obvious problems that impair performance but which the community collectively does not discuss or confront.
Between April and June 2010, the authors polled all the chairs of departments of medicine and of surgery at the then 127 U.S. medical-degree-granting medical schools, using a combination of Web and postal surveys.
Of the 254 chairs polled, 139 (55%) responded. Of 137 chairs, 95 (69%) reported that elephants in their organizations were common or widespread. The most common elephant reported was misalignment between goals and available resources. Chairs felt that the main reason faculty are silent is their perception that speaking up will be ignored and that the consequences of elephants include impaired organizational learning, flawed information resulting in poor decisions, and negative effects on morale. Chairs felt elephants were more problematic among deans and hospital leaders than in their own departments. Of 139 chairs, 87 (63%) said that elephants were discussed inappropriately, and of 137 chairs, 92 (67%) believed that creating a culture that dealt with elephants would be difficult. Chairs felt the best antidote for elephants was having senior leaders lead by example, yet 77 of 139 (55%) reported that the actions of top leaders fed, rather than dispelled, elephants.
AHC elephants are prevalent and detrimental to learning, organizational decision making, and morale, yet the academic medicine community, particularly its leadership, insufficiently confronts them.
... With the current economics of health care, to survive fi nancially, physicians are forced to see more patients, and they face the constant threat of moral erosion from factors inherent in the corporatization of medicine. 17 Many advocate examination of the ethical and moral aspects of everyday practice. Epstein identifi es the foun-C M E dation of professional excellence as knowledge of and respect for the patient as a person with needs and values. ...
Beginning of article:
“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” --Sir William Osler, MD, 1932.
The pediatric encounter requires skillful communication between patient and physician, expert communication with parents and other family members, and an understanding of family dynamics and the child’s cognitive and developmental stage.
There is a direct association between the physician’s interpersonal and communication skills and ability to reflect, and health care quality and outcomes. All encounters between patients and health care professionals, and among members of health care teams, take place within a broader moral universe that includes personal integrity, professionalism, and the everyday ethics of practice. . .
... Les discussions dans les ouvrages spécialisés se multiplient. Bon nombre de ces récents ouvrages considèrent que le professionnalisme médical est menacé; ils interprètent les menaces et proposent des solutions pour les écarter [1][2][3][4][5][6] . Les articles et les études scientifi ques sur la façon d'enseigner et d'évaluer le professionnalisme -et la façon de formuler des attentes raisonnables envers les médecins en matière de compétences mesurables et de comportements associés au professionnalisme -prolifèrent 2,3,7 . ...
... This requires medical leadership, as the medical profession itself is largely responsible for the way in which medical expertise is organized. Medical professions must recognize that the proposed long-term vision is a promising route towards both improving performance in healthcare and protecting the values and principles of medical professionalism against the countervailing forces of the free market and bureaucracy [45,46]. The likelihood that professions will take up this endeavour could be increased by a set of well-calibrated external policy pressures in at least seven areas (Table 1). ...
The professional organization of medical work no longer reflects the changing health needs caused by the growing number of complex and chronically ill patients. Key stakeholders enforce coordination and remove power from the medical professions in order allow for these changes. However, it may also be necessary to initiate basic changes to way in which the medical professionals work in order to adapt to the changing health needs.
Medical leaders, supported by health policy makers, can consciously activate the self-regulatory capacity of medical professionalism in order to transform the medical profession and the related professional processes of care so that it can adapt to the changing health needs. In doing so, they would open up additional routes to the improvement of the health services system and to health improvement. This involves three consecutive steps: (1) defining and categorizing the health needs of the population; (2) reorganizing the specialty domains around the needs of population groups; (3) reorganizing the specialty domains by eliminating work that could be done by less educated personnel or by the patients themselves. We suggest seven strategies that are required in order to achieve this transformation.
Changing medical professionalism to fit the changing health needs will not be easy. It will need strong leadership. But, if the medical world does not embark on this endeavour, good doctoring will become merely a bureaucratic and/or marketing exercise that obscures the ultimate goal of medicine which is to optimize the health of both individuals and the entire population.
Learning medical professionalism is a challenging, evolving, and life-long endeavor. Professionalism in Medicine: A Case-Based Guide for Medical Students helps begin this process by engaging students and their teachers in reflection on cases that resonate with the experiences of life in medicine. Through the book's seventy-two cases, commentaries, videos, and literature-based reviews, students explore the many challenging areas of medical professionalism. Readers will appreciate the provocative professionalism dilemmas encountered by students from the pre-clinical years and clinical rotations and by physicians of various specialities. Each case is followed by two commentaries by writers who are involved in health care decisions related to that case, and who represent a wide variety of perspectives. Authors represent 46 medical schools and other institutions and include physicians, medical students, medical ethicists, lawyers, psychologists, nurses, social workers, pharmacists, health care administrators, and patient advocates.
Learning medical professionalism is a challenging, evolving, and life-long endeavor. Professionalism in Medicine: A Case-Based Guide for Medical Students helps begin this process by engaging students and their teachers in reflection on cases that resonate with the experiences of life in medicine. Through the book's seventy-two cases, commentaries, videos, and literature-based reviews, students explore the many challenging areas of medical professionalism. Readers will appreciate the provocative professionalism dilemmas encountered by students from the pre-clinical years and clinical rotations and by physicians of various specialities. Each case is followed by two commentaries by writers who are involved in health care decisions related to that case, and who represent a wide variety of perspectives. Authors represent 46 medical schools and other institutions and include physicians, medical students, medical ethicists, lawyers, psychologists, nurses, social workers, pharmacists, health care administrators, and patient advocates.
Learning medical professionalism is a challenging, evolving, and life-long endeavor. Professionalism in Medicine: A Case-Based Guide for Medical Students helps begin this process by engaging students and their teachers in reflection on cases that resonate with the experiences of life in medicine. Through the book's seventy-two cases, commentaries, videos, and literature-based reviews, students explore the many challenging areas of medical professionalism. Readers will appreciate the provocative professionalism dilemmas encountered by students from the pre-clinical years and clinical rotations and by physicians of various specialities. Each case is followed by two commentaries by writers who are involved in health care decisions related to that case, and who represent a wide variety of perspectives. Authors represent 46 medical schools and other institutions and include physicians, medical students, medical ethicists, lawyers, psychologists, nurses, social workers, pharmacists, health care administrators, and patient advocates.
Learning medical professionalism is a challenging, evolving, and life-long endeavor. Professionalism in Medicine: A Case-Based Guide for Medical Students helps begin this process by engaging students and their teachers in reflection on cases that resonate with the experiences of life in medicine. Through the book's seventy-two cases, commentaries, videos, and literature-based reviews, students explore the many challenging areas of medical professionalism. Readers will appreciate the provocative professionalism dilemmas encountered by students from the pre-clinical years and clinical rotations and by physicians of various specialities. Each case is followed by two commentaries by writers who are involved in health care decisions related to that case, and who represent a wide variety of perspectives. Authors represent 46 medical schools and other institutions and include physicians, medical students, medical ethicists, lawyers, psychologists, nurses, social workers, pharmacists, health care administrators, and patient advocates.
