1. The Healer and The Professional in Society

2. “ 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

3. 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.

4. The Physician Has Two Roles
Healer
Professional

5. The two roles
Served simultaneously.
Analyzed separately.

6. 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

7. 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

8. The Primary Role is that of the Healer

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

10. 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

11. 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”

12. 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”

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

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

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

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. 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

23. 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.

24. 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

25. 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

26. 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

27. Listing characteristics seems to make them equal.
They Are Not

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

29. 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

30. 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

31. 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.

32. “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

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

34. 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.

35. Loss of Influence
Opportunity to rebuild trust

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

37. 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.

38. 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

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

40. 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

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

42. 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.

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

44. 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

45. 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

46. Who Speaks for Medicine?
AMA
Other
BMA
CMA

47. 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.

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

49. 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

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

51. Public Policy Must Support The Professional Model

52. “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