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S.Y. Tan, MD, JD
The doctor’s badge is his white coat, his stethoscope. What message is my badge sending these days? Does it still proudly proclaim that the health and dignity of patients will be my first concern? Or does it say that I will treat your medical ills for a fee? That I will sell you an "MC" without a legitimate medical reason? That I will put savings before quality as instructed by my employer? In my adopted country of America, the medical badge is tarnishing. Buffeted by litigation run amuck and increasing mercantilism, the American physician is beginning to turn his back on the healthcare system he works in, and the patients he serves. Physicians are complaining about inadequate reimbursements, and brazenly embracing unionization, even pondering boycotts. To its shame, the U.S. has over 40 million uninsured, many therefore deprived of medical services. And it has allowed the cancer of for-profit managed care organizations to slowly eat away at the patient’s right to choose high quality care.
Which is why the Singapore Medical Association’s Center for Professionalism and Ethics is such an extraordinary achievement, refreshing in its rarity, and important beyond mere symbolism. In safeguarding all that is sacred about the medical profession, your precious Center is making a simple and uncompromising statement that the patient will always come first. I feel extremely privileged to be a speaker on this momentous occasion of the Center’s founding. I thank you all for this high honor.
I shall begin my reflections on medical professionalism by telling you a short but true story. It isn’t my story, and you can read about it as originally told by Dr. Faith Fitzgerald, the Assistant Dean of student affairs at the University of California, Davis (1). The story concerns a student who wanted to be a doctor. He had applied to the University of California at Davis, but his application was assigned to the rejection bin. He did not have the outstanding academic grades that would get him onto the interview list. Based on his college grades and admission test scores, he simply wasn’t sufficiently competitive. As is the habit at UC Davis, a faculty member reviews all rejection folders to see if an otherwise worthy student had been inadvertently bypassed. Dr. Faith Fitzgerald performed this task, and noticed an unusual letter of recommendation for an applicant. She writes: "It was from a professor of biochemistry in some small college I have never heard of. He said he dealt very little with premedical students, and did not really know what the admissions committee might be looking for. The student he was recommending, he went on, was not an intellectual giant – though highly competent. He had not excelled in athletics, was not terribly literary, had no outstanding talents as regards art or music, and in general was a solid, steady, unexceptional young man – except in one respect. He had, the professor said, a "servant’s heart." And though he wasn’t sure, the professor went on, since he really didn’t know what the medical school thought was important, the professor believed that, as a patient, he would want to be cared for by a doctor who had a "servant’s heart." The year was 1996. UC Davis interviewed the student and accepted him into medical school. I am told he recently graduated and will undertake residency training in pediatrics. As a medical student, he was elected into the Alpha Omega Alpha (AOA) honor society whose motto is " Worthy to serve the suffering"(2).
Webster’s Collegiate Dictionary defines professionalism as the conduct, aims or qualities that characterize or mark a profession or a professional person. All professionals share common characteristics such as self-governance, accountability, life-long learning, fiduciary responsibilities, and most of all, a Code to abide by. Medical professionalism differs from other professions in both content and motivation. It is a service profession dedicated to patients, centering on the doctor-patient relationship. The goals of Medicine were recently re-articulated in a research project out of the Hasting’s Center (3). Medicine seeks the prevention of disease and injury, the promotion and maintenance of health, the relief of pain and suffering, the care and cure of those with a malady, the avoidance of premature death, and the pursuit of a peaceful death. Modern medicine’s mind-boggling scientific advances are taught only in medical schools. Yet, it was not long ago, within the space of a single lifetime, that the likes of Sir William Osler helped changed medical schools from mercenary trade schools into intellectually demanding academic institutions (4). But it is not what we do as doctors but how we do it that defines medical professionalism. It is the unconditional caring of the patient, putting others before self, regardless of ability to pay or station in life. Allusions to Medicine’s nobility can be found in antiquity. Charaka Samhita developed an elaborate Indian code of conduct, asserting "He who practices not for money nor for caprice but out of compassion for living beings (bhuta-daya), is the best among all physicians"(5). The Islamic code considers health to be a basic human necessity and not a luxury. A patient should not be denied services even if he or she cannot afford the fee (6). And the Chinese equivalent of the Hippocratic Oath, authored by China’s best known medical ethicist Sun Simiao, in the 7th century, exhorts the physician to develop first a sense of compassion and piety, and then to make a commitment to try to save every living creature, to treat every patient on equal grounds, and to avoid seeking wealth because of his expertise (7). Nearly 2,500 years ago, Hippocrates, Medicine’s founding father, articulated enduring ethical principles that he felt should define the healing profession. These principles, embodied in the Hippocratic oath, remind us of our prime duty to patients, to teach, and to preserve doctor-patient confidentiality. Together with preaching against the taking of human life, even in the name of mercy, Hippocrates invoked the celestial vow that "with purity and with holiness, I will pass my life and practice my Art." Enduring words, indeed, of an ancient sage, spoken "with the grace of humility"(8). Most of us know instinctively what is meant when we hear the words "he’s so professional." The designation evokes an image of high competence and high ethics. Someone commanding respect. To formalize and expand on these notions, and to ensure that board certification in the specialty of internal medicine reflects properly learnt attitudes and values, the American Board of Internal Medicine recently embarked on a study of medical professionalism. In a monograph entitled "Project Professionalism" published in 1995, the Board characterized professionalism in medicine as, first and foremost, requiring the physician "to serve the interests of the patient above his or her own self-interest." It specifically spelled out these 8 elements of professionalism: altruism, accountability, excellence, duty, service, honor, integrity and respect for others (9). These may be simplified into the big 3: altruism, excellence, and ethics. Let me now share my thoughts on each.