Learning medical professionalism is a challenging, evolving, and life-long endeavor. Professionalism in Medicine: A Case-Based Guide for Medical Students helps begin this process by engaging students and their teachers in reflection on cases that resonate with the experiences of life in medicine. Through the book's seventy-two cases, commentaries, videos, and literature-based reviews, students explore the many challenging areas of medical professionalism. Readers will appreciate the provocative professionalism dilemmas encountered by students from the pre-clinical years and clinical rotations and by physicians of various specialities. Each case is followed by two commentaries by writers who are involved in health care decisions related to that case, and who represent a wide variety of perspectives. Authors represent 46 medical schools and other institutions and include physicians, medical students, medical ethicists, lawyers, psychologists, nurses, social workers, pharmacists, health care administrators, and patient advocates.
Learning medical professionalism is a challenging, evolving, and life-long endeavor. Professionalism in Medicine: A Case-Based Guide for Medical Students helps begin this process by engaging students and their teachers in reflection on cases that resonate with the experiences of life in medicine. Through the book's seventy-two cases, commentaries, videos, and literature-based reviews, students explore the many challenging areas of medical professionalism. Readers will appreciate the provocative professionalism dilemmas encountered by students from the pre-clinical years and clinical rotations and by physicians of various specialities. Each case is followed by two commentaries by writers who are involved in health care decisions related to that case, and who represent a wide variety of perspectives. Authors represent 46 medical schools and other institutions and include physicians, medical students, medical ethicists, lawyers, psychologists, nurses, social workers, pharmacists, health care administrators, and patient advocates.
Learning medical professionalism is a challenging, evolving, and life-long endeavor. Professionalism in Medicine: A Case-Based Guide for Medical Students helps begin this process by engaging students and their teachers in reflection on cases that resonate with the experiences of life in medicine. Through the book's seventy-two cases, commentaries, videos, and literature-based reviews, students explore the many challenging areas of medical professionalism. Readers will appreciate the provocative professionalism dilemmas encountered by students from the pre-clinical years and clinical rotations and by physicians of various specialities. Each case is followed by two commentaries by writers who are involved in health care decisions related to that case, and who represent a wide variety of perspectives. Authors represent 46 medical schools and other institutions and include physicians, medical students, medical ethicists, lawyers, psychologists, nurses, social workers, pharmacists, health care administrators, and patient advocates.
Learning medical professionalism is a challenging, evolving, and life-long endeavor. Professionalism in Medicine: A Case-Based Guide for Medical Students helps begin this process by engaging students and their teachers in reflection on cases that resonate with the experiences of life in medicine. Through the book's seventy-two cases, commentaries, videos, and literature-based reviews, students explore the many challenging areas of medical professionalism. Readers will appreciate the provocative professionalism dilemmas encountered by students from the pre-clinical years and clinical rotations and by physicians of various specialities. Each case is followed by two commentaries by writers who are involved in health care decisions related to that case, and who represent a wide variety of perspectives. Authors represent 46 medical schools and other institutions and include physicians, medical students, medical ethicists, lawyers, psychologists, nurses, social workers, pharmacists, health care administrators, and patient advocates.
Learning medical professionalism is a challenging, evolving, and life-long endeavor. Professionalism in Medicine: A Case-Based Guide for Medical Students helps begin this process by engaging students and their teachers in reflection on cases that resonate with the experiences of life in medicine. Through the book's seventy-two cases, commentaries, videos, and literature-based reviews, students explore the many challenging areas of medical professionalism. Readers will appreciate the provocative professionalism dilemmas encountered by students from the pre-clinical years and clinical rotations and by physicians of various specialities. Each case is followed by two commentaries by writers who are involved in health care decisions related to that case, and who represent a wide variety of perspectives. Authors represent 46 medical schools and other institutions and include physicians, medical students, medical ethicists, lawyers, psychologists, nurses, social workers, pharmacists, health care administrators, and patient advocates.
Learning medical professionalism is a challenging, evolving, and life-long endeavor. Professionalism in Medicine: A Case-Based Guide for Medical Students helps begin this process by engaging students and their teachers in reflection on cases that resonate with the experiences of life in medicine. Through the book's seventy-two cases, commentaries, videos, and literature-based reviews, students explore the many challenging areas of medical professionalism. Readers will appreciate the provocative professionalism dilemmas encountered by students from the pre-clinical years and clinical rotations and by physicians of various specialities. Each case is followed by two commentaries by writers who are involved in health care decisions related to that case, and who represent a wide variety of perspectives. Authors represent 46 medical schools and other institutions and include physicians, medical students, medical ethicists, lawyers, psychologists, nurses, social workers, pharmacists, health care administrators, and patient advocates.
Medical unprofessionalism and the deprofessionalization of medicine have of late become serious concerns to physicians, medical educators, and the public. Medical professionalism, which signifies a set of values, behaviors, and a relationship that underpins the trust the public places in physicians, is a core feature of medical practice. Commercialism and consumerism in medicine are among the main factors currently contributing to medical unprofessionalism and the deprofessionalization of medical practice. The unprofessionalism and deprofessionalization of physicians produce negative images of physicians. In this article we argue for a virtue-ethics approach to solving the problems of medical unprofessionalism and deprofessionalization. We argue for the promotion of certain virtues among physicians and the need for virtuous role models. Furthermore, we claim that since physicians are also members of society,the nurturing of virtue within the medical profession both promotes and requires the nurturing of virtue within society at large.
Vikersund MAIN MESSAGE According to hospital doctors, being a good doctor means demonstrating a high degree of professional dedication. Professional dedication is demonstrated through a strong willingness to work intensively and effectively with the patients, while also going to great lengths to be available beyond regular working hours. Becoming a good doctor is described as a lifelong process. BACKGROUND In today's society, doctors are confronted with a number of opposing interests , from other colleagues, patients and employers. The development and regulation of the medical profession have been widely studied. However, less research has been devoted to the doctors' own perception of what it means to be a good doctor.
MAIN MESSAGE According to hospital doctors, being a good doctor means demonstrating a high degree of professional dedication. Professional dedication is demonstrated through a strong willingness to work intensively and effectively with the patients, while also going to great lengths to be available beyond regular working hours. Becoming a good doctor is described as a lifelong process. BACKGROUND In today's society, doctors are confronted with a number of opposing interests , from other colleagues, patients and employers. The development and regulation of the medical profession have been widely studied. However, less research has been devoted to the doctors' own perception of what it means to be a good doctor.
As health care has become of great importance to both individual citizens and to society, it has become more important to understand medicine's relationship to the society it serves in order to have a basis for meaningful dialogue. During the past decade, individuals in the medical, legal, social sciences, and health policy fields have suggested that professionalism serves as the basis of medicine's relationship with society, and many have termed this relationship a social contract. However, the concept of medicine's social contract remains vague, and the implications of its existence have not been fully explored. This paper endorses the use of the term social contract, examines the origin of the concept and its relationship to professionalism, traces its evolution and application to medicine, describes the expectations of the various parties to the contract, and explores some of the implications of its use.
Object: Clarify the commonalities and differences in perspective toward physicians and medical care between patients and physicians.
Methods: 9 items questionnaires, created in a previous study regarding physicians and medical care, were sent to primary care physicians to compare the perspective of physician and medical care by patients which became clear in previous study.
Results: Among the 408 questionnaires sent, 301 responses were received (response rate 73.8%). Physicians thought that the profession of physicians is a pressing job and hence physicians can be trusted similar to tendency of patients in past research. As for the state of the profession of physicians, the tendency among physicians to consider the profession as that of service industry not as a scared profession was indicated.
Discussion: For both patients and physicians, it was indicated that common awareness exits in them regarding the labor and behavior of physicians. Although there was an awareness that there is a tendency for physicians to consider the profession as part of service industry and for patients to consider being a physician as a sacred profession, it was indicated that the viewpoint toward physicians was not uniform for both groups.
