the healer and the professional in society. “ neither economic incentives, nor technology, nor...
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“ “ Neither economic incentives, nor Neither economic incentives, nor technology, nor administrative control technology, nor administrative control has proved an effective surrogate for the has proved an effective surrogate for the commitment to integrity evoked in the commitment to integrity evoked in the ideal of professionalism ” ideal of professionalism ”
Sullivan, 1995Sullivan, 1995
General PerceptionsGeneral PerceptionsGeneral PerceptionsGeneral PerceptionsWe live in a time of unprecedented change.We live in a time of unprecedented change.
We live in a questioning society.We live in a questioning society.
Professions and medicine have lost status.Professions and medicine have lost status.
We will not return to the golden period.We will not return to the golden period.
The future will depend in part on how medicine The future will depend in part on how medicine responds.responds.
Professionalism is the key to public trust.Professionalism is the key to public trust.
The two rolesThe two roles
• Served simultaneously.Served simultaneously.
• Analyzed separately.Analyzed separately.
AntiquityAntiquity
HippocratesHippocrates
technologytechnology““curing”curing”
The PresentThe Present
Professionalism and MedicineProfessionalism and MedicineProfessionalism and MedicineProfessionalism and MedicineThe concept of the healerThe concept of the healer The concept of the professionalThe concept of the professional
Code of Code of EthicsEthics
Middle agesMiddle ages““Learned professions”Learned professions”clergy, law, medicineclergy, law, medicine
1850: Legislation1850: Legislation
1900: University linkage1900: University linkage
The PresentThe Present
ScienceScience
CompetenceCompetenceCommitmentCommitmentConfidentialityConfidentialityAltruismAltruism
Integrity and honestyIntegrity and honestyMorality and ethicsMorality and ethicsResponsibility to the Responsibility to the professionprofession
Autonomy Autonomy
Self-regulationSelf-regulation
Responsibility Responsibility to societyto society
Team workTeam work
Caring and compassionCaring and compassion
InsightInsight
OpennessOpennessRespect for the Respect for the healing functionhealing functionRespect patientRespect patient dignity anddignity and autonomyautonomy
Presence Presence
Healer Professional
Physician
Healer Professional
Physician
Medicine’s Values Are Medicine’s Values Are Derived From Both The Derived From Both The
Healer and the ProfessionalHealer and the Professional
To HealTo Heal
To make whole or sound in bodily To make whole or sound in bodily conditions; to free from disease or ailment, conditions; to free from disease or ailment, to restore to health or soundness.to restore to health or soundness.
Oxford English DictionaryOxford English Dictionary
DefinitionDefinition Profession Profession
DefinitionDefinition Profession Profession
““An occupation whose core element is work based upon the mastery of a 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 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 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 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 and profess a commitment to competence, integrity and morality, altruism, and to the promotion of the public good within their domain. These commitments 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 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 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. right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.”Professions and their members are accountable to those served and to society.”
Derived from the Oxford English Derived from the Oxford English Dictionary and the Literature on ProfessionalismDictionary and the Literature on Professionalism
In Press, “Teaching and Learning in Medicine”In Press, “Teaching and Learning in Medicine”
Society uses the concept of the Society uses the concept of the professional as a means of professional as a means of
organizing the delivery of complex organizing the delivery of complex services which it requires, services which it requires,
including that of the healer.including that of the healer.
““The Professional Model”The Professional Model”
Other Models are AvailableOther Models are Available
• BureaucraticBureaucratic
• Free MarketFree Market
Neither Share the Values of the HealerNeither Share the Values of the Healer
none purenone pure>
• The social contract in health care The social contract in health care hinges on professionalism.hinges on professionalism.
• It serves as the basis for the It serves as the basis for the expectations of both medicine expectations of both medicine and society.and society.
