Professionalism in Medicine--November 20, 2021

So, have we learned anything in Peoria regarding conflict of interest and our EMS System? 

For the past 20 years or so I have been stating that the best-trained person who arrives first on the scene of a medical 911 call should be able to provide care for the pre-hospital patient. The first few minutes in a medical emergency can be the most important for the patient. The best trained most knowledgeable medic on scene should not have to wait to treat the patient.

In Peoria, the Project Medical Director--the physician in charge of all ambulances in central Illinois-- received a salary from Advanced Medical Transport which is the only Peoria agency that is allowed to give Advanced Life Support and transport the patient. Two decades ago, the Peoria Fire Department offered only Basic medical care for the prehospital patient and it seemed it was very difficult for them to advance their service for Peorians. Please note that the PFD was not paying the Project Medical Director who made the final decisions which agencies were Advanced Life Support. 

However, EMS has changed for the better in Peoria during the last two decades. Even though the doctors who controlled EMS in Peoria fought long and hard for AMT, 11 of 12 PFD Stations in 2021 are now Advanced Life Support and the PFD firefighter-paramedics no longer have to wait until AMT Paramedics arrive to give life-saving care. 

In 2007, the New England Journal of Medicine had an article on The Developing Physician and How to Teach Professionalism.

Here are some main points—

• Students at most schools now begin their first year with a “white-coat” ceremony, in which they learn the meaning of the responsibility that comes with wearing a white coat, the expectations for humanism and professionalism.

• Most medical schools now require students to take a formal ethics course.

• Obtaining experience in underserved communities and international settings often helps students understand the social role of physicians.18,1

• The authors noted that a “hidden curriculum” of teaching occurs regarding professionalism. "In the context of medical student education, the hidden curriculum of rules, regulations, and routines is transmitted mostly by residents (rather than faculty) in clinic hallways and the hospital, often late at night, when residents and students are on call."

• Teaching in the hidden curriculum happens through role modeling and the telling of parables as well as through the framework of the educational environment itself. Faculty often perceive themselves as role models for students and claim that this is one of the primary means through which they teach professionalism. But a role model is “someone who, in the performance of a role, is taken as a model by others.”23 Role modeling is in the eye of the beholder — the student, not the teacher. “Individuals who are seen as mentors may not realize that they are teaching professional values, and those not seen as mentors may believe that they are.”24

• Similarly, modeling professional behavior on the part of a teacher (e.g., showing compassion to a dying patient or offering reassurance about recovery) without following up with discussion constitutes a missed opportunity for teaching professionalism.

• Measures of professionalism are no longer subjective. Innovative new admissions procedures are showing promise in detecting aspects of professional behavior even before a candidate enters medical school. For example, it is now possible to reliably predict interpersonal and communication skills with the use of multiple, brief standardized interpersonal interactions (the so-called multiple medical interview).

• The solutions rest not only with developing our skills as teachers25-28 but also with improving the environment in which we teach.55 Students need to see that professionalism is articulated throughout the system in which they work and learn. In our academic medical centers, this means providing an environment that is consistently and clearly professional not only in medical school but throughout the entire system of care. The challenge becomes even more daunting when the goal is to institute an attitude of professionalism in multiple organizations.56 Some of the most powerful and important interventions can be made at the administrative level57: removing barriers to compassionate care, ensuring access to care, designing efficient health care delivery systems, and acknowledging teamwork as a fundamental principle of health care. Improving the health care system will go a long way toward promoting the professionalism of students and trainees.

  Comments regarding this article were noted in Correspondence—

• It is gratifying to see the subject of medical professionalism considered in the review article by Stern and Papadakis (Oct. 26 issue).1 However, the article fails to meaningfully address the reality that physicians are increasingly employed by or dependent on organizations with a business ethic that is indifferent and occasionally hostile to the values and behaviors of professionalism. Medical practitioners are expected to placate profit-driven employers and insurance carriers, for example, while remaining loyal to the highest standards of medical professionalism. The educational imperative should be not only to teach the values of medical professionalism but also to provide practical instruction for their implementation.

• Stern and Papadakis underscore the importance of instilling a sense of professionalism again in physicians and students, and they warn us about what medicine stands to lose if we do not do so. However, they leave out something crucially important that was identified by the sociologist Talcott Parsons more than 50 years ago: “The `ideology' of the profession lays great emphasis on the obligation of the physician to put the `welfare of the patient' above his personal interests, and regards `commercialism' as the most serious and insidious evil with which it has to contend.”1 In 1995, George Lundberg, then editor-in-chief of the Journal of the American Medical Association, repeated this admonishment: “The fundamental purpose of a business is to make money. . . . On the other hand, the fundamental purpose of a profession is to provide a service that reflects commitment to a worthy cause that transcends self-interest.”2 Specialty hospitals, boutique care at a price, and a range of other practices threaten the core of trust on which our profession stands. We need to teach our students — and model for them in our own practices — that commercialism has no place in the profession of medicine.

• The authors reply: Howland and Barr reflect on the challenges that doctors face when confronted with the practice settings, health care systems, and commercial interests that test our professional resolve. It is here that we must not only aspire to the principles of professionalism but also wisely apply them. Medical practice cannot be insulated from an otherwise commercial world, and financial solvency is a necessity. Rather than condemn all forms of commercial interest, we encourage our students to engage in the development of regulatory policies and systems that benefit patients and are concordant with our values. Advocacy at the local, national, and international levels is critical to such engagement.1

My Comments in 2021—

This article seemed to be written with OSF in Peoria in mind.

Was the welfare of the pre-hospital patient in Peoria at the center of discussion when PFD Paramedics were not allowed to use their skills for the 911 patient?

Where was OSF’s Administration assuring that the prehospital patient in Peoria would be taken care of in a professional matter? They were supporting Advanced Medical Transport’s monopoly on prehospital care in Peoria.

What about the young resident physicians at OSF and the medical students from UICOMP? Was the welfare of patients in Peoria placed above the business interests of the physicians and medical center? Were the residents and medical students in Peoria being taught professionalism as advocated by the Journal’s authors above?

And will a scenario like this occur again in Peoria? If it does, will anyone be aware or care to address conflict of interest? 

John A. Carroll, MD

www.haitianhearts.org