The Healer and The Professional in Society

“ Neither economic incentives, nor technology, nor administrative control has proved an effective surrogate for the commitment to integrity evoked in the ideal of professionalism ” Sullivan, 1995

General Perceptions We live in a time of unprecedented change. We live in a questioning society. Professions and medicine have lost status. We will not return to the golden period. The future will depend in part on how medicine responds. Professionalism is the key to public trust.

The Physician Has Two Roles Healer Professional

The two roles Served simultaneously. Analyzed separately.

The concept of the healer The concept of the professional Professionalism and Medicine The concept of the healer The concept of the professional Middle ages “Learned professions” clergy, law, medicine 1850: Legislation 1900: University linkage The Present Antiquity Hippocrates technology “curing” The Present Code of Ethics Science

Attributes Professional Healer Caring and compassion Insight Openness Respect for the healing function Respect patient dignity and autonomy Presence Autonomy Self-regulation Responsibility to society Team work Competence Commitment Confidentiality Altruism Integrity and honesty Morality and ethics Responsibility to the profession Professional Healer

The Primary Role is that of the Healer

Medicine’s Values Are Derived From Both The Healer and the Professional

To Heal Oxford English Dictionary To make whole or sound in bodily conditions; to free from disease or ailment, to restore to health or soundness. Oxford English Dictionary

Definition Profession “An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and to the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.” Derived from the Oxford English Dictionary and the Literature on Professionalism In Press, “Teaching and Learning in Medicine”

Society uses the concept of the professional as a means of organizing the delivery of complex services which it requires, including that of the healer. “The Professional Model”

Other Models are Available > Bureaucratic Free Market Neither Share the Values of the Healer none pure

The social contract in health care hinges on professionalism. It serves as the basis for the expectations of both medicine and society.

This Contract Has Always Been Implicit (largely unwritten) Evolving (being constantly renegotiated)

The Social Contract TRUST Medicine Society fulfill the role of the healer guaranteed competence altruistic service morality and integrity promotion of the public good openness accountability Society monopoly autonomy trust and respect self-regulation adequate resources status and rewards financial non-financial TRUST

To Preserve Its Traditional Values, Medicine Must Understand: The role of the healer The role of the professional Their interrelationship The obligations necessary to maintain professional status

Characteristics of the Medical Profession Characteristics are linked to obligations. Obligations are  individual  collective

Characteristics and Obligations of a Profession Specialized knowledge and skills not easily understood Obligation maintain competence teach students and trainees patients public protect integrity of knowledge and its use support research applies both individually and collectively

Characteristics and Obligations of a Profession Commitment to Service to individual patients to society Obligation Altruism individual collective Fundamental to trust in the individual and the profession Conflicts of Interest Generational issue - lifestyle

Characteristics and Obligations of a Profession Morality Honesty Integrity Obligation be governed by professional and ethical standards of conduct at all times applies both individually and collectively

Characteristics and Obligations of a Profession codes of ethics Obligation individual to know and be governed by the appropriate codes collective develop and maintain codes

Characteristics and Obligations of a Profession Autonomy individual Obligation use autonomy in practice to best serve the patient. use autonomy wisely to best serve society. collective resist restrictions of autonomy which interfere with ability to best serve patients and society.

Characteristics and Obligations of a Profession Licensing Bodies and Professional Associations state sanctioned authority collegiality major self-regulatory role set and maintain standards discipline advise public Obligation (collective) demonstrate morality and virtue guarantee competence be open and transparent be governed by an institutional code

Licensing Bodies and Professional Associations MUST MANAGE CONFLICT OF ROLES altruism vs self-interest public good vs union function POTENTIAL TO PROMOTE OR SUBVERT THE IMAGE OF MEDICINE

Characteristics and Obligations of a Profession Self-Regulation Obligation (individual) maintain competence participate in and submit to the process of self regulation support professional associations and regulatory bodies ensure their integrity

Listing characteristics seems to make them equal. They Are Not

Essential Elements Specialized knowledge Service to others Morality Science Art Service to others Morality