Conclusions: It can be thought that it is important to understand that there are differences in sentiment among physicians and patients regarding physicians and medical care for building a better relationship between patients and physicians.
M odern day medical professionalism has been advocated by multiple professional organizations and individual scholars. Most of the statements publicly issued emphasize particular moral traditions and the highest professional standards along with doctors' social role to recover society's trust, which have proved ineffective in bringing any change. Based on the perspective that medical professionalism is a norm of practice, acknowledged and shared by the majority of current ordinary doctors, the author traced the emergence of modern professionalism to challenge the legitimacy of those virtue-based arguments within a historical context. With the increasing complexities of both society and the health care system, new types of health clinics have been practiced especially by young generation doctors. As these are explored, several factors related with those stated professionalism that are creating conflicts are discussed. It is criticized that those statements demand individual doctors to adhere to the ideal professionalism regardless of any circumstances, so that it excludes any discussion about professionalism from the broader social contextual background. Given that professionalism is a context-dependent concept, it is stressed that modern day medical professionalism is required to evolve along with societal change. As medicine is recognized as a system in which numerous societal areas are involved, medical professionalism is expected to be rewritten into a consensus-based, more realistic and explicit compact.
Despite an extensive literature within medical education touting the necessity in developing professionalism among future physicians, there is little evidence these ‘calls’ have thus far had an appreciable effect. Although various researchers have suggested that the hidden curriculum within medical education has a prominent role in stunting the development of professionalism among future physicians, there has been minimal discussion of how the content of the hidden curriculum actually function to this end. In this article, we explore: (i) how the hidden curriculum may function within medical education as a countervailing force to medicine’s push for professionalism and (ii) why the hidden curriculum continues to persist within medical training and particular aspects so difficult to dilute. We conclude by proposing mechanisms to assuage elements of the hidden curriculum, which may, in turn, allow the principles of professionalism to blossom among medical students.
Introduction:
We undertook a systematic review and narrative synthesis of the literature to identify how professionalism is defined in the medical education literature.
Methods:
Eligible studies included any articles published between 1999 and 2009 inclusive presenting viewpoints, opinions, or empirical research on defining medical professionalism.
Results:
We identified 195 papers on the topic of definition of professionalism in medicine. Of these, we rated 26 as high quality and included these in the narrative synthesis.
Conclusion:
As yet there is no overarching conceptual context of medical professionalism that is universally agreed upon. The continually shifting nature of the organizational and social milieu in which medicine operates creates a dynamic situation where no definition has yet taken hold as definitive.
Profound socioeconomic pressures on medical student education have been catalogued extensively. These pressures include teaching patient shortages, teacher shortages, conflicting systems, and financial problems. Many of these problems have been caused by an unregulated free market affecting medicine overall, with market values sometimes overshadowing the academic values of education, research, and patient care. This has caused profound changes in the conduct of medical student education. Particularly important has been a reduction in the "gold standard" of teaching: direct student-teacher and supervised student-patient interaction, replaced by a potpourri of online and simulated modules. The aggregate of these changes constitutes a revolution that challenges whether medical schools, school buildings, classes, and dedicated faculty are even necessary. The author posits several recommendations in response to this revolution: (1) recognize the revolution as such, and carefully guide or abort it, lest its outcome be inadequate, inauthentic, or corrupt, (2) prioritize academic rather than business values, (3) ensure that funds allotted for education are used for education, (4) insist that medical schools, not industry, teach students, (5) value authentic education more than simulation, (6) adopt learner-centered teaching without misusing it, (7) maintain acceptable class attendance without requiring it, (8) provide, from the first school day, authentic, patient-centered medical education characterized by vertical integration, humanism, early patient exposure, biopsychosocial orientation, and physician role modeling, (9) ensure that third- and fourth-year students have rich patient-care responsibility, and 10) keep tenure. These actions would permit the preservation of an educational gold standard that justifies medical education's cost.
Enhancing professionalism is an important goal of all physicians, both as individuals and as members of educational and institutional communities of practice. Despite a great deal of dialogue and discourse, the medical profession struggles to ensure that all physicians are able to embrace and live the values of professionalism, notwithstanding the myriad stressors present in today's evolving health care environment. The authors suggest a move beyond the traditional educational paradigms focused on reinforcing rules, providing role models, rewarding right behavior, and removing those who falter, and that we instead view the problem of professionalism as a complex adaptive challenge requiring new learning. Approaching lapses in professionalism as a form of medical error may provide a fresh outlook and may lead to the development of successful strategies to help physicians realize their commitment to the values of professionalism, despite the inevitable challenges that arise throughout their careers.
To explore clinical faculty members' knowledge and attitudes regarding their teaching and evaluation of professionalism.
Clinical faculty involved in medical education at University of Toronto Faculty of Medicine were recruited to participate in focus groups between 2006 and 2007 to discuss their knowledge, beliefs, and attitudes about teaching and evaluating professionalism and to determine their views regarding faculty development in this area. Focus groups were transcribed, analyzed, and coded for themes using a grounded theory approach.
Five focus groups consisting of 14 faculty members from surgical specialties, psychiatry, anesthesia, and pediatrics were conducted. Grounded theory analysis of the 188 pages of text identified three major themes: Professionalism is not a static concept, a gap exists between faculty members' real and ideal experience of teaching professionalism, and "unprofessionalism" is a persistent problem. Important subthemes included the multiple bases that exist for defining professionalism, how professionalism is learned and taught versus how it should be taught, institutional and faculty tolerance and silence regarding unprofessionalism, stress as a contributor to unprofessionalism, and unprofessionalism arising from personality traits.
All faculty expressed that teaching and evaluating professionalism posed a challenge for them. They identified their own lapses in professionalism and their sense of powerlessness and failure to address these with one another as the single greatest barrier to teaching professionalism, given a perceived dominance of role modeling as a teaching tool. Participants had several recommendations for faculty development and acknowledged a need for culture change in teaching hospitals and university departments.
While historic medical oaths and numerous contemporary medical organizations offer guidelines for professionalism, the nature of the professional aspirations, commitments, and values of current medical students is not well known. We sought to provide a thematic catalogue of individual mission statements written by medical students nationally.
In the Healer's Art elective course, students write a personal mission statement about their highest professional values. In 2006-2007, we randomly selected 100 student mission statements from 10 representative schools nationally. Three researchers coded content using a team-based qualitative approach and categorized the codes into major themes. Student mission statements were compared with classic medical oaths and contemporary professionalism guidelines.
The mission statements were similar across different schools. Three major themes emerged, comprised of codes identified in 20% or more of the mission statements. The first theme, professional skills, includes dealing with the negatives of training, listening and empathy, growth and development. The second theme, personal qualities, includes wholeness, humility, and constancy/perfectionism. The third theme, scope of professional practice, includes physician relationships, positive emotions, healing, service, spirituality, and balance. Unlike the content of classic oaths and contemporary professionalism statements, the students' statements dealt with fears, personal-professional balance, love, nonhierachical relationships, self-care, healing, and awe as key to being a physician.
In their personal mission statements, this national cohort of medical students described an expanded view of physicianhood that includes such elements as presence, love, and awe. Medical school curricula may require adaptation to support the personal aspirations of those now entering the profession.
