So if the first great cultural transformation in modern medicine was a collective mindset shift in the approach to quality and safety, what is the next transformation? It could be -- and I believe should be -- an analogous shift in thinking around issues of professionalism.
Concepts of professionalism have deep roots in medicine, from the time of Hammurabi and Hippocrates. John Gregory (1724-1773), a Scottish physician, philosopher and ethicist, believed intellectual and moral excellence in medicine demanded adherence to three fundamental principles.1 First, the physician must accept the intellectual discipline of science, so that his practice is as free from bias as possible (in other words, evidence based medicine). Second, the physician's primary consideration must be the protection and promotion of the patient's health. Finally, all other forms of self-interest (economic benefit, status, lifestyle) must be secondary to the needs of the patient. Furthermore, he believed these core principles were supported by key virtues of integrity, self-sacrifice, self-effacement and compassion. Although written in 1770, I am not sure this definition can be greatly improved upon.
Some physicians would embrace these concepts as an almost sacred duty. Others might view them as a professional North Star: aspirational, unobtainable but an important directional beacon. Few (I would hope none) would reject them out of hand.
So as a profession, how do we work to raise the bar of professionalism today? It is my contention that current progress in this area is where our commitment to quality was 25 years ago. If we refer back to our two previous bell curves, we tend to root out the bad apples (eliminate the underperforming tail of he curve):
We typically do not effectively shift the curve -- for those with deficiencies in the "soft skills" (e.g. communication, working effectively in teams, interpersonal skills), we need to help remediate those with severe weaknesses; help the average improve, and at times, excel; and support the truly outstanding to set a new aspirational standard:
How do hospitals, physician practices, medical executive committees, professional societies, licensing boards and accrediting bodies deal with issues of professionalism today? By dealing with the outliers on the left side of the curve.
Our national medical culture allows some behaviors, and prohibits others. As a very broad generalization, you cannot use obscenity, at least routinely. However, you can be sarcastic and subtly belittle others. You cannot flip over an instrument tray in a display of frustration in the operating room. You can throw an occasional instrument. You cannot publicly berate another member of the care delivery team. You can react to a patient complaint by casting aspersions on other members of the team, undermining the effectiveness of the team ("I'm sorry your dressing did not get changed. We've had real trouble with nursing on this floor").
The profession needs a fundamental shift in thinking. It cannot just be about the bad apples. The physician with average communication skills needs to become a more effective team member. The brilliant clinician needs to improve his empathic skills. The physician who routinely displays exceptional integrity, self-sacrifice, self-effacement and compassion must be recognized, celebrated and acknowledged as a role model.
This transition will not occur by natural evolution or serendipity. It will only occur as the result of deliberate effort. Just like at the dawn of the quality revolution, without some required foundational components, the transformation will not occur. Here are seven conditions I believe are necessary:
Commitment. Physician professional societies, specialty boards, health care systems must aspire to shift the culture. Progress has been made. The ACGME core competencies have clearly focused attention on some of medicine's softer skills. The Arnold P. Gold Foundation has established a national recognition system for physicians with exceptional humanistic qualities. Societies have developed to promote some of medicine's "softer" skills, such as the American Academy on Communication in Healthcare.
Our national medical culture allows some behaviors, and prohibits others. As a very broad generalization, you cannot use obscenity, at least routinely. However, you can be sarcastic and subtly belittle others. You cannot flip over an instrument tray in a display of frustration in the operating room. You can throw an occasional instrument. You cannot publicly berate another member of the care delivery team. You can react to a patient complaint by casting aspersions on other members of the team, undermining the effectiveness of the team ("I'm sorry your dressing did not get changed. We've had real trouble with nursing on this floor").
The profession needs a fundamental shift in thinking. It cannot just be about the bad apples. The physician with average communication skills needs to become a more effective team member. The brilliant clinician needs to improve his empathic skills. The physician who routinely displays exceptional integrity, self-sacrifice, self-effacement and compassion must be recognized, celebrated and acknowledged as a role model.