This Contract Has Always BeenThis Contract Has Always Been
• Implicit (largely unwritten)Implicit (largely unwritten)
•Evolving (being constantly Evolving (being constantly renegotiated)renegotiated)
The Social ContractThe Social ContractMedicineMedicine
• fulfill the role of the healerfulfill the role of the healer• guaranteed competenceguaranteed competence• altruistic servicealtruistic service• morality and integritymorality and integrity• promotion of the public promotion of the public
goodgood• opennessopenness• accountabilityaccountability
SocietySociety• monopolymonopoly• autonomyautonomy• trust and respecttrust and respect• self-regulationself-regulation• adequate resourcesadequate resources• status and rewardsstatus and rewards
financialfinancial non-financialnon-financial
TRUSTTRUST
To Preserve Its Traditional Values, To Preserve Its Traditional Values, Medicine Must Understand: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 ProfessionCharacteristics of the Medical Profession
• Characteristics are linked to obligations.Characteristics are linked to obligations.
• Obligations areObligations are individual individual collective collective
Characteristics and Obligations of a ProfessionCharacteristics and Obligations of a Profession
CharacteristicCharacteristic Specialized knowledge Specialized knowledge
and skillsand skills
not easily understoodnot easily understood
ObligationObligation• maintain competencemaintain competence• teachteach
students and traineesstudents and traineespatientspatientspublicpublic
• protect integrity of knowledge protect integrity of knowledge and its useand its use
• support researchsupport research• applies both individually and applies both individually and
collectivelycollectively
Characteristics and Obligations of a ProfessionCharacteristics and Obligations of a Profession
CharacteristicCharacteristic Commitment to ServiceCommitment to Service
to individual to individual patientspatients
to societyto society
ObligationObligation• AltruismAltruism
individualindividual
collectivecollective
• Fundamental to trust in the individual and the profession Fundamental to trust in the individual and the profession • Conflicts of InterestConflicts of Interest• Generational issue - lifestyle Generational issue - lifestyle
Characteristics and Obligations of a ProfessionCharacteristics and Obligations of a Profession
CharacteristicCharacteristic MoralityMorality HonestyHonesty IntegrityIntegrity
ObligationObligation• be governed by be governed by
professional and ethical professional and ethical standards of conduct at all standards of conduct at all timestimes
• applies both individually applies both individually and collectivelyand collectively
Characteristics and Obligations of a ProfessionCharacteristics and Obligations of a Profession
CharacteristicCharacteristic codes of ethicscodes of ethics
ObligationObligation• individualindividual
to know and be governed to know and be governed by the appropriate codesby the appropriate codes
• collectivecollective develop and maintain develop and maintain
codescodes
Characteristics and Obligations of a ProfessionCharacteristics and Obligations of a Profession
CharacteristicCharacteristic AutonomyAutonomy
individualindividual
ObligationObligation
• use autonomy in practice use autonomy in practice to best serve the patient.to best serve the patient.
• use autonomy wisely to use autonomy wisely to best serve society.best serve society.
collectivecollective
• resist restrictions of autonomy which interfere with ability resist restrictions of autonomy which interfere with ability to best serve patients and society.to best serve patients and society.
Characteristics and Obligations of a ProfessionCharacteristics and Obligations of a Profession
CharacteristicCharacteristic Licensing Bodies and Licensing Bodies and
Professional AssociationsProfessional Associations• state sanctioned authoritystate sanctioned authority• collegialitycollegiality• major self-regulatory rolemajor self-regulatory role
set and maintain standardsset and maintain standards
disciplinediscipline• advise publicadvise public
ObligationObligation (collective) (collective)• demonstrate morality and demonstrate morality and
virtuevirtue
• guarantee competenceguarantee competence
• be open and transparentbe open and transparent
• be governed by an be governed by an institutional codeinstitutional code
Licensing Bodies and Professional AssociationsLicensing Bodies and Professional Associations
MUST MANAGE CONFLICT OF ROLESMUST MANAGE CONFLICT OF ROLES
altruism vs self-interestaltruism vs self-interest
public good vs union functionpublic good vs union function
POTENTIAL TO PROMOTE OR POTENTIAL TO PROMOTE OR SUBVERT THE IMAGE OF MEDICINESUBVERT THE IMAGE OF MEDICINE
Characteristics and Obligations of a ProfessionCharacteristics and Obligations of a Profession
CharacteristicCharacteristic Self-RegulationSelf-Regulation
ObligationObligation (individual) (individual)• maintain competence maintain competence • participate in and submit to participate in and submit to
the process of self regulationthe process of self regulation• support professional support professional
associations and regulatory associations and regulatory bodiesbodies
• ensure their integrityensure their integrity
Listing characteristics seems to make Listing characteristics seems to make them equal.them equal.