Literature Early - supportive of professionalism - recognized tension between altruism and self-interest 60’s and 70’s - very critical - documented medicine’s failures - questioned relevance to society

Literature - 80’s to present Reflects the New Reality “Countervailing Forces” dominance of state and/or corporate sector influence of medicine “Accounting Logic” value systems of the state and/or corporate sector values of professionalism in health care

Literature - 80’s to present Because of society’s need for the healer, physicians will continue to have status and to be reasonably well compensated whether they are independent practitioners or employees. Reasonable autonomy will be preserved because neither the state or the market place wish to be responsible for “life or death” issues. Now supports a renewed “professional model”. “civic professionalism” - Sullivan “ reborn professionalism” - Freidson “ reinvented ” professionalism - Stevens uncertain as to how much influence the professions will regain.

“In spite of its failings, professionalism is based on the real character of certain services - it is not a clever invention of selfish minds”. Marshall, 1939

The social scientists have returned to faith in the value of professions. It is critically important that society also support the professional model.

Optimism Can Be Justified The public is dissatisfied. Medicine retains more trust than the state or corporate sector. The state and/or corporate sector control the market place. they and not medicine are blamed for defects in the system. Health is a political issue - public good/right. The political process will lead to change. The principle cause for optimism is society’s need for the healer.

Loss of Influence Opportunity to rebuild trust

The Social Contract is Being Re-Negotiated Legitimate worries and concerns on both sides

Negotiations Can involve virtually all stakeholders with an interest in health, and take place in many settings. Influence on negotiations can be either direct or indirect and lead to minor or major changes. Medicine is no longer the dominant player - but it is at the table.

Society’s Needs and Expectations The healer working as a professional using knowledge to heal and/or cure guaranteeing competence working in partnership with patients demonstrating morality and virtue being accountable

Accountability Traditional To patients and colleagues For advice on public policy Self-regulation and discipline

PROFESSIONS MUST SELF-REGULATE There have been high-profile failures in the area of self-regulation. These failures led to trust and a consequent inability to influence the newer levels of accountability now demanded. PROFESSIONS MUST SELF-REGULATE

Accountability - New Economic (to payors) Political (to wider society) corporate state Political (to wider society) impact on resources population health

The Professions’ Needs and Expectations 1) Deserve trust and respect despite some failings. 2) Expertise should be recognized and used. 3) Autonomy sufficient to act in best interests of patients and society. 4) Regulatory procedures that are reasonable and validated. 5) Adequate resources. 6) A health care system which promotes (and does not subvert) those values which society wishes in its healers - caring, altruism, courtesy and competence.

Fulfill the Role of Healer What Must Medicine Do? Fulfill the Role of Healer

What Should Medicine Do? Address Principle Causes of Loss of Trust perception of altruism failure to self-regulate behavior of some of medicine’s institutions lack of a single voice representing medicine

What Should Medicine Do? Individual/Collective Responsibility Understand professionalism. teach and evaluate it at all levels Understand and meet the obligations needed to sustain the professional model. altruism integrity self-regulation accountability

Who Speaks for Medicine? AMA Other BMA CMA

Those Negotiating on Behalf of the Profession Must recognize and deal with the conflict of roles. Must place societal needs above those of the profession.

Those Negotiating on Behalf of the Profession Must look for partners patients advocacy groups health professionals ? government ? corporate sector media others

Those Negotiating on Behalf of the Profession Must negotiate a social contract that supports the attributes and values of the healer. Rewards quality rather than volume. Rewards professional and penalizes unprofessional behavior. Issues to consider: financial incentives/disincentives - individual - institutional use of competition for cost control regulation of conflicts of interest regulation of marketing of products

“The International Charter” Convince Society of the Advantages of the Professional Model “The International Charter” “American College of Surgeons Code of Professional Conduct"

Public Policy Must Support The Professional Model

“The most important problem for the future of professionalism is neither economic nor structural but cultural and ideological. The most important problem is its soul” Freidson, 2001