Modern-day discourse on medical professionalism has largely been dominated by a "nostalgic" view, emphasizing individual motives and behaviors. Shaped by a defining conflict between commercialism and professionalism, this discourse has unfolded through a series of waves, the first four of which are discovery, definition, assessment, and institutionalization. They have unfolded in a series of highly interactive and overlapping sequences that extend into the present. The fifth wave-linking structure and agency-which is nascent, proposes to shift our focus on professionalism from changing individuals to modifying the underlying structural and environmental forces that shape social actors and actions. The sixth wave-complexity science-is more incubatory in nature and seeks to recast social actors, social structures, and environmental factors as interactive, adaptive, and interdependent. Moving towards such a framing is necessary if medicine is to effectively reestablish professionalism as a core principle.
A study explored entrepreneurship in theresearch university. The data were collected in 2 surveys conducted in 1985 -one of a sample of life scientists located in major research universities andthe other of key administrators in the same universities. Five types ofacademic entrepreneurship were identified: 1. engaging in externally fundedresearch, 2. earning supplemental income, 3. gaining industry support foruniversity research, 4. obtaining patents or generating trade secrets, and 5.forming or holding equity in private companies based on a faculty member's ownresearch. Individual attitudes and characteristics were the most importantpredictors of large-scale science and supplemental income, while local groupnorms played a more important role in predicting active involvement incommercialization. (Publisher abstract)
As post World War II science has flourished it was accompanied by an exponential growth in journals. In recent years, the credibility of scientific publications, particularly in the biomedical fields, has been challenged by the perception of financial conflicts of interest involving both scientists and their academic institutions. Woolf, a sociologist of science, has summarized the problem:
In modern science the disinterestedness of scientists has been linked to their objectivity and thus to the reliability of their research. Although most people recognize that scientists are unlikely to be completely neutral with respect to their studies, they are skeptical about scientists who appear as advocates for certain positions rather than as objective presenters of fact [citation]. In several allegations of research misconduct, there have been charges that apparent financial conflicts of interest have distorted the knowledge base on which other decisions depend (Woolf 1994, 90)
The authors propose that professionalism, rather than being left to the chance that students will model themselves on ideal physicians or somehow be permeable to other elements of professionalism, is fostered by students' engagement with significant, integrated experiences with certain kinds of content. Like clinical reasoning, which cannot occur in a vacuum but must be built on particular knowledge, methods, and the development of skills, professionalism cannot flourish without its necessary basis of knowledge, methods, and skills. The authors present the need for an intellectual widening of the medical curriculum, so that students acquire not only the necessary tools of scientific and clinical knowledge, methods, and skills but also other relevant tools for professional development that can be provided only by particular knowledge, methods, and skills outside bioscience domains. Medical students have little opportunity to engage any body of knowledge not gained through bioscientific/empirical methods. Yet other bodies of knowledge-philosophy, sociology, literature, spirituality, and aesthetics are often the ones where compassion, communication, and social responsibility are addressed, illuminated, practiced, and learned. To educate broadly educated physicians who develop professionalism throughout their education and their careers requires a full-spectrum curriculum and the processes to support it. The authors sketch the ways in which admission, the curriculum (particularly promoting a sociologic consciousness, interdisciplinary thinking, and understanding of the economic/ political dimensions of health care), and assessment and licensure would function.
Many have recommended changing the professional development of physicians. Concluding that further educational process specification was inadequate, the Accreditation Council for Graduate Medical Education (ACGME) decided to specify six general competencies of graduate medical education (GME): patient care; medical knowledge; practice-based learning and improvement; professionalism; interpersonal skills and communication; and systems-based practice. Coupling them with a developmental view of professional knowledge and skill acquisition, the ACGME invited further specification and development of desired learning from the extended medical specialty community, including the specialty boards. This collaborative process offers a model of the role accrediting agencies can play in fostering workforce developmental change.
Despite increasing awareness about the potential impact of financial conflicts of interest on biomedical research, no comprehensive synthesis of the body of evidence relating to financial conflicts of interest has been performed.
To review original, quantitative studies on the extent, impact, and management of financial conflicts of interest in biomedical research.
Studies were identified by searching MEDLINE (January 1980-October 2002), the Web of Science citation database, references of articles, letters, commentaries, editorials, and books and by contacting experts.
All English-language studies containing original, quantitative data on financial relationships among industry, scientific investigators, and academic institutions were included. A total of 1664 citations were screened, 144 potentially eligible full articles were retrieved, and 37 studies met our inclusion criteria.
One investigator (J.E.B.) extracted data from each of the 37 studies. The main outcomes were the prevalence of specific types of industry relationships, the relation between industry sponsorship and study outcome or investigator behavior, and the process for disclosure, review, and management of financial conflicts of interest.
Approximately one fourth of investigators have industry affiliations, and roughly two thirds of academic institutions hold equity in start-ups that sponsor research performed at the same institutions. Eight articles, which together evaluated 1140 original studies, assessed the relation between industry sponsorship and outcome in original research. Aggregating the results of these articles showed a statistically significant association between industry sponsorship and pro-industry conclusions (pooled Mantel-Haenszel odds ratio, 3.60; 95% confidence interval, 2.63-4.91). Industry sponsorship was also associated with restrictions on publication and data sharing. The approach to managing financial conflicts varied substantially across academic institutions and peer-reviewed journals.
Financial relationships among industry, scientific investigators, and academic institutions are widespread. Conflicts of interest arising from these ties can influence biomedical research in important ways.
To investigate whether funding of drug studies by the pharmaceutical industry is associated with outcomes that are favourable to the funder and whether the methods of trials funded by pharmaceutical companies differ from the methods in trials with other sources of support.
Medline (January 1966 to December 2002) and Embase (January 1980 to December 2002) searches were supplemented with material identified in the references and in the authors' personal files. Data were independently abstracted by three of the authors and disagreements were resolved by consensus.
30 studies were included. Research funded by drug companies was less likely to be published than research funded by other sources. Studies sponsored by pharmaceutical companies were more likely to have outcomes favouring the sponsor than were studies with other sponsors (odds ratio 4.05; 95% confidence interval 2.98 to 5.51; 18 comparisons). None of the 13 studies that analysed methods reported that studies funded by industry was of poorer quality.
Systematic bias favours products which are made by the company funding the research. Explanations include the selection of an inappropriate comparator to the product being investigated and publication bias.
Personalized pharmaceutical marketing to physicians, including the provision of gifts and sponsorship of educational and recreational activities, raises ethical issues. We sought to determine the degree to which physicians regarded common pharmaceutical marketing activities as ethically problematic, and to compare the views of experienced physicians and physicians-in-training.
A questionnaire that included 18 scenarios portraying interactions between physicians and the pharmaceutical industry was distributed to residents and faculty members at a US medical school.
Most marketing activities were not thought to pose major ethical problems. Respondents tended to make distinctions about the ethical appropriateness of gifts on the basis of the monetary value and type of gift. Some respondents' views would be in violation of recent professional guidelines that address interactions between physicians and pharmaceutical companies. However, some respondents were troubled by activities that are permitted by professional guidelines. The responses of residents and faculty physicians were similar.
Despite the recent publicity about ethical problems in relationships between physicians and the pharmaceutical industry, inexperienced and experienced physicians at a single institution continue to have a rather permissive view about a variety of marketing activities.