They Are NotThey Are Not
Essential ElementsEssential Elements
• Specialized knowledgeSpecialized knowledgeScienceScience
ArtArt
• Service to othersService to others
• MoralityMorality
Literature Literature • Early Early - supportive of professionalism- supportive of professionalism
- recognized tension between - recognized tension between altruism altruism and self-interest and self-interest
• 60’s and 70’s 60’s and 70’s - very critical - very critical
- documented medicine’s failures- documented medicine’s failures - questioned relevance to society- questioned relevance to society
Literature - 80’s to presentLiterature - 80’s to present
““Countervailing Forces”Countervailing Forces”
• dominance of state and/or corporate sectordominance of state and/or corporate sector
influence of medicineinfluence of medicine
““Accounting Logic”Accounting Logic” • value systems of the state and/or corporate sectorvalue systems of the state and/or corporate sector
values of professionalism in health carevalues of professionalism in health care
Reflects the New RealityReflects the New Reality
Literature - 80’s to presentLiterature - 80’s to present• Because of society’s need for the healer, physicians will continue Because of society’s need for the healer, physicians will continue
to have status and to be reasonably well compensated whether they to have status and to be reasonably well compensated whether they are independent practitioners or employees.are independent practitioners or employees.
• Reasonable autonomy will be preserved because neither the state Reasonable autonomy will be preserved because neither the state or the market place wish to be responsible for “life or death” or the market place wish to be responsible for “life or death” issues.issues.
• Now supports a renewed “professional model”.Now supports a renewed “professional model”.““civic professionalism” - Sullivancivic professionalism” - Sullivan“ “ reborn professionalism” - Freidsonreborn professionalism” - Freidson“ “ reinvented ” professionalism - Stevensreinvented ” professionalism - Stevens
• uncertain as to how much influence the professions will regain.uncertain as to how much influence the professions will regain.
““In spite of its failings, In spite of its failings, professionalism is based on the real professionalism is based on the real
character of certain services - it is not character of certain services - it is not a clever invention of selfish minds”.a clever invention of selfish minds”.
Marshall, 1939 Marshall, 1939
• The social scientists have returned The social scientists have returned to faith in the value of professions.to faith in the value of professions.
• It is critically important that society It is critically important that society also support the professional model.also support the professional model.
Optimism Can Be JustifiedOptimism Can Be Justified• The public is dissatisfied.The public is dissatisfied.• Medicine retains more trust than the state or corporate Medicine retains more trust than the state or corporate
sector.sector.• The state and/or corporate sector control the market place.The state and/or corporate sector control the market place.
– they and not medicine are blamed for defects in they and not medicine are blamed for defects in the system.the system.
• Health is a political issue - public good/right.Health is a political issue - public good/right.• The political process will lead to change.The political process will lead to change.• The principle cause for optimism is society’s need for the The principle cause for optimism is society’s need for the
healer.healer.
The Social Contract is The Social Contract is Being Re-NegotiatedBeing Re-Negotiated
Legitimate worries and Legitimate worries and concerns on both sidesconcerns on both sides
NegotiationsNegotiations• Can involve virtually all stakeholders with an Can involve virtually all stakeholders with an
interest in health, and take place in many settings.interest in health, and take place in many settings.
• Influence on negotiations can be either direct or Influence on negotiations can be either direct or indirect and lead to minor or major changes.indirect and lead to minor or major changes.
• Medicine is no longer the dominant player - but it Medicine is no longer the dominant player - but it is at the table.is at the table.
