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35-Professionalism
in medicine –striving for excellence |
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"Is it not
also true that no physician, in so far as he is
a physician, considers or enjoins what is for the
physician’s interest, but that all seek the
good of their patients? For we have agreed that
a physician strictly so called, is a ruler of bodies,
and not a maker of money, have we not?"
- Plato. |
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Doctors are proud that they are members of the most highly
respected profession. They have traditionally always been
held in high regard, but this status is now under siege. There
are many reasons for this "deprofessionalization"
of medicine, and doctors finds they are threatened today by
many forces: technology, corporatization, specialization,
failure, and greed.
Technology. While modern technology is very glamorous and
allows physicians to bask in success stories which are highlighted
in the media, the same technology also reduces the physician's
role to that of a mere provider of healthcare services, so
that the physician is perceived as more of a technician than
a professional. Technology can depersonalize medicine and
"de-professionalize" a physician.
Corporatization of medicine. The advent of profit making corporate
hospitals in India is transforming medical care , so that
it is now becoming part of what Arnold Relman called "the
new medical-industrial complex" , where patents and profits
are more important than patient care, the doctor-patient relationship
or bedside manner. Patients now choose medical care like they
select their hotels – by brand name, rather than the
competence of the doctor.
Specialization. Superspecialisation and subspecialisation
have become the norm in medicine today. Specialists often
have no personal relationship with the patient, so that most
specialists now identify patients by their disease , rather
than as human beings who happen to have a disease. Patients
in corporate hospitals are often shuttled from specialist
to specialist without any coordination or continuity of care,
so they often end up feeling like cattle – and this
breeds discontent and unhappiness.
Limitations of modern medicine. Patients are now becoming
aware that doctors don’t have cures or magic bullets
for most illnesses. The doctor is no longer seen to be omnipotent
, and with the realization that there are limits to what medical
science can do, there is now increasing interest in alternative
systems of medicine, further threatening the exalted status
of the doctor.
Greed. When patients are bombarded with accounts of gross
negligence, incompetence, greed, and fraud on the part of
doctors in the media, they lose trust in their physicians.
Each newspaper article which describes babies being sold,
racketeering in kidneys or scams in MBBS examinations digs
a deeper grave for all doctors’ reputations. “
Ask not form whom the bell tolls – it tolls for thee”.
Physicians the world over are now realizing that their professional
status is under threat, as a result of which many are now
organizing to restore the professionalism of physicians. The
Medical Council of India has also issued an updated version
of its
Code of Medical Ethics , to help restore the lost luster of
the profession.
We need to remember that medical professionalism rests on
three pillars : expertise, ethics, and autonomy. Expertise
derives from a body of specialized knowledge and skills whose
utility is constantly invigorated by the results of research;
ethical behaviour flows from a unique combination of values
and standards, where doctors are expected to put their patient’s
interests ahead of their own; and autonomy means that society
is willing to allow the profession to function independently,
because it expects the profession to police itself. Our autonomy
also rests on three claims: firstly, that there is such an
unusual degree of knowledge and skill involved in medical
work that it can only be regulated by doctors; secondly, that
doctors are responsible and may be trusted to work conscientiously,
without supervision; and, thirdly, that the profession will
regulate itself by taking appropriate action when individual
doctors do not perform competently or ethically.
Autonomy is given on the understanding that professionals
will put the welfare of both the patient and society above
their own, and that they will be governed by a code of ethics.
This is why professional self regulation is key to the concept
of an "independent profession." However, for self
regulation and professional independence to continue, patients
must feel able to trust their doctors , and society must feel
able to trust the medical profession. We must become more
transparently accountable for our performance and show, in
ways that the public can understand and relate to, that self
regulation really works.
Today, however, society feels that the profession has done
a very bad job in regulating itself. The Medical Council of
India, the medical profession’s apex body has itself
become a hotbed of corruption. Many laypeople feel that doctors
are bound in a conspiracy of silence in which they refuse
to testify against the negligent actions of other bad doctors.
This is one of the reasons why the Government brought doctors
under the purview of the Consumer Protection Act, so that
they could become more answerable for their actions to their
patients.