Medical and health science schools occupy a prestigious place in U.S. society. When they express a position on tobacco use--either by action or silence--that expression is consequential. Recognizing this, the tobacco industry has worked to sustain and exploit relationships with academic health sciences institutions. Corporate contributions to medical research are more visible, but institutional investments in tobacco stocks are also crucial to these relationships. The American Medical Association divested (sold) its tobacco holdings in 1986, urging others to do the same. Yet, as late as 2004, at least five of the leading dozen medical schools have not divested, and those that have seem reluctant to publicize their actions. The authors use internal tobacco industry documents and secondary source material to describe and analyze Philip Morris's response to two cases of threatened academic divestment. In each case, the world's largest tobacco company succeeded in minimizing the impact of divestment activities--in the first, by muting the consequences of a divestment, and in the second, by convincing university decisionmakers to recommend against tobacco stock divestment. In addition to arguing that tobacco divestment would lead to other pressures or be ineffective, the company exploited university concerns about losing corporate research funding as a key element of its antidivestment strategy. If academic medical centers regard protection of the public's health as a primary mission, divestment from tobacco holdings is essential; profiting from tobacco either through investments or research funding undermines this mission. Silent divestment squanders opportunities for ethical leadership and public dialogue.
The role of the physician in modern society has undergone an extraordinary transformation in the past few decades31,42. Those who entered practice a generation ago had almost unquestioned authority, could usually pick their geographic location and mode of practice, and generally had substantial control over the method and amount of remuneration as well as over their lifestyle. The resources allocated to health care were expanding, and science was providing new and exciting methods to relieve human suffering. Physicians were treading relatively familiar paths, perpetuating patterns and practices of medicine that they believed were part of its tradition. Finally, they genuinely felt that as professionals they were providing useful services both to their patients and to society and thus were engaged in a noble calling. As the medical profession, including orthopaedic surgery, faces a new century, much has changed and medicine's response has often been defensive and insensitive to the needs of society40. In the nineteenth century, professionals were granted prestige, status, and financial rewards under the assumption that they would organize their lives around the concepts of service and altruism and would address the principal concerns of society. This arrangement is now understood to have constituted a social contract between medicine and society9,43,44, and it appears to have been one of the casualties of recent years, in which all forms of authority were regarded with skepticism by a questioning society7. The contract has been mostly unwritten and therefore implicit, and, until recently, it evolved slowly. The value system and the obligations necessary to sustain it were transmitted by respected role models in a relatively unstructured way, a process that was facilitated by the homogeneous nature of the medical profession and the relative simplicity of both society …
Many observers of medicine have expressed concerns that new doctors are not as well prepared as they should be to meet society's expectations of them. To assist medical schools in their efforts to respond to these concerns, in January 1996 the Association of American Medical Colleges (AAMC) established the Medical School Objectives Project (MSOP). The goal for the first phase of the project-which has been completed and is reported in this article-was to develop a consensus within the medical education community on the attributes that medical students should possess at the time of graduation, and to set forth learning objectives that can guide each medical school as it establishes objectives for its own program. Later reports will focus on the implementation phase of the MSOP. In this report, each of the four attributes agreed upon by a wide spectrum of medical educators is stated and explained, and then the learning objectives associated with the school's instilling of that attribute are stated. The first of the four attributes is that physicians must be altruistic. There are seven learning objectives, including the objective that before graduation, the student can demonstrate compassionate treatment of patients and respect for their privacy and dignity. The second attribute is that physicians must be knowledgeable; one of the six learning objectives is that the student can demonstrate knowledge of the normal structure and function of the body and of each of its major organ systems. The third attribute is that physicians must be skillful; one of the eleven learning objectives is that the student have knowledge about relieving pain and ameliorating the suffering of patients. The last attribute is that physicians must be dutiful; one of the six learning objectives is that the student have knowledge of the epidemiology of common maladies within a defined population, and the systematic approaches useful in reducing the incidence and prevalence of those maladies. The report ends by stating that (1) if a school's curriculum is shaped by the set of learning objectives presented in the report, the graduates will be well prepared to assume the limited patient care responsibilities expected of new residents and also will have begun to achieve the attributes needed to practice contemporary medicine; (2) schools should feel a sense of urgency in responding to the intent of the report; and (3) it is important to measure the outcomes of learning objectives, and better assessment methods should be developed, particularly ones to assess outcomes related to attitudes and values. Acad. Med. 1999;74:13-18.
Purpose: The author interprets the state of the art of assessing professional behavior. She defines the concept of professionalism, reviews the psychometric properties of key approaches to assessing professionalism, conveys major findings that these approaches produced, and discusses recommendations to improve the assessment of professionalism. Method: The author reviewed professionalism literature from the last 30 years that had been identified through database searches; included in conference proceedings, bibliographies, and reference lists; and suggested by experts. The cited literature largely came from peer-reviewed journals, represented themes or novel approaches, reported qualitative or quantitative data about measurement instruments, or described pragmatic or theoretical approaches to assessing professionalism. Results: A circumscribed concept of professionalism is available to serve as a foundation for next steps in assessing professional behavior. The current array of assessment tools is rich. However, their measurement properties should be strengthened. Accordingly, future research should explore rigorous qualitative techniques; refine quantitative assessments of competence, for example, through OSCEs; and evaluate separate elements of professionalism. It should test the hypothesis that assessment tools will be better if they define professionalism as behaviors expressive of value conflicts, investigate the resolution of these conflicts, and recognize the contextual nature of professional behaviors. Whether measurement tools should be tailored to the stage of a medical career and how the environment can support or sabotage the assessment of professional behavior are central issues. Final thought: Without solid assessment tools, questions about the efficacy of approaches to educating learners about professional behavior will not be effectively answered.
It is becoming increasingly evident that the conditions that fostered the growth and dominance of the professions during the early part of this century are being eroded by social change. Social, economic, and political trends are undermining claims to autonomy and monopoly by previously well-entrenched groups such as the legal profession in America. These trends include changes in the knowledge base, shifts in the composition of the profession, emerging employment patterns, consumerism, and encroachment from allied professions. The process of deprofessionalization is manifest in a variety of restrictions upon traditional prerogatives, which suggests a general weakening of the very legitimacy of the unregulated professional model of social organization.
The current trend toward the invasion of commerce into medical care, an arena formerly under the exclusive purview of physicians, is seen by the authors as an epic clash of cultures between commercial and professional traditions in the United States. Both have contributed to US society for centuries; both have much to offer in strengthening medical care and reducing costs. At the same time, this invasion by commercialism of an arena formerly governed by professionalism poses severe hazards to the care of the sick and the welfare of communities: the health of the public and the public health. Some of these hazards are briefly listed and reviewed, together with a brief outline of standards that might be established nationally to abate these hazards. A national agency in the private sector is proposed, the National Council on Medical Care, to set standards and provide an approval mechanism that would then be the basis for state enforcement through licensing. Two models for such an initiative are outlined, one based on the National Academy of Sciences as the initiating force, and the other on an initiative provided by a consortium of national charitable foundations interested in health policy. In both cases, wide support from the national foundations would be essential. In the case of the academy model, some government funds might also be available without loss of the freedom of a private-sector initiative. Some operational options for such a national council, its membership, and the conduct of its affairs are briefly outlined as a basis for further discussion.
