by Mike Magee MD
As I mentioned last week, I’ve been in the early stages of a purposefully disruptive project titled “Advanced Professionalism”, which involves reviewing a decade of Medical Education literature on the topic with an eye toward challenging traditional thinking. All sources this week pointed to the seminal work of Dr. Thomas S. Inui, “A Flag In The Wind: Educating For Professionalism In Medicine”. As a Petersdorf Scholar-in-Residence at the Association of American Medical Colleges (AAMC) in 2002, Dr. Inui opened his mind and heart to try to understand whether and how professionalism could be taught to medical students and residents.(1)
At one point he reflects on the varied definitions or lists of characteristics that had been compiled by multiple organizations and experts, and then comments:
“From my own perspective, I have no reservations about accepting any, or all of the foregoing articulations of various qualities, attitudes, and activities of the physician as legitimate representations of important attributes for the trustworthy professional. In fact, I find it difficult to choose one list over others, since they each in turn seem to refer largely to the same general set of admirable qualities. While we in medicine might see these as our lists of the desirable attributes of professionalism in the physician, as the father of an Eagle Scout I know that Boy Scout leaders use a very similar list to describe the important qualities of scouts: ‘A Scout is trustworthy, loyal, helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean, reverent (respecting everyone’s beliefs).’ I make this observation not to descend into parody, but to make a point. These various descriptions are so similar because when we examine the field of medicine as a profession, a field of work in which the workers must be implicitly trustworthy, we end by realizing and asserting that they must pursue their work as a virtuous activity, a moral undertaking.”(1)
This is an important observation. Later in the report, he shares: “The processes of formation include experience and reflection, service, growth in knowledge of self and of the field, and constant attention to the inner life as well as the life of action. ‘Who am I becoming as I move towards this life of service?’ is a critical question in formation, as disciplinary acculturation and expertise increases. Acknowledging that the educational process in medicine changes – in some substantive sense – who we are as well as how we relate to others, may be the key to understanding why we need to be mindful, articulate, and reflective about the process.”(1)
“Who am I becoming?” is the right question. But equally important (perhaps more) is “Why am I becoming that?” In the same year when Dr. Inui was doing his AAMC fellowship, John Inglhart, founding editor of Health Affairs, interviewed Steven Schroeder, who had announced his coming retirement as CEO of the Robert Wood Johnson Foundation. Schroeder said, “If physicians and nurses, who are central to the operation of the system, however care is financed, are dissatisfied and feel undervalued, I grieve for that system because that is a system in trouble.”(2) Here we see a shift, away from “I” to “it”. It is the “system”, not an individual or even an individual’s teachers, that is “in trouble”. “Bad people or bad design?”, Deming might ask.(3) (more on that next week)
This is the starting point of my disruptive thinking. Here is the troublesome question that underpins the need for “Advanced Professionalism”: What if our failings in ‘professionalism’ are more fundamental and foundational, the result of a non-adaptive and ancient system – still centered on a brick and mortar “hospital-medical office loop”; still backward facing and reacting to illness rather then forward-facing and managing customized and personalized strategic health planning; still over-investing at the tail end of life and under-investing in conception to age three; still unaware that the home could be a center of health and the care team could have (should have) a 24/7 health professional presence in it?
What if our mentors are able to “voice” and “model” professionalism, and even appear to be “practicing” professionalism, but the system itself makes it impossible for them and for their students to “realize” professionalism?
My early assessment: “The Health Care System in the United States is actively transforming. Health is rapidly becoming synonymous with reaching full human potential. Health care provision has been redefined as a right carrying with it responsibilities for individuals, families and community. Provision of care is increasingly a collaborative effort with individual providers giving ground to health care teams, and consumers joining hands with providers in strategic health planning and mutual decision making.”(4) The role of ‘professionalism’ in training of physicians and in the delivery of care has been heralded by major scientific bodies including the AAMC, Institute of Medicine, the ACGME and the ABMS. Their listing of desirable attributes in health care professionals is helpful. But absent the context of rapid environmental change, the modeling of new approaches to care that are emerging from both the consumer and provider side, and the integration of the latest social science concepts which impact human planning, development and potential, physicians will predictably under perform in the modern world and not fully realize either the professionalism they desire or their full leadership potential in the future.
What does Advanced Professionalism require? “Who am I becoming?” must be accompanied by “What am I building, where, how and for whom?” More to come next week.
1. Inui, TS. A Flag In The Wind: Educating For Professionalism In Medicine. February, 2003. AAMC. https://services.aamc.org/publications/index.cfm?fuseaction=Product.displayForm&prd_id=111&showTopics=true
2. Iglehart JK. Interview: Addressing Both Health And Health Care: An Interview With Steven A. Schroeder.2002.http://content.healthaffairs.org/cgi/content/full/21/6/244
3. Deming, W. Edwards (2000). The New Economics for Industry, Government, Education (2nd ed.). MIT Press. http://www.worldcat.org/oclc/44162616
4. Magee M. Powering Healthcare Visions: Taking Advantage of Complexity, Connectivity, and Consumerism. Intel Technology Journal. Volume 13, Issue 3, 2009. http://www.intel.com/technology/ITJ/2009/v13i3/ITJ9.3.0-Healthcare-Visions.htm