PROFESSIONALISM IN EMERGENCY MEDICINE

https://doi.org/10.1016/S0733-8627(05)70070-5Get rights and content

“Every house where I come … only for the good of my patients.”
HIPPOCRATES

There is a common understanding that the practice of emergency medicine is a profession. Under ordinary circumstances, this concept could be part of the background of the practice. Emergency physicians would operate under certain assumptions about appropriate behaviors, high educational standards, and self-scrutiny that would define emergency medicine as a profession. They are not in ordinary circumstances, however. Instead, they are in the middle of a healthcare revolution. The United States system of healthcare financing and delivery is being re-created so that costs can be controlled. Although perhaps necessary, this re-creation also threatens the fundamentals of the profession. At this juncture, emergency physicians must reaffirm and even extend important elements of medical professionalism. If they fail to do so, they threaten to lose essential aspects of their identity.

The re-creation of the healthcare system is premised on concepts that have served US businesses well so far. Competitive pressures enhance productivity, quality, and cost-effectiveness. Strong business organizations, with healthy competition, respond to the consumer to survive. Similar concepts applied to healthcare seem logical, especially to the corporations that pay for much of healthcare and must operate under such assumptions themselves. In the past, those delivering medical care never had to be particularly responsive to cost-concerns because hospitals and medical practices were essentially oligopolies, rarely threatened by competitive or cost pressures. In the care systems now being created, larger organizations are forming, financial risk is being given to those delivering the care, and powerful incentives to control costs are moving to center stage. Without debating the risks and merits of the new system, one clear danger must be recognized: the very identity of the medical professional could change. In a delivery system organized for cost-efficiency, physicians become expendable providers, not professionals operating according to self-defined standards. As physicians' personal incentives are aligned with organizational, financial, and service incentives, the new provider naturally must shift attention to corporate goals, perhaps even over patients' interests. More threatening are financial incentives applied directly to the individual physician, because the physician's financial interests might be contrary to the patient's medical interests. This setting causes mistrust and diminution of professionalism.

Medical professionalism is based on society and the individual patient's trust. The patient–physician relationship is grounded in the mutual belief that the actions of the physician are directed at the well-being of the individual patient. With this understanding, society gives physicians the right to select who enters the profession, the right to decide how the training is conducted, and the right to ensure the members' quality. Trust is created when a doctor is predictable and consistent in his or her competence and values. Trust also is necessary for good clinical care, including thorough examination, disclosure of personal information, and acceptance of treatment prescribed.1 When professionalism is intact and trust is generated, the patient–physician relationship succeeds. Professionalism is a manifestation of values, attitudes, and behaviors that result in serving the patient and society's interest before the physician's own.15 To act as a professional, a physician must demonstrate integrity, service, compassion, conscientiousness, commitment to clinical and scientific excellence, and appropriate behavior toward colleagues.3

Furthermore, when professionalism is intact, society grants a profession the ability to regulate itself.1 In this way, physicians set and enforce their own standards, select who enters, and function autonomously.8 Conversely, if this power if excessive or if there is lack of explicit attention paid to professionalism, there is consequential erosion of trust, status, and self-regulation.2

In this time of healthcare financing turmoil, radical changes could occur in the way physicians are perceived and in the way medical practice is understood. Powerful incentives that cause physicians to attend to the financing of care could erode the trust of patients and society.14 As these changes emerge, it is essential that physicians maintain the highest level of professionalism. While physicians are in the middle of change and receive unanswered questions about the financing of care, it is helpful to understand the roots of the modern practice and historical concepts of professionalism to set a course for the future.

Section snippets

HISTORY

In the past, medicine did not have standards of competence or even a minimal, required knowledge base in the United States. Most individuals in the early 1700s became doctors through unregulated apprenticeships. The practice was more of a trade, but was also a good source of income for established doctors. In contrast, a candidate for the clergy of colonial New England had to have graduated from college, completed an apprenticeship, passed an examination, and been accepted by a congregation.

CURRENT APPLICATION TO EMERGENCY MEDICINE

Despite or because of current turmoil, physicians must remind themselves of their commitment to professionalism. A profession is “an occupation that regulates itself through systemic, required training and collegial discipline; that has a base in technical, specialized knowledge; [and] that has a service rather than a profit orientation enshrined in its code of ethics.”18 The essence of professionalism is that behaviors must be directed toward the patient's best interests. Because there are

METHODS FOR PROMOTING PROFESSIONALISM

Professionalism first can be promoted by explicit acknowledgment and discussion of standards while the physicians are still in training. Part of the requirements of a profession is to train new practitioners in the technical skills and professional requirements. Professionalism should be discussed formally in medical schools and during residency. Furthermore, professional behaviors should be stressed in physicians-in-training evaluations.1, 6

After residency, professionalism should be discussed

SUMMARY

At its root, medical professionalism is service delivered according to patient's interest. It is essential to reinforce this notion because financial pressures threaten the integrity of the patient–physician relationship. Excessive commercialism directly contrasts the ideals of medical professionalism. This fact necessitates re-examination and reaffirmation of professional behavior. If historical standards of professionalism give way to market-driven incentives, the provision of medical care

References (19)

  • J. Adams et al.

    Professionalism in emergency medicine

    Acad Emerg Med

    (1998)
  • G. Agich

    Professionalism and ethics in healthcare

    J Med Philos

    (1986)
  • American Board of Internal Medicine

    Project professionalism: Staying ahead of the wave

    Am J Med

    (1994)
  • American College of Emergency Physicians Policy Statement. Code of Ethics for Emergency Physicians,...
  • American College of Emergency Physicians Policy Statement. Ethics Manual,...
  • American College of Emergency Physicians Policy Statement. Gifts to Emergency Physicians from the Biomedical Industry,...
  • American Medical Association. Principles of Medical Ethics: Code of Medical Ethics: Current Opinions with Annotations,...
  • D Blumenthal, The vital role of professionalism in healthcare reform. Health Aff (Millwood),...
  • R. Crawshaw et al.

    Patient–physician covenant

    JAMA

    (1995)
There are more references available in the full text version of this article.

Cited by (11)

Address reprint requests to James G. Adams, MD, Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, e-mail: [email protected]

View full text