The authors raise questions regarding the wide-spread calls emanating from lay and medical audiences alike to intensify the formal teaching of ethics within the medical school curriculum. In particular, they challenge a prevailing belief within the culture of medicine that while it may be possible to teach information about ethics (e.g., skills in recognizing the presence of common ethical problems, skills in ethical reasoning, or improved understanding of the language and concepts of ethics), course material or even an entire curriculum can in no way decisively influence a student's personality or ensure ethical conduct. To this end, several issues are explored, including whether medical ethics is best framed as a body of knowledge and skills or as part of one's professional identity. The authors argue that most of the critical determinants of physician identity operate not within the formal curriculum but in a more subtle, less officially recognized "hidden curriculum." The overall process of medical education is presented as a form of moral training of which formal instruction in ethics constitutes only one small piece. Finally, the authors maintain that any attempt to develop a comprehensive ethics curriculum must acknowledge the broader cultural milieu within which that curriculum must function. In conclusion, they offer recommendations on how an ethics curriculum might be more fruitfully structured to become a seamless part of the training process.
The current trend toward the invasion of commerce into medical care, an arena formerly under the exclusive purview of physicians, is seen by the authors as an epic clash of cultures between commercial and professional traditions in the United States. Both have contributed to US society for centuries; both have much to offer in strengthening medical care and reducing costs. At the same time, this invasion by commercialism of an arena formerly governed by professionalism poses severe hazards to the care of the sick and the welfare of communities: the health of the public and the public health. Some of these hazards are briefly listed and reviewed, together with a brief outline of standards that might be established nationally to abate these hazards. A national agency in the private sector is proposed, the National Council on Medical Care, to set standards and provide an approval mechanism that would then be the basis for state enforcement through licensing. Two models for such an initiative are outlined, one based on the National Academy of Sciences as the initiating force, and the other on an initiative provided by a consortium of national charitable foundations interested in health policy. In both cases, wide support from the national foundations would be essential. In the case of the academy model, some government funds might also be available without loss of the freedom of a private-sector initiative. Some operational options for such a national council, its membership, and the conduct of its affairs are briefly outlined as a basis for further discussion.
As society, including the medical profession, moves into a new century, the rate of change in the relationship between professions and society is unprecedented. All societies need healers, and in the English-speaking world the services of the physician-healer have been organized around the concept of the professional. The great increase in both state control and corporate involvement has seriously intruded into the traditional autonomy enjoyed by both the medical profession and individual physicians, and further changes can be expected. More physicians are becoming either employees or managers in the state or corporate sector, while others are being forced to compete in a marketplace that rewards entrepreneurial behavior. It is the responsible behavior of the professional that will protect the role of the healer. Medicine has been rightly criticized for placing undue emphasis on both income and power and for protecting incompetent or unethical colleagues; and it has failed to accept responsibility for injustices or inequities in health care systems and has moved slowly to address new diseases or issues. Nonetheless, all evidence indicates that society still values the healer-professional and does not wish to abandon professionalism as a concept--it appears to prefer an independent and knowledgeable professional to deal with its problem rather than the state or a corporation. For this reason, medicine's professional associations and academic institutions must ensure that all physicians understand professionalism and accept its obligations. In doing so, the objective should be to encourage the moral and intellectual growth of physicians by setting standards based on higher aspirations than can or should be enforced. In facing the complex world of our future, such action will both serve society and maintain the integrity of the profession.
Throughout this century there have been many efforts to reform the medical curriculum. These efforts have largely been unsuccessful in producing fundamental changes in the training of medical students. The author challenges the traditional notion that changes to medical education are most appropriately made at the level of the curriculum, or the formal educational programs and instruction provided to students. Instead, he proposes that the medical school is best thought of as a "learning environment" and that reform initiatives must be undertaken with an eye to what students learn instead of what they are taught. This alternative framework distinguishes among three interrelated components of medical training: the formal curriculum, the informal curriculum, and the hidden curriculum. The author gives basic definitions of these concepts, and proposes that the hidden curriculum needs particular exploration. To uncover their institution's hidden curricula, he suggests that educators and administrators examine four areas: institutional policies, evaluation activities, resource-allocation decisions, and institutional "slang." He also describes how accreditation standards and processes might be reformed. He concludes with three recommendations for moving beyond curriculum reform to reconstruct the overall learning environment of medical education, including how best to move forward with the Medical School Objectives Project sponsored by the AAMC.
The forces of rationality and commodification, hallmarks of the managed care revolution, may soon breach the walls of organized medical education. Whispers are beginning to circulate that the cost of educating future physicians is too high. Simultaneously, managed care companies are accusing medical education of turning out trainees unprepared to practice in a managed care environment. Changes evident in other occupational and service delivery sectors of U.S. society as diverse as pre-college education and prisons provide telling insights into what may be in store for medical educators. Returning to academic medicine, the author reflects that because corporate managed care is already established in teaching hospitals, and because managed research (e.g., corporate-sponsored and -run drug trials, for-profit drug-study centers, and contract research organizations) is increasing, managed medical education could become a reality as well. Medical education has made itself vulnerable to the intrusion of corporate rationalizers because it has failed to professionalism at core of its curricula-something only it is able to do--and instead has focused unduly on the transmission of esoteric knowledge and core clinical skills, a process that can be carried out more efficiently, more effectively, and less expensively by other players in the medical education marketplace such as Kaplan, Compass, or the Princeton Review. The author explains why reorganizing medical education around professional values is crucial, why the AAMC's Medical School Objectives Project offers guidance in this area, why making this change will be difficult, and why medical education must lead in establishing how to document the presence and absence of such qualities as altruism and dutifulness and the ways that appropriate medical education can foster these and similar core competencies. "Anything less and organized medicine will acknowledged... that it has abandoned its social contract and entered the temple of those who clamor, 'I can name that tune in four notes.'"
The diagnosis of contact dermatitis caused by clothing may be difficult because of its clinical polymorphism. Data in the literature suggest that textile dermatitis is more common than previously thought.
Our purpose was to study our patients suspected of having textile contact dermatitis from 1991 to 1997.
The records of the patients with positive reactions to allergens from the Textile Colors and Finish series in 3 contact dermatitis clinics were reviewed. All the patients were clinically evaluated and patch tested with the European Standard series and the Textile Colors and Finish series (Chemotechnique Diagnostics, Malmö, Sweden).
Twenty-two of the 55 patients (40%) had positive patch tests to the textile dye allergens. Four of them had occupationally related textile dermatitis. The most frequent allergens were Disperse Blue 124, Disperse Blue 85, Disperse Red 17, and Disperse Blue 106. Erythematosquamous lesions were the most common forms of textile dermatitis (56%), followed by pustular lesion (16%) and hyperpigmented patches (8%).
The relatively high percentage of positive results (40%) was attributable to the selected cohort of patients. In our series, positive reactions to the allergens Disperse Blue 124, 85, and 106 were common findings. Clinically, pustular allergic contact dermatitis, triggered by textile dyes was observed along with the more frequent erythematosquamous clinical form.
Clinical practice is changing rapidly. New cardiovascular drugs, antiinflammatory drugs, cancer chemotherapy, and other pharmacologic weapons are being added to physicians' therapeutic armamentarium virtually daily. Most clinical studies that bring new drugs from bench to bedside are financed by pharmaceutical companies. Many of these drug trials are rigorously designed, employing the skills of outstanding clinical researchers at leading academic institutions. But academic medical centers are no longer the sole citadels of clinical research. The past 10 years have seen the spectacular growth of a new research model. Commercially oriented networks of contract-research organizations (CROs) and site-management organizations (SMOs) have altered . . .
This article has no abstract; the first 100 words appear below.
In 1984 the Journal became the first of the major medical journals to require authors of original research articles to disclose any financial ties with companies that make products discussed in papers submitted to us.¹ We were aware that such ties were becoming fairly common, and we thought it reasonable to disclose them to readers. Although we came to this issue early, no one could have foreseen at the time just how ubiquitous and manifold such financial associations would become. The article by Keller et al.² in this issue of the Journal provides a striking example. The authors' ties with . . .