Society’s Needs and ExpectationsSociety’s Needs and Expectations
The healer working as a professionalThe healer working as a professional – using knowledge to heal and/or cureusing knowledge to heal and/or cure
– guaranteeing competenceguaranteeing competence
–working in partnership with patientsworking in partnership with patients
– demonstrating morality and virtuedemonstrating morality and virtue
– being accountablebeing accountable
AccountabilityAccountabilityTraditionalTraditional
• To patients and colleaguesTo patients and colleagues
• For advice on public policyFor advice on public policy
• Self-regulation and discipline Self-regulation and discipline
• There have been high-profile failures in the area of There have been high-profile failures in the area of self-regulation.self-regulation.
• These failures led to trust and a consequent These failures led to trust and a consequent inability to influence the newer levels of inability to influence the newer levels of accountability now demanded.accountability now demanded.
PROFESSIONSPROFESSIONS MUST SELF-REGULATEMUST SELF-REGULATE
Accountability - NewAccountability - New• Economic (to payors)Economic (to payors)
corporatecorporate
statestate
• Political (to wider society)Political (to wider society)impact on resourcesimpact on resources
population healthpopulation health
The Professions’ Needs and The Professions’ Needs and ExpectationsExpectations
1) Deserve trust and respect despite some failings.1) Deserve trust and respect despite some failings.
2)2) Expertise should be recognized and used.Expertise should be recognized and used.
3) Autonomy sufficient to act in best interests of patients and 3) Autonomy sufficient to act in best interests of patients and society.society.
4) Regulatory procedures that are reasonable and validated.4) Regulatory procedures that are reasonable and validated.
5) Adequate resources.5) Adequate resources.
6) A health care system which promotes (and does not subvert) 6) A health care system which promotes (and does not subvert) those values which society wishes in its healers - caring, those values which society wishes in its healers - caring, altruism, courtesy and competence.altruism, courtesy and competence.
What Should Medicine Do?What Should Medicine Do?
Address Principle Causes of Loss of TrustAddress Principle Causes of Loss of Trust
• perception of altruismperception of altruism
• failure to self-regulatefailure to self-regulate
• behavior of some of medicine’s institutionsbehavior of some of medicine’s institutions
• lack of a single voice representing medicinelack of a single voice representing medicine
What Should Medicine Do?What Should Medicine Do?
• Understand professionalism.Understand professionalism.
teach and evaluate it at all levels teach and evaluate it at all levels
• Understand and meet the obligations needed Understand and meet the obligations needed
to sustain the professional model.to sustain the professional model. altruismaltruism integrityintegrity self-regulationself-regulation accountabilityaccountability
Individual/Collective ResponsibilityIndividual/Collective Responsibility
Those Negotiating on Behalf of the ProfessionThose Negotiating on Behalf of the Profession
• Must recognize and deal with the conflict of Must recognize and deal with the conflict of roles.roles.
• Must place societal needs above those of the Must place societal needs above those of the profession.profession.
Those Negotiating on Behalf of the ProfessionThose Negotiating on Behalf of the Profession
• Must look for partnersMust look for partners» patientspatients
» advocacy groupsadvocacy groups
» health professionalshealth professionals
» ? government? government
» ? corporate sector? corporate sector
» mediamedia
» othersothers
Those Negotiating on Behalf of the ProfessionThose Negotiating on Behalf of the Profession
Must negotiate a social contract that supports the attributes and values Must negotiate a social contract that supports the attributes and values of the healer.of the healer.• Rewards quality rather than volume.Rewards quality rather than volume.
• Rewards professional and penalizes unprofessional behavior.Rewards professional and penalizes unprofessional behavior.
• Issues to consider:Issues to consider:
– financial incentives/disincentives financial incentives/disincentives - individual- individual- institutional- institutional
– use of competition for cost controluse of competition for cost control
– regulation of conflicts of interestregulation of conflicts of interest
– regulation of marketing of productsregulation of marketing of products
““The International Charter”The International Charter”
Convince Society of the Advantages Convince Society of the Advantages of the Professional Modelof the Professional Model
““American College of Surgeons American College of Surgeons Code of Professional Conduct"Code of Professional Conduct"
““The most important problem The most important problem for the future of professionalism is for the future of professionalism is neither economic nor structural but neither economic nor structural but cultural and ideological. The most cultural and ideological. The most important problem is its soul”important problem is its soul”
Freidson, 2001
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