Some complex concepts are better caught than taught. Professionalism in Medicine is an acquired demeanor perceived by patients, their families, health care workers, and trainees to indicate that the physician has commitment to the needs of the patient, clinical competence, compassion, integrity, and self awareness (1-3). Each of these attributes have their roots in qualities of the exemplary physician: excellence and compassion.
The pursuit of excellence in medicine is a complex process, based on a balanced knowledge of one’s capabilities and limitations in acquiring familiarity with a body of information so broad and deep that no one can master it all (4). Accordingly, we need to master the limited knowledge we use. A good guideline is to master what interests or fascinates us. Then what we acquire in terms of facts is less important than our acquisition of the search for excellence – a process that we can apply to every new learning situation. Excellence is partly taught, but is mostly caught by the process of working side by side with role models who have it, so mentorship should be actively sought as an integral part of striving for excellence (5).
A recent survey of Dutch Critical Care Fellows confirmed striving for excellence as the most relevant element of professionalism (6). Excellence meant having a superior knowledge, good technical skills, and attitudes conducive to communication, feedback, and record keeping. Other factors relevant for professionalism in intensivists were teamwork and dealing with ethical dilemmas like end of life decisions and limitation of treatment. This survey also noted that role modeling is of paramount importance in developing professional values, attitudes, and behaviors, and such modeling became more important when combined with reflection and discussion of the modeled action (6).
Excellence is necessary for the acquisition of professionalism, but it is not sufficient. It needs another quality, and acquiring compassion is just as difficult as acquiring excellence. Compassion is our ability to be with our patients in their distress. As compassion grows, so empathy grows, conferring an active receptivity for the patient’s story. Since excellence depends in large part in our capacity to hear the patients story and respond with intelligent, data based decision-making, compassion enhances excellence. We draw on our own woundedness to provide the strength to be with, to comfort without cure. That process gets better with time and with our surviving more losses. We become “wounded healers” using our own processed grief as a source of personal strength from which compassion flows effortlessly (7). The good news is that all our past present and future losses add compassion to our excellence when we process them well.
The Dutch survey also identified dealing with ethical dilemmas like end-of-life decisions and limitations of treatment as most relevant to professionalism (6). Attributes of compassion used in managing grief include being the patients advocate, empathic listening, assembling support, acknowledging the loss, introducing the vocabulary of grief, and providing helpful information (8). Note that learning these skills is often more available to hospice personnel, social workers, psychologists, and clinical pastoral associates than to ICU personnel. When providing care to dying patients and their families, even exercising compassion may not be enough. Critical care physicians, trainees, and nurses must sharpen their communications skills continuously, evaluate their procedures, identify their inadequacies and mistakes, and work toward correcting them (9).
NURTURING THE ROOTS OF PROFESSIONALISM
To the extent that nurturing excellence and compassion enhance professionalism, we should identify and apply the growth factors in our medical education programs. These include:
- Build mentorship and role modeling programs, both positive and negative.
- Develop reflection sessions and discussions for our health care teams around topics of excellence and compassion.
- Initiate management of death and dying and limits on therapy in the curriculum.
- Provide explicit affirmation for observed acts of excellence and compassion.
- Import training programs from cross disciplines – especially Hospice and Social Workers and Clinical Psychologists.
- Facilitate and encourage access to counseling for our trainees.
These tactics seek and gain greater understanding of how the admissions process can select for professionalism in 20yo applicants to medical school. In so doing, we accept our responsibility to support our trainees search for a higher level of maturity.
- Stephenson AE, Adshead LE, Riggs RH. The teaching of professional attitudes within UK medical schools: reported difficulties and good practice. Med Educ 2006;40:1072-1080.
- Klein EJ, Jackson JC, Krantz L, Marcuse ER, McPhillips HA, Sugarman RP, Watkins S, Stapleton FB. Teaching professionalism to residents. Acad Med 2003;78:26-34
- Wilkinson TJ, Wade WB, Knock DL. A blueprint to assess professionalism: results of a systematic review. Acad Med 2009;84:551-558.
- Peters TJ, Waterman RH jr. Part 2: toward a new theory. In: In search of excellence. New York: First Collins Business Essentials; 2006. Pp.29-86.
- Wood LDH. Mentorship in pulmonary and critical care medicine. AM J Respir Crit Care Med 2010;182:1215-1216.
- Van Mook WNKA, deGrave WS, Gorter SJ, Muijtjens AMM, Zwaveling JH, Schuwirth LW, van der Vieuten CPM. Fellows in intensive care medicine views on professionalism and how they learn it. Intensive Care Med 2010;36:296-303.
- Morgan PP. Wounded healers can help give hospital patients more humane care. Can Med Assoc J 1984;131:1335.
- Hall JB, Schmidt GA, Wood LDH. Managing death and dying in the ICU. In: Hall JB, Schmidt GA, Wood LDH, editors. Principles of critical care, 4th New York: MCGraw-Hill; 2015 pp 3-5.
- Curtis JR, Engelberg RA, Wenrich MD, Shannon SE, Treece PD, Rutenfeld GD. Missed opportunities during family conferences about end-of-life care in the intensive care unit. AM J Respir Crit Care Med 2005;171:844-849.
Lawrence D.H. Wood – Larry Wood is a father of modern critical care. He published 100’s of original scientific articles, many which lie at the foundations of 21st century evidence-based practice, and was the senior founder-editor of Principles of Critical Care, the definitive text of CCM. Larry also mentored a tribe of national figures in PCCM who began their careers at University of Chicago.