Norig Ellison, M.D.
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].
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.
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.