The Unspoken Challenges to the Profession of Medicine

More and more, we are practicing in a challenging environment. Job satisfaction for our profession is at an all-time low, burnout at an all-time high and there exists an alarming depression rate. As a profession, we face no shortage of problems. Our medical student graduates await many hurdles and need to be prepared to deal with increasing educational costs, ACGME duty hour changes, declining interest in primary care, health care reform, declining Medicare reimbursement, assaults to fee for service designs, bundled payments, care for the uninsured, medical malpractice, ABIM recertification, and MOC changes, the electronic health record, among many others.

If you are like most physicians, you have found yourself grappling with patients seeking a particular drug especially when that drug is a controlled substance or an antibiotic. You want your patient’s approval of your care and maybe even avoidance of their anger while providing the appropriate care that is based on your best judgment.  The accrediting bodies like American Board of Medical Specialties and ACGME in overall policies require that those seeking board certification have demonstrated “altruism, accountability, excellence, duty, service, honor, integrity and respect for others” (1). A reaction of anger or disapproval challenges our wish to strive toward achieving goals of being altruistic, knowledgeable, skillful, and dutiful. How does a patient review on various internet sites or hospital administrators’ perspectives address essential elements of medical professionalism? Most of us now work for large organizations (2). So we all have an interest in conforming to their wishes. In fact we do not have independent choice in what we do and probably very few docs practice with independent choice. Whether it be medication formularies, patient satisfaction scores or performance measures that seem geared more to justify institutional financial goals than to truly improve patient care. 

Uncertainty has long characterized the practice of medicine despite advances in technology or biomedical knowledge. Medical professionalism is defined by what we do and how we act, by demonstrating that we are worthy of the trust bestowed upon us by our patients and the public. My friend shared with me “I try to use independent judgment but always take into account how much or what to do for a patient, thinking what would seem acceptable to others at work if the patient went home and died, and my care got reviewed”. More and more we are judged by everyone, and not just our peers. The opinions of non-medical professionals who lack insight are taken into account and some of that has to do with the lack of solidarity to our peers in front of the public which diminishes confidence for the whole profession (3). 

Listening to our patients is the first key step in adding critical insight to our decisions. Long term we are expected to be providing fiscally prudent appropriate care to the public. In an era of ever increasing drug abuse we need to focus on making our decisions and behavior based on patient’s best interests and the publics good and not on current organizational financial goals, health trends or other distractions from our profession.  

Medical professionalism requires subordinating your own interest to the interest of the patient’s and public’s health. We have a duty to do right and to avoid doing wrong in principles of beneficence and nonmaleficence. As an example, our profession has been criticized for both under and over prescribing pain medications and antibiotics. Resisting the current trends or an individual’s unsupported drug request in favor of patient and public’s good is what we need to exercise. We need to exercise accountability not just for ourselves but for our colleagues, including intervening and not abrogating our responsibility early in the slippery slope of such behaviors as being chronically late for over commitments for monetary gain, derogatory comments about institution/hospital that degrade trust in our profession to the public, outbursts of anger and inappropriate work place sexual harassment or alternatively false allegations of such type of behavior (4). The Public trust demands that we make appropriate decisions in face of complex environments and often unscientific pressures for the overall care of patient and public if we are to do our part in maintaining a profession (5). We need to continue to strive toward benefiting our patients and subordinating our interests to best meet the needs of our patients and we should stand our ground to pillars of our profession, otherwise maybe we should amend our thinking to accept the fact that we have become corporate or political factotums and not here for a higher calling. Our voices should be united, altruistic and with medical professionalism to maintain public’s trust. Create goals that will prevent burnout and focus lifestyle expectations that realistic and fulfilling in order to avoid the need to rush through the long queues of patients in the waiting room and its associated dissatisfaction (6).  

F. Brian Boudi, MD

Phoenix Veterans Administration Health Care System

University of Arizona College of Medicine

Phoenix, Arizona

Connie S. Chan, MD

Phoenix Veterans Administration Health Care System

Phoenix, Arizona 

References

1. American Board of Internal Medicine. Project Professionalism. 2013. Available at:  https://medicinainternaucv.files.wordpress.com/2013/02/project-professionalism.pdf (accessed 6/29/17).
2. G Hamel, Zanini M.  More of us are working in big bureaucratic organizations than ever before. Harvard Business Review. July 5, 2016. Available at: https://hbr.org/2016/07/more-of-us-are-working-in-big-bureaucratic-organizations-than-ever-before (accessed 6/29/17). 
3. Pardes H. The future of medical schools and teaching hospitals in the era of managed care. Acad Med. 1997 Feb;72(2):97-102. [CrossRef] [PubMed]
4. Scott KM, Berlec Š, Nash L, Hooker C, Dwyer P, Macneill P, River J, Ivory K. Grace Under Pressure: a drama-based approach to tackling mistreatment of medical students. Med Humanit. 2017 Mar;43(1):68-70. [CrossRef] [PubMed]
5. Relman AS. Education to defend professional values in the new corporate age. Acad Med. 1998 Dec;73(12):1229-33. [CrossRef] [PubMed]
6. Barkil-Oteo A. Have physicians finally joined the working class? KevinMD.com. November 3, 2016. Available at: http://www.kevinmd.com/blog/2016/11/physicians-finally-joined-working-class.html (accessed 6/29/16).

Cite as: Boudi FB, Chan CS. The unspoken challenges to the profession of medicine. Southwest J Pulm Crit Care. 2017;14(6):222-4. doi: https://doi.org/10.13175/swjpcc085-17 PDF