Altruism is almost an old-fashioned word, discarded by the modernist, and uncomfortably acknowledged by some physicians. But it needs to be strongly embraced, because it is the essence of medical professionalism. Altruism means doing good for others, and putting their interests before our own, sometimes at great personal sacrifice. Doctors regularly give up their weekends and sleep time to care for those whose healthcare needs cannot wait. They put themselves at risk for hepatitis and AIDs. They are exhorted to treat all irrespective of ability to pay. All to benefit the patient. Few other professions extract such demands from their members. Sir William Osler, arguably the most famous of modern-day physicians, said it best in these simple words: "The profession of medicine is distinguished from all others by its singular beneficence"(4). "The grocer who refuses free food to the hungry is not condemned; The builder does not earn scorn by failing to give houses to the homeless; The clothier is not expected to hand out winter coats to those who have none. But if a doctor turns away a sick person because he or she has no money, we are revulsed"(10). It is fashionable these days to speak of medicine as a business. There is, in reality, nothing inconsistent about being both a noble profession and a business at the same time. In a way, we are all entrepreneurs, some of us more so than others. Yet professionalism finds a comfortable home between the two extremes of medical service. At one end are the "money grubbers", those whose motivation to serve the sick is guided by personal gain and power. At the other extreme, we have the saintly "altruistic missionaries" whose calling must surely come from a higher power. Professionalism thrives on this rocking-horse of Medicine, so long as we are mindful of the perils of greed, and the need to always put the patient first (11). Ours is a profession in which we do well for ourselves by doing well for others. Or, as Dean John Benson, president emeritus of the American Board of Internal Medicine, said: "Professional behavior will provide an enduring answer that will outlive current notions framed around market values, managed access and even technology as the foundation of the health care system"(12). How do we perpetuate a progeny of professionals who will always put the patient first, ahead of the employer, the health plan, even the doctor himself? I suspect that much of altruism is learnt early in life through the positive influence of parents, teachers, religious leaders and good friends. By the time the student enters medical school, it is probably too late. Oh, they will tell you during the interview all the right answers: how they will serve mankind, how money matters little, how they are attracted to the challenge of mastering a fascinating field. These are socially correct responses, and they will parrot for us what we wish to hear. If we wish to have doctors who treat their work as a calling rather than a trade, then medical school admission committees ought to look more closely for evidence of altruistic behavior in the applicant. This may not be easy, but volunteer work in Hospice or a HIV clinic, serving the poor at soup kitchens, and other indicia of community service may be very important criteria indeed. Ah, we seek a servant’s heart and the motivation to serve. Motivation is not exactly the same as incentive. Motivation comes from within, an innate drive. It is a humane value, whereas incentives are social constructs or individually valued rewards for desired behavior. This is not to say that incentives are unimportant as "an impoverished, shunned, deprived, unhappy person is less likely to behave altruistically"(13). Still, the balance between motive and incentive is an important determinant of physician behavior. In the new world of managed care, one must be particularly cognizant of the danger of double agency. The doctor owes a duty to the patient, always paramount, but he now owes a duty to the managed care organization that pays his salary. This latter duty may come loaded with perverse incentives, such as rewarding the physician to do less by withholding care. Even in the private-practice situation, there are incentives galore to tempt the unwary. Such as performing excessive and unnecessary testing or treatment for profit. Or in practicing defensive medicine to ward off real or imagined litigation, thus raising medical costs yet increasing patient risks.
An excellent way to foster altruism in our members is a return to volunteerism. This should be encouraged at a young age, as early as primary school. We badly need role models to inspire the belief that in giving to others without expectation of something in return, one gains immeasurably in personal growth and fulfillment. Students and trainees should be given ample opportunities, under supervision, to provide volunteer medical services to the sick. The young are likely to be more susceptible to such influences. Free service to the sick is a wonderful expression of Medicine at its altruistic best. It is every doctor’s obligation.
