the healer and the professional in society. “ neither economic incentives, nor technology, nor...

The Healer and The The Healer and The Professional in SocietyProfessional in Society

“ “ 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 Physician Has Two RolesThe Physician Has Two Roles

• HealerHealer

• ProfessionalProfessional

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

The Primary Role is that The Primary Role is that of the Healerof the Healer

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


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


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


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


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.


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


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.

Loss of InfluenceLoss of Influence

Opportunity to rebuild trustOpportunity to rebuild trust

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 Must Medicine Do?What Must Medicine Do?

Fulfill the Role of HealerFulfill the Role of Healer

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

Who Speaks for Medicine?Who Speaks for Medicine?

• AMA AMA

• OtherOther

BMA BMA CMACMA

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.


• Must look for partnersMust look for partners» patientspatients

» advocacy groupsadvocacy groups

» health professionalshealth professionals

» ? government? government

» ? corporate sector? corporate sector

» mediamedia

» othersothers


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 - individualindividual- 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"

Public Policy Must Support Public Policy Must Support

The Professional ModelThe Professional Model

““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

the healer and the professional in society. “ neither economic incentives, nor technology, nor...

Documents

healer slide

pure slide

professional model slide

present science slide

questioning society

present professionalism

society team work

social contract