This transition will not occur by natural evolution or serendipity. It will only occur as the result of deliberate effort. Just like at the dawn of the quality revolution, without some required foundational components, the transformation will not occur. Here are seven conditions I believe are necessary:
Commitment. Physician professional societies, specialty boards, health care systems must aspire to shift the culture. Progress has been made. The ACGME core competencies have clearly focused attention on some of medicine's softer skills. The Arnold P. Gold Foundation has established a national recognition system for physicians with exceptional humanistic qualities. Societies have developed to promote some of medicine's "softer" skills, such as the American Academy on Communication in Healthcare.
However, at times these efforts still feel like fringe issues -- not a core focus of the House of Medicine.
Definition. What specifically are we trying to develop? Can professionalism be broken down into component skills-- e.g. communication, empathy, cultural competence?
Real Patient Engagement. At the end of the day, patients and their families should be the beneficiaries of a renaissance of professionalism. We need to engage them deeply and broadly to understand what is important to real people. Which is more important? That their doctor took a ballpoint pen from a drug rep, or if he is effective in delivering unexpected and life altering news?
Measurement. Valid, reliable and practical assessment tools must continue to be developed, with meaningful benchmarks.
Pedagogy. We need tested and effective educational methods to build skills and culture, rooted in sound adult learning principles. We may not have a clear vision today of what this entails, but we clearly know it is something more than giving an annual lecture on ethics.
Selection. If a college student scores a 36 on the MCAT, and has a science GPA of 3.8, barring a random cataclysmic event, there is a 100% chance they will succeed in medical school. We deliberately select bright students, and help them to use their gifts to practice medicine. As hard as we might try, the high school drop out who never made it through introductory algebra cannot be adequately supported to be successful. Similarly, I will never be drafted to play for the NFL, and it would be comical to try. However, we currently accept a number of students into medical school-- hopefully few -- who are inherently poor communicators or are clearly lacking in natural empathic skills. We need better tools to select students with strong inherent traits that we can enhance and polish. As hard as we might try, we will almost never take an individual with a lifetime of poor communication skills, and turn him into a good communicator.
Resources. This cultural transformation is difficult; perhaps impossible. It clearly will not occur unless organized medicine and the delivery system commits time, talent and treasure to support continuing and deliberate progress.
Definition. What specifically are we trying to develop? Can professionalism be broken down into component skills-- e.g. communication, empathy, cultural competence?
Real Patient Engagement. At the end of the day, patients and their families should be the beneficiaries of a renaissance of professionalism. We need to engage them deeply and broadly to understand what is important to real people. Which is more important? That their doctor took a ballpoint pen from a drug rep, or if he is effective in delivering unexpected and life altering news?
Measurement. Valid, reliable and practical assessment tools must continue to be developed, with meaningful benchmarks.
Pedagogy. We need tested and effective educational methods to build skills and culture, rooted in sound adult learning principles. We may not have a clear vision today of what this entails, but we clearly know it is something more than giving an annual lecture on ethics.
Selection. If a college student scores a 36 on the MCAT, and has a science GPA of 3.8, barring a random cataclysmic event, there is a 100% chance they will succeed in medical school. We deliberately select bright students, and help them to use their gifts to practice medicine. As hard as we might try, the high school drop out who never made it through introductory algebra cannot be adequately supported to be successful. Similarly, I will never be drafted to play for the NFL, and it would be comical to try. However, we currently accept a number of students into medical school-- hopefully few -- who are inherently poor communicators or are clearly lacking in natural empathic skills. We need better tools to select students with strong inherent traits that we can enhance and polish. As hard as we might try, we will almost never take an individual with a lifetime of poor communication skills, and turn him into a good communicator.
Resources. This cultural transformation is difficult; perhaps impossible. It clearly will not occur unless organized medicine and the delivery system commits time, talent and treasure to support continuing and deliberate progress.
I think it would be worth the investment.
1Hendrikson, MA, Qual Manag Health Care. 17(1):9-18, 2008 Jan-Mar.
1Hendrikson, MA, Qual Manag Health Care. 17(1):9-18, 2008 Jan-Mar.
Excellent summary of a critical issue for medicine. There are groups working on creating a climate in which we can move forward in the areas Jim discusses. The American Academy on Communication and Healthcare (www.aachonline.org) offers courses, resources, and training programs for professionals who want to develop these skills.
ReplyDeleteStuart Sprague, PhD
AnMed Health, Anderson South Carolina