Marcia Angell, M.D.
Morality and integrity. Physicians are expected to demonstrate morality and integrity in their practice, and in their day-to-day lives. Physicians who do not do so will, without question, lose trust, and this will reflect upon the profession as a whole.
Autonomy. Autonomy is essential to the practice of medicine and has been labeled by some sociologists as the hallmark of a profession [10]. Physicians expect to be granted sufficient autonomy to act in the best interests of their patients. Traditionally, autonomy has been incomplete, with customs, codes of ethics, and legal constraints setting the boundaries. In cases where the medical profession feels that it is being restricted in its efforts to act in the best interests of the patient, however, it can legitimately resist unreasonable intrusions into that autonomy. The profession as a whole also requires sufficient autonomy to self-regulate.
Monopoly. Medicine's monopoly is granted under licensing laws. Because society appears to accept that licensure leads to higher standards, and because of the long education and training required, medicine expects that the monopoly will be maintained.
Little is known about the factors that influence housestaff attitudes toward pharmaceutical industry promotions or, how such attitudes correlate with physician behaviors. We studied these attitudes and practices among internal medicine housestaff.
Confidential surveys about attitudes and behaviors toward industry gifts were distributed to 1st- and 2nd-year residents at a university-based internal medicine residency program.
Ninety percent of the residents (105 of 117) completed the survey. A majority of respondents considered seven of nine types of promotions appropriate. Residents judged the appropriateness of promotions on the basis of their cost (median percentage of items considered appropriate 100% for inexpensive items vs. 60% for expensive ones) more than on the basis of their educational value (80% for educational items vs.75% for noneducational ones; P < .001 for comparison of appropriateness based on cost vs. educational value). Behaviors were often inconsistent with attitudes; every resident who considered conference lunches (n = 13) and pens (n = 18) inappropriate had accepted these gifts. Most respondents (61%)stated that industry promotions and contacts did not influence their own prescribing, but only 16% believed other physicians were similarly unaffected (P< .0001). Nonetheless, more than two thirds of residents agreed that it is appropriate for a medical institution to have rules on industry interactions with residents and faculty.
Residents hold generally positive attitudes toward gifts from industry, believe they are not influenced by them, and report behaviors that are often inconsistent with their attitudes. Thoughtful education and policy programs may help residents learn to critically appraise these gifts.
To determine senior residents' views on the meaning of professionalism and how they learned about it.
By means of a modified Dillman technique, all senior residents at two faculties of medicine (n = 533) were surveyed about professionalism during the 1998-99 academic year. The residents were asked to list attributes of professionalism and to rank methods they found most useful for learning about professionalism, to rate the adequacy and quality of their teaching about professionalism and their comfort in explaining the concept of professionalism to a more junior trainee, to list suggestions about how teaching about professionalism could be improved, and to name the medical organization most concerned with matters of professionalism.
A total of 258 residents (48.4%) responded. They listed 1,052 attributes they associated with professionalism. The three most common attributes, all listed by more than 100 respondents, were respect, competence, and empathy. The respondents had learned the most about professionalism from observing role models, they rated the quantity and quality of teaching about it positively, and they felt comfortable explaining professionalism to a junior resident. Only 56% of the residents correctly identified the Canadian medical organization most concerned with professionalism.
Residents' knowledge about professionalism reflects their early stage of development as physicians and their daily activities, where such aspects of professionalism as the social contract, codes of ethics, participation in professional societies, and altruism are not highlighted. Residency programs should develop teaching activities focusing on professionalism that relate to issues residents face in their daily work.
This article has no abstract; the first 100 words appear below.
Primary care practitioners in several states have recently decided to restructure their practices in a way that enables them to see a much smaller number of patients and to spend more time with the ones they do see. Patients enrolled in these practices, referred to as “luxury primary care,” pay an annual fee to the practice. In return for this annual fee, they can expect certain amenities that are not currently part of primary care, such as access to their physicians 24 hours a day, 7 days a week, using cell phones or prompt paging devices.¹ When they see their . . .
Troyen A. Brennan, M.D., J.D., M.P.H.
Brigham and Women's Hospital, Boston, MA 02115
I am indebted to Atul Gawande, Michelle Mello, David Studdert, David Fairchild, and George Thibault for their advice on earlier drafts of this article.
Source Information
Address reprint requests to Dr. Brennan at Brigham and Women's Hospital, 75 Francis St., Clinics 3 PBB, Boston, MA 02115, or at tabrennan@partners.org.
The author interprets the state of the art of assessing professional behavior. She defines the concept of professionalism, reviews the psychometric properties of key approaches to assessing professionalism, conveys major findings that these approaches produced, and discusses recommendations to improve the assessment of professionalism.
The author reviewed professionalism literature from the last 30 years that had been identified through database searches; included in conference proceedings, bibliographies, and reference lists; and suggested by experts. The cited literature largely came from peer-reviewed journals, represented themes or novel approaches, reported qualitative or quantitative data about measurement instruments, or described pragmatic or theoretical approaches to assessing professionalism.
A circumscribed concept of professionalism is available to serve as a foundation for next steps in assessing professional behavior. The current array of assessment tools is rich. However, their measurement properties should be strengthened. Accordingly, future research should explore rigorous qualitative techniques; refine quantitative assessments of competence, for example, through OSCEs; and evaluate separate elements of professionalism. It should test the hypothesis that assessment tools will be better if they define professionalism as behaviors expressive of value conflicts, investigate the resolution of these conflicts, and recognize the contextual nature of professional behaviors. Whether measurement tools should be tailored to the stage of a medical career and how the environment can support or sabotage the assessment of professional behavior are central issues. FINAL THOUGHT: Without solid assessment tools, questions about the efficacy of approaches to educating learners about professional behavior will not be effectively answered.
Altruism, accountability, duty, integrity, respect for others and lifelong learning are qualities that have been identified as central to medical professionalism. However, we do not have a systematically developed understanding of what is needed to optimise medical students' personal and professional development (PPD). We need some level of agreement on how to teach and assess PPD, but traditional educational methods may not be strong determinants of students' or graduates' actual behaviour in clinical settings.
This paper considers the factors that demonstrably influence doctors' behaviour as a contribution to the development of a model for considering PPD within the broader context of medical practice. The model presented acknowledges that behaviour change comes about through a number of influences including education, feedback, rewards, penalties and participation. These elements can be plotted against the cognitive, affective and metacognitive processes that are intrinsic to learning.
A framework that promotes the consideration of all of these factors in PPD can provide guidance for schools undergoing curriculum reform and inform further research into one of the most important and challenging aspects of medical education.
To investigate the relative impact on publication bias caused by multiple publication, selective publication, and selective reporting in studies sponsored by pharmaceutical companies.
42 placebo controlled studies of five selective serotonin reuptake inhibitors submitted to the Swedish drug regulatory authority as a basis for marketing approval for treating major depression were compared with the studies actually published (between 1983 and 1999).
Multiple publication: 21 studies contributed to at least two publications each, and three studies contributed to five publications. Selective publication: studies showing significant effects of drug were published as stand alone publications more often than studies with non-significant results. Selective reporting: many publications ignored the results of intention to treat analyses and reported the more favourable per protocol analyses only.
The degree of multiple publication, selective publication, and selective reporting differed between products. Thus, any attempt to recommend a specific selective serotonin reuptake inhibitor from the publicly available data only is likely to be based on biased evidence.
