Hello and welcome to our first weekly Virtual Journal Club. I chose to start out the year with two articles this week which relate to one of the Milestones of the Month: Professionalism. Both of these are qualitative essays, rather than quantitative studies, so an approach to discussion is less about hypothesis testing and quantitative analysis and more about considering the authors' perspectives and what applications they may have to our practices.
First up is Professionalism in medicine:
definitions and considerations for teaching, by Lynne M. Kirk. (Proc (Bayl Univ Med Cent) 2007;20:13–16). Dr. Kirk explores some of the history of how professionalism became a focus of medical education, and attempts to deliniate how it should be defined, assessed, and taught. Characteristics of professionalism are listed as a set of specific commitments and as measurable behaviors. What do you think of these lists? Are there things that are included that you don't think of as necessary? Are there necessary items left off the list?
Next is The moral foundation of medical leadership: The professional
virtues of the physician as fiduciary of the patient, by Frank A. Chervenak, MD, and Laurence B. McCullough, PhD. (Am J Obstet Gynecol: 184(5): 875-880. 2001). They distill professionalism to a basis of four core virtues: self-effacement, self-sacrifice, compassion, and integrity. What do these terms mean to you? Do you think that it is still relevant to talk about medical professionalism in terms of "virtues" and "vices" in the modern age of corporate medicine? Why or why not? To what extent do these virtues characterize your life as a physician, and how might you develop them--if possible.
I look forward to your comments and hearing about your discussions. Both papers are available on New Innovations, under Resources/Readings of the Week/07July.
[Added google drive links: Kirk. Chervenak.
Unfortunately, these cannot be accessed from Regions or HealthPartners sites. Sorry.]
In the professionalism article I did not find anything I would add. I like the idea of training at all levels as no one is perfect.
ReplyDeleteThe moral foundation article has ideals to strive for. We do have many pressures on us at all times and this seems more like something a try and meet. The risk I see here is burnout; giving more to the patients than you can give and still function. The business world is very much in contrast with the medical world and that will lead to continued disagreement.
Dr. Kirk's article is a good reminder of the professionalism we are expected to demonstrate and commit. I think that one of the trait, "just distribution of infinite resources," is something physicians are moving away from more. This is because 1. there's more resources (e.g., treatment centers, more mass productions of medications, more available vaccines, etc.) and 2. this responsibility has partially shifted to social workers and case managers.
ReplyDeleteAlso, I am curious if we do "360-degree evaluations" (evaluations by peers, nurses, patients, and etc.)? If not, maybe that's something we can incorporate in the future. There are some programs during my clerkships that evaluate lectures/presenters and I think the residents liked it because presenters that were helpful a previous year were invited to come back the subsequent year.
I agree with Chervenak and McCullough's idea about compassion, but there is a thin line between healing and hurting patients complaining of pain. Pain medications are overused in society and more people are dying from medication overdose. We need to have a better approach than medicating patients who are complaining of pain and demanding for pain medications. In instances like this, it might be more beneficial to be sympathetic, but reluctant to provide symptomatic treatment (e.g., refer him/her to pain clinic instead). Of course, when it comes to differentiating addicts and compliance, it requires experience and is something I am constantly working to differentiate and further my clinical judgment on.
Sometimes it feels a little odd to consider oneself a moral fiduciary for a patient who would actively disagree with that assessment. I liked the idea of professionalism stemming from an idea of competence and intellectual rigor, as opposed to other standards of excellence one might strive toward (those espoused by Enron execs, the "smartest guys in the room", etc).
ReplyDeleteAs regards the previous post re: 360 degree evals, yes, you are required to do them (i.e. ask people you work with who are not physicians to do them), so yes, they have been incorporated into the residency evaluation system. You do get to choose whom you ask to do them, which does possibly give a bit of a biased slant to the eval system.
I am curious as to the amount of paternalism and "academicus oblige" others perceived in the articles, and whether it is possible to avoid this? Is there a part of our professionalism that obliges us to put forth some opinion on "this is what I think the patient would want, if the patient were able to see the whole picture as I can see it, through the lens of suffering that I understand this patient is facing, and will face in the future"?
It sure is tough being somebody else's fiduciary anything.
Thanks for your comments. A couple of responses--it's clear that these values are fraught with ethical tightropes to tread. Can we be so self-sacrificial that we burnout and fail to be useful? Can we be too compassionate, to the point that we enable behaviors that are not in the patient's long-term best interest? Or do we take on a role that is so paternalistic that we violate a patient's autonomy--and when and how might it be right to do so? Seeing oneself as a professional entails internalizing a set of values that guides our behavior through these various risk-benefit trade-offs, and also entails being a part of a community that shares and hones those values through discussion and supervision.
ReplyDeleteI realized during graduate school that one of the things that frustrated me most about it was that there never seemed to be a "Right Answer". After 17 years of multiple choice questions, that was infuriating! Residency and practice are also like that sometimes--the patients and dilemmas rarely fit the textbook cases and board exam vignettes. Enjoy the Process--and all of the discussions along the way!