Chapter 35: Professionalism in medicine –striving for excellence
|"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?"|
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 physicians 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 youre 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
I = Intimacy
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 publics 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