Shamefully, matters today have come to such a sad pass that
doctors are being compelled by law to declare that they will
not perform illegal acts ! Gynecologists are being asked by
the Government to prominently display boards which say that
fetal sex determination ( an act which has been illegal in
India since 1997 after the passage of the PNDT Act) is not
performed in their clinics ! We all are to blame for this
sad state of affairs, because we have done such a poor job
of policing ourselves . A few bad sheep give the entire profession
a bad name, and because we turn a blind eye , we make a bad
situation even worse. As the cancer of kickbacks and “under
the table “ payments spreads, the practise is pardoned,
condoned, and tolerated , until it finally becomes the norm
– so that doctors who are not corrupt are considered
to be abnormal !
Remember that each individual doctor-patient interaction allows
you the opportunity to shine as a professional – make
the most of it ! Being a professional does not mean being
cold and impersonal . In fact, a doctor who is a good professional
has a very close personal relationship with his patients,
because he knows that he is in the service industry, where
everything is based on personal relationships.
The best way of being a good professional is to follow the
golden rule – do unto others as you would have them
do unto you. If you put yourself in your patient’s shoes,
you will always know how to behave. It’s helpful to
remember what you go through when you need to hire a professional
, such as a lawyer or an accountant. Retaining a professional
requires you to put your affairs in someone else’s hands.
You are forced into an act of faith, and while you can research
their background and check their technical skills, when the
final decision on whom to hire comes, you must ultimately
decide to trust someone, which is never a comfortable thing
to do. What you want is someone who you can trust will do
the right thing- and so do your patients !
So how do you get your patients to trust you ? By proving
that you deserve their trust – and you need to earn
this, by being generous with your knowledge; showing your
patients that you care; respecting their time; and fulfilling
your promises. The hallmark of doctors who have been elevated
to the status of being treated as trusted advisors by their
patients is that the doctor places a higher value on maintaining
and preserving the doctor-patient relationship itself , rather
than on the outcome of the current consultation.
Establishing a history of reliability is one way to build
trust. For example, if you tell the patient you're going to
call with lab results, make certain that you do just that.
Doing this the first time will show your patients that they
can count on you. Doing it again and again will build trust.
To win your patient’s trust, you have to behave as a
professional – someone who will place the patient’s
interests before his own – so that both of you benefit
in the long run ! This is why senior doctors valued their
reputation so much – it was built on the foundation
of a lifetime of hard work – and even though it is intangible,
it represents the fact that patients have trust in you.
The Trust Equation , as defined by David Maister, is simple.
T = C + R + I/ S, where
T = Trustworthiness
C= Credibility
R= Reliability
I = Intimacy
S= Self-orientation
Credibility = can your patient trust what you say ?
Reliability = can he trust your actions, confident that you
will act honorably ?
Intimacy = is he comfortable discussing his feelings and emotions
with you ?
Self-orientation = can he trust your motives, knowing that
you care about him, and will act in his best interests ?
If you want to be respected as a professional, it is also
important that you look like one ! Personal grooming is vitally
important, as is your bedside manner. Remember that patients
examine you in great detail, and the way you carry yourself
is very important.
You must look successful to convince your patients that you
are – and the packaging can be as important as the product
! Many patients say they feel better just after seeing the
doctor , which is you need to take time and trouble over the
way you look. Not only should you be fit and not smoke; you
should also be well-dressed and well-groomed. A sloppily dressed
doctor can be invisibly signaling to his patients that he
may be sloppy in his operative technique as well. For example,
wearing a smart suit can help to enhance your image –
and if it helps your patients to get better sooner, surely
this is a worthwhile investment !
Remember that professional status is not a doctor’s
inherent right, but rather a right which is granted by doctors
to society. Its maintenance depends on the public's belief
that physicians are trustworthy, and to remain trustworthy,
doctors must meet the obligations expected by society. Professionalism
should be taught at all levels of medical education , so future
generations of doctors will still be proud to be a part of
this ancient and respected profession. Remember that if you
are a good professional, you will become a trusted advisor
to your patients, so that not only will you be their doctor,
you will also become their friend, philosopher and guide –
enriching both their life as well as
yours !
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