Medical schools, once devoted primarily to educating medical students, have evolved into complex academic medical centers (AMCs), some of which place a greater emphasis on research and the clinical business than on educating future physicians. This occurred primarily as the result of outside forces, specifically the available revenue streams that have fostered growth. Discipline-based departments have been at the center of the governance structure of medical schools, but many AMCs now have research institutes and centers to enhance research productivity, and faculty group practices to maximize clinical revenue. Although AMCs have been successful in making scientific discoveries, developing new technologies, and providing state-of-the-art clinical care, their successes have not always been favorable to the education mission. Furthermore, the roles of departments and their chairs have not always been carefully considered; a mismatch between organizational and governance structures is occurring. In this article several suggestions are offered to help medical schools rediscover their unique reason for existence and better distinguish core missions from core businesses. Mission-based management and mission-based budgeting provide the framework for maximum success of all the missions. Specific suggestions include (1) organizing a national task force to consider optimal organizational and governance structures of modern AMCs, (2) establishing a core teaching faculty, (3) creating a matrix letter of assignment that aligns salary rates with assigned activities, (4) linking education to the provision of health care to the underinsured, and (5) forming education centers to effectively centralize governance of the education mission.
The American Journal of Bioethics 4.2 (2004) 28-31
Delese Wear and Mark G. Kuczewski's characterization (2004) of professionalism as a "movement" is both apt (the activities taking place within organized medicine to establish professionalism as a core medical value fit the sociological definition of a "social movement") and timely (given American medicine's current state of institutional evolution). Over the past 30-plus years a variety of social forces have buffeted organized medicine's status as a profession, including:
All of these forces—and others—helped to create an overall sociopolitical and economic environment that would first challenge the professional prerogatives and privileges of organized medicine and then serve as a backdrop for organized medicine's announcement that "professionalism" would be its solution to the ever-enveloping shroud of medical commercialism and the commodification of healthcare.
The appearance of "big business" and "corporate medicine" at the city gates of organized medicine was greeted by the inhabitants with a mixture of distain and fear. First-tier medical journals such as JAMA, The New England Journal of Medicine, and the Annals of Internal Medicine published a barrage of articles and commentaries about what one authoring team labeled "[an] epic class of cultures between commercial and professional traditions in the United States" (McArthur and Moore 1997). Battle lines were drawn and sides labeled. Within this milieu of physician disillusionment and organizational consternation, a variety of groups within organized medicine (see below) began to identify "professionalism" as the horse that would carry medicine out of its valley of death by commodification. What is key—as Wear and Kuczewski note—is that the various activities and actions pursued by organized medicine constitute a new social movement and that the eventual paths that this movement will take in the future have defining implications for both healthcare in general and organized medicine in particular.
As organized medicine's newly-found fascination with professionalism began to unfold in the 1980s, two broad orientations toward professionalism appeared. The first was a "prodigal son" form of argument where medicine had fallen from grace or lost its professional bearings and therefore needed to reconnect with, reestablish, or recommit to "core professional values." The second "call" to professionalism stressed more the sociopolitical and economic changes in society (and medicine) and argued for a "new professional ethic" (Irvine 1999; Mechanic 2000). Regardless of one's analytical proclivities, the "popularization of professionalism" within organized medicine revealed a rather embarrassing fact—at least for an occupational group that had long claimed the professionalism high ground. There was little consensus about how the term professionalism was to be defined (Swick 2000) and measured (Arnold 2002). This definitional and operational lacunae notwithstanding, a number of groups—including trade associations (e.g., American Medical Association, Association of American Medical Colleges), specialty societies (e.g., American Board of Internal Medicine or ABIM, American College of Surgeons), accrediting bodies (e.g., Liaison Committee on Medical Education, Accreditation Council for Graduate Medical Education), and organizations involved in occupational licensure (e.g., National Board of Medical Examiners)—began to organize initiatives to define, and/or measure "professionalism" (Arnold 2002). The most recent and widely-circulating document in this regard is the Medical Professionalism Project (see...
Mentoring skills are valuable assets for academic medicine faculty, who help shape the professionalism of the next generation of physicians. Mentors are role models who also act as guides for students' personal and professional development over time. Mentors can be instrumental in conveying explicit academic knowledge required to master curriculum content. Importantly, they can enhance implicit knowledge about the "hidden curriculum" of professionalism, ethics, values and the art of medicine not learned from texts. In many cases, mentors also provide emotional support and encouragement. The relationship benefits mentors as well, through greater productivity, career satisfaction, and personal gratification. Maximizing the satisfaction and productivity of such relationships entails self-awareness, focus, mutual respect, and explicit communication about the relationship. In this article, the authors describe the development of optimal mentoring relationships, emphasizing the importance of experience and flexibility in working with beginning to advanced students of different learning styles, genders, and races. Concrete advice for mentor "do's and don'ts"is offered, with case examples illustrating key concepts.
Most medical schools now include some component of professionalism in their curriculum, ranging from "white coat" ceremonies to didactic and small-group, case-based discussions. Often this format does not provide a context for the course content nor does it necessarily make the curricular themes relevant to population groups and communities most vulnerable to the inequities and injustices present in health care. The authors describe a community-based professionalism curriculum for preclinical and clinical year medical students and report evaluation data from three years (2001-2003) of this national demonstration project. The curriculum emphasized four themes: service, community, advocacy, and ethical behavior and was based on a service-learning pedagogy applied within community-based organizations. As part of the program evaluation, 95 students from 33 medical schools between the years 2001 and 2003 (response rate: 84.8%) completed an anonymous questionnaire. When asked what did they learn about professionalism that they did not learn (or expect to learn) in their medical school curriculum, the most common themes were (1) factors and influences affecting professional behavior, with many specifically citing pharmaceutical companies and insurance carriers (46.3%); (2) the role and importance of physician advocacy on behalf of their patients (37.9%); and (3) issues specific to the needs of vulnerable and disadvantaged populations (20.0%). This project demonstrates that community-based experiences can provide unique and relevant learning in a professionalism curriculum that can complement existing medical-school-based efforts.
A productive and ethical relationship between the pharmaceutical industry and physicians is critical to improving drug discovery and public health. In response to concerns about inappropriate financial relationships between the pharmaceutical industry and physicians, national organizations representing physicians or industry have made recommendations designed to reduce conflicts of interest, legal exposure, and dissemination of biased information. Despite these initiatives, the prescribing practices of physicians may be unduly influenced by the marketing efforts of industry and physicians may inadvertently distribute information that is biased in favor of a commercial entity. Moreover, physicians may be vulnerable to prosecution through federal anti-kickback and false claims statutes because of potentially inappropriate financial relationships with pharmaceutical companies. Since academic medical centers have a critical role in establishing professional standards, the faculty of Yale University School of Medicine developed guidelines for the relationships of faculty with the pharmaceutical industry, which were approved in May 2005. Input from clinical faculty and from representatives of the pharmaceutical industry was utilized in formulating the guidelines. In contrast to existing recommendations, the Yale guidelines, which are presented as an Appendix here, ban faculty from receiving any form of gift, meal, or free drug sample (for personal use) from industry, and set more stringent standards for the disclosure and resolution of financial conflict of interest in Yale's educational programs. The growing opportunities for drug discovery, the need to use medications in a more evidence-based manner, and preservation of the public trust require the highest professional standards of rigor and integrity. These guidelines are offered as part of the strategy to meet this compelling challenge.
- Wilkes