The 29th
edition of Dorland’s Illustrated Medical
Dictionary1 defines
“professional” as “1) Pertaining
to one’s profession or occupation; 2) one who
is a specialist in a particular field or occupation.”
These are hardly illuminating definitions. My difficulty
in defining professionalism has similarities to a
1964 U.S. Supreme Court decision in which Justice
Potter Stewart, writing a concurring opinion on a
case involving hardcore pornography, stated: “I
shall not today attempt further to define [obscenity]
…but I know it when I see it.”2
Certainly, I suggest, each of us can recall professors
and others who have served as role models and demonstrated
professionalism consistently. For me, my mentor, Robert
D. Dripps, M.D., typifies the true professional. The
descriptors I apply to one who demonstrates professionalism
include competence, confidence, compassion and integrity.
Such individuals command the respect of others and
often are consulted by them.
A professional appearance also counts. Remember, Hippocrates
advised that the physician be “clean, well-dressed
and anointed with sweet-smelling unguents.”
While the last is no longer required, a neat, clean
appearance is desired by patients even in this era
of more casual attire. Scrub suits should be clean
and unstained, and a clean white coat over the scrub
suit is essential outside the operating room.3
Progress toward professionalism in anesthesiology
practice has been manifest in many ways, including,
but not limited to, the encouragement and direct facilitation
of scientific research and advances; improvements
in relationships with and recognition by other physicians
and their medical organizations; support of innovative
contributions to medical education; constructive interaction
with a variety of governmental bodies; encouragement
of beneficial new advances in the delivery of medical
care; and, especially, a widely recognized and lauded
leadership in initiating innovations in the provision
of effective quality control measures for the delivery
of safe medical care.
Internet and literature searches indicate that the
concept of professionalism is a hot topic in many
fields. Articles dealing with professionalism have
appeared recently in legal, engineering, computing
and educational publications and in other medical
specialty publications.
Within medicine a most ambitious program was introduced
in 2002 by the American Board of Internal Medicine
(ABIM) Foundation, the American College of Physicians-American
Society of Internal Medicine (ACP-ASIM) Foundation
and the European Federation of Internal Medicine.
Together they have prepared a “Charter on Medical
Professionalism” based on three fundamental
principles and 10 professional responsibilities/commitments
[Table 1].
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This charter was created in response to many physicians
“experiencing frustration as changes in health
care delivery systems in virtually all industrialized
nations threaten the very nature and values of medical
professionalism.”4
In anesthesiology the pressures to increase productivity
in the operating room (e.g., decreasing downtime
and lengthening the day) to compensate for decreased
reimbursement to both hospitals and physicians illustrate
this threat. The explosive growth in day surgical
centers — where there may be less time for
preoperative evaluation, and postoperative follow-up
is often reduced to a telephone call — is
another potential threat. In such situations, the
opportunity to establish true rapport with patients
is decreased, if not eliminated. Anesthesiologists
must respond to these pressures but must do so in
a way that does not threaten “the very nature
and values of medical professionalism.”
Interestingly the principles advocated in the charter
are remarkably similar to three assumptions concerning
anesthesia presented by then ASA President-Elect
Peter L. McDermott, M.D., to the 1993 ASA House
of Delegates, namely that we:
• Place service to patients and to society
above personal gains;
• Are physicians first and anesthesiologists
second; and
• View medicine as a profession, not an
institutional service.5
In my 1995 President-Elect address, I added a fourth
assumption:
• We are anesthesiologists first and subspecialists
within the specialty of anesthesiology second.6
Collectively these assumptions apply the Charter
on Medical Professionalism to anesthesiology. The
unique feature not addressed in the charter is the
assertion that anesthesia is not an institutional
service. This is an issue about which anesthesiologists
have had to educate hospital administrators and
boards for many years.
In providing care to patients, whether in the traditional
mode of “rendering a patient insensible to
the manipulation of the surgeon” (admittedly
a woefully inadequate description) or one of the
subspecialties (pain, critical care, obstetric anesthesia,
etc.), we must conduct ourselves as physicians concerned
for the entire patient (not, for example, just their
airway). We must listen to the patient’s concerns,
explain the therapeutic options honestly and openly
and recommend an anesthetic plan. Equally important
is the need to acknowledge patient autonomy in determining
the treatment plan. By doing so in an honest and
compassionate manner while administering care in
a competent manner, we will be fulfilling our obligations
as medical professionals.
This article began with a definition of a professional,
but not professionalism. This was not an omission.
“Professionalism” like “art”
and “justice” are abstract concepts.
Forget the dictionary definition and paraphrase
Justice Stewart’s decision: “I may not
know how to define professionalism, but I know it
when I see it.” Professionalism starts with
a commitment to achieve something more satisfying
than immediate personal gain and requires a commitment
and devotion to quality, excellence and personal
sacrifice that goes beyond an eight-hour day. Professionalism
must rest on a solid base of education, experience
and skill and must encompass real respect for other
professionals as well as patients.
| References: |
| 1. Anderson DM, ed. Dorland’s Illustrated
Medical Directory. Philadelphia: WB Saunders.
2000:1463. |
| 2. Jacobellis vs. Ohio, 387 U.S. 184, 198,
(1964). |
| 3. Brandt LJ. On the value of am old dress
code in the new millennium. Arch Intern.
2003; 163:1277-1281. |
| 4. Medical professionalism in the new millennium:
A physician charter. Ann Int Med. 2002;
136:243-246. |
| 5. McDermott P. President-Elect address. 1993
ASA House of Delegates. 412-2. |
| 6. Ellison N. President-Elect address. 1995
ASA House of Delegates. 412-2. |
| |
|
Norig Ellison, M.D., is Emeritus Professor of
Anesthesia, University of Pennsylvania School
of Medicine, Philadelphia, Pennsylvania. He
was ASA President in 1996. |
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