I wish now to tell you a second short story. It too is not an original, and was in fact told in a recent article in the Singapore Medical Journal by Associate Professor JK Candlish of the Department of Biochemistry (14): "There is the old story, is there not, about a beautiful actress fainting in a restaurant and the sound system asking whether there was a doctor in the house? A lone medical doctor was beaten to the star’s languishing form by a doctor of philosophy, a doctor of music, and a doctor of divinity. The PhD was a mine of pathophysiological knowledge, the musician had superb powers of communication, and the divine had unsurpassed compassion, but the medic was able to elbow them aside because, in that situation, he had the relevant competence. And that for me is the crunch. Competence above all, please!" This story is not meant to disparage the important qualities of compassion and communication. However, being a thoroughly competent doctor is clearly a necessary component of our professionalism. It is a cliché to nag that much of medical knowledge quickly becomes obsolete, and that clinical skills will rust out with time. Life-long learning in order to keep at Medicine’s cutting edge is expected of all of us, generalists and specialists alike. But how many doctors do keep up? Enter the world of continuing medical education, fondly referred to as CMEs. They purport to provide useful learning for doctors, and many locales have demanded mandatory credit hours for re-licensure. The idea is that we can now force doctors to update their area of practice. The outcomes data are unfortunately more sobering. Practice patterns do not change materially after most lecture-styled CME programs (15). And those who need the learning most are also apt to be the ones to thwart the system. No CME committee or enforcement agency can prevent the recalcitrant doctor from dreaming his time away at a conference. Or attempt to police his attendance records, which are easily falsified. A better approach is to instill in physicians the curiosity of discovery, encouraging them to be seekers of knowledge, not rote learners or copiers of lecture notes. The problem- based-learning (PBL) method that is being adopted by NUS and which is the mainstay at our medical school, is a step in that direction. The arrival of the informatics age will help doctors further. Regular usage of Medline searches for the latest in diagnosis, pathogenesis and treatment keeps high the passion for learning, which translates into optimal patient care. Medicine becomes interesting and exciting again.
Finally, to be excellent, one needs to be refreshed, to recharge. In his book, "The 7 habits of highly effective people"(16), Stephen Covey calls this sharpening the saw. He tells the story of the woodcutter sawing furiously without stopping to rest or to sharpen his saw that had obviously gone blunt. As a result, he was far less efficient and effective in his task. We too have need to sharpen our saw as we feverishly pursue our profession, caught up in the ritual of clinical duties, much like the woodcutter and his logs. To maintain excellence in our work, we must strike a balance that ensures rest for the mind and body, with time out for family and for hobbies.
A code of conduct characterizes all professional bodies and is not unique to the medical profession. The engineers have one, the lawyers have one. Incidentally, a recent headline in The Business Times proclaimed: "Global code of conduct for financial pros unveiled"(17). It reported on the good work of Singaporean banker Eddie Tan of Citibank, whose committee worked 2 years on the project. "Personal conduct" and "dealing practice" are issues addressed by the code. So you see, businessmen and stockbrokers too have a code.
The Hippocratic code of medical ethics celebrates notions of duty, honor and integrity that are all part of the professionalism formula. Although it’s been around for a long time, and we all recited it when we took the oath on graduation day, we must continue to remind ourselves of these ethical duties by which we are bound: beneficence, non-maleficence, fidelity, patient autonomy, and distributive justice. Add to that the ethics of working in a managed care environment (18), interactions with the pharmaceutical industry (19), the commission of medical errors (20), human experimentation (21), and the new genetics (22). And so on (23). We have a Code, be it the AMA Code (24) or the Hippocratic Oath (8), so let’s live by it. It is easy to neglect the ethical roots of the profession as we try to keep up with the explosive discoveries of fanciful molecular biology, and the exhausting rigors of practice. But the code is the moral compass that keeps us on the straight and narrow. Invariably, it will be our ethics that will distinguish us as the good doctor.
Society has given us the unique opportunity to acquire the specialized knowledge of doctoring. It has conferred on us the exclusive privilege to treat the sick. In return, our covenant is to be accountable to the patients we have sworn to serve, and to be society’s unconditional guardian of health. The medical profession is under siege. The public increasingly distrusts us because we are too condescending to listen, too mediocre to keep up, and too greedy to truly care about their welfare. Once upon a time, there was an empathic, scholarly, humanist named Doc, but as he grew popular and successful, he began to trade in his badge of service. His descent was gradual, barely perceptible, but nonetheless real. Finally, he found himself transformed into an arrogant, incompetent and materialistic three-headed god. This describes some of us, but many more of our colleagues are falling. Now is the time to again wear that badge with humility, and renew our pledge to society.
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