Medical Professionalism

Got to thank Dr Rafidah for this awesome article. I consider it a must-read to all healthcare community members.
_______________________________________________________________ Medical Professionalism
Robert W. Cantrell, MD
Arch Otolaryngol Head Neck Surg. 2008;134(3): 237-240.

Physicians have suffered a significant reduction in the prestige and respect that they once enjoyed. There are many reasons for this: the commercialization of the practice of medicine; the surrender of control of the physician-patient relationship to insurance companies, health maintenance organizations, and other business entities; and the increasingly high cost of delivering medical care. Even when most
of the increased costs are driven by drug, hospital, laboratory, and radiological fees, these are perceived by many patients as "doctor bills." To maintain viable practices, physicians must increase their patient volume and spend less time with each, which contributes to the diminution of physicians in the eyes of the public and the changed image of our calling as a business rather than a profession. With an increasingly cynical, testy, and confrontational populace exemplified by the behavior on both sides of the political spectrum during election campaigns, we physicians find ourselves "less loved," and, in some cases, "dissed" (using street language), and we don't like it.

Most individuals enter the profession of medicine because of a sincere desire to alleviate suffering in their fellow man. If, however, you "scratch below the surface," you will find that many of us also want to be loved and respected for the dedication that we exhibit and the valuable service we render. This is not unique to our profession, but physicians, like other medicine men and women since time immemorial, have usually occupied positions of respect in the tribe or society in which they have lived. Today, we feel ourselves slipping from that pedestal.

Today, anyone with a computer can go online and find multiple discussions of any symptoms, disease, or other disorder plus recommendations, not always valid, for correcting the medical problems. So, do we need the physician anymore? More people are seeking medical care from physicians than ever before, and it is not just because they haven't figured out a way to perform surgery over the Internet.

For those of us who studied science in high school, worked hard to get into a good college where we diligently studied to get accepted into medical school, where we studied diligently to obtain a residency, where we worked hard to join a successful practice, where we worked hard to pay the bills, oblivious to the changing world around us, we have had little opportunity to evaluate and contemplate these issues. It is not until you retire, as I have, that you have the opportunity to consider these issues and determine the solutions, if any, but by this time, even if you still care (and some don't) or you can still think (and some can't), few will listen to someone who may be considered to be out of touch.

If any of what I have said rings true, let me offer you some advice that may assist in negotiating the bumps in the road of your career.

GIVING ADVICE

First, be chary of giving advice; wise people don't need it, and fools won't heed it. Sometimes it is worth what you pay for it. As physicians, however, our advice is often sought, and we need guidelines on how to provide it. So, here is some free advice. Remembering it may be worth what you pay for it.

Consider that you won't always have the answer to a patient's question, so don't be afraid to admit it. Owing to the amount of medical information available to laymen, patients sometimes already know the answers to the questions they ask; they may be testing you and can recognize a false answer. Also, don't be too certain that what you were taught as fact is so. When I graduated from medical school in 1960, I thought I knew all the answers to all the medical questions. It all went downhill after graduation, and it was not long before I discovered that I didn't have all the answers—that putting an X in the right box on a multiple-choice examination was far different from putting my finger on the right spot in the examination of a patient. Physicians have an obligation to learn as much as possible about what is considered current, but they also have an obligation not to accept something until it has been studied properly and proven.

Physicians should be as scientific as possible, which means having an inquiring mind open to new facts and not being reluctant to question old ones. As Alexander Pope said, "Be not the first by whom the new are tried, nor yet the last to lay the old aside."

ETHICS

Physicians should embody the highest standards of ethics: honesty, integrity, morality, and fidelity. These virtues are regarded as old fashioned by many who subscribe to postmodern, secular thinking, and they are indeed old fashioned, if by that one means they have been around for a long time. These principles have survived because it has been learned, sometimes through bitter experience by failing to apply them, that these standards are the best way to live. Fashionable today are situational ethics, the concept that the truth changes with the circumstances. Nothing is certain; people don't do something without an ulterior motive; virtue is no longer its own reward. More likely the driving force is, "If it feels good, do it!" There may be professions that can adopt this thinking and survive (although I doubt it), but medicine is not one of them. To the extent that we have adopted this thinking, it can be directly related to the degree to which our respect has fallen.

It is crucial that a physician always be truthful, and truth does not change with circumstance. This doesn't mean that what is said is always 100% accurate or correct; I used to tell the residents that half of what I was teaching them was wrong, I just didn't know which half it was. One should always relate what he or she believes is true. This may be more difficult than one might think. I've had people say to me, "If Granddad has cancer, don't tell him. It would just kill him." My response has always been, "If Granddad has cancer, he has a right to know, and he didn't get to be Granddad by avoiding the truth. While I will be sensitive to the situation, if he asks me, I most certainly will tell him the truth." The net effect of this is to increase your veracity in the eyes of the family members, because if you would lie to Granddad, you would probably lie to them. Also, I was always too busy to keep different stories straight.

I also told the residents and students that in my experience, there are 3 things that have diminished or ruined careers: drinking too much alcohol, financial improprieties, and sexual involvement with the patients or those with whom you work. These 3 things are frequently related. This is not only a moral issue, it is good business to avoid these traps.

HUMILITY

Humility is a virtue that not many physicians possess. This is understandable when one considers the life-and-death decisions physicians are sometimes called on to make and the adulation we sometimes receive from patients and their families. We must, however, always guard against becoming arrogant. Not all of the patients we treat have good outcomes. Many patients will either die or get well in spite of what the physician does. Voltaire said prior to 1778, "The art of medicine consists in amusing the patient while nature cures the disease." Or, as Ambrose Paré, the father of French surgery stated before 1590, "Physicians treat, God heals."

TALKING TO PATIENTS

I'm always amazed when I hear a physician, often young but not always, say to a patient with cancer or some other potentially fatal disease, "Madam, you have 1 chance in 3 of living 2 more years if you follow my recommendations. " Or, worse, "Only 59.5% of patients with your disease will live 5 years." This is applying a scientific precision to a situation that cannot be that precise.

Statistics are fine for writing papers or evaluating a given treatment, assuming valid controls are present, but a single patient is not a statistic, and you should not make the patient into one. If 90% of a particular group of patients will be dead in 5 years according to statistical analysis, it follows that 10% will be alive in 5 years. To which group does the patient you are addressing at the moment belong? Granted, patients have a right to know generally their chances of survival in order to make plans, but as physicians, we don't always know what these chances are for a specific patient. I've seen patients who I thought did not have much chance of surviving who went on to respond well to treatment and live many years. Conversely, I've seen patients who seemed as though they would do very well deteriorate after standard treatment and die. It is not easy to predict outcomes.

Norman Cousins, former editor of the Saturday Review of Literature, was once diagnosed with a terminal illness. Rather than seek palliative therapy in a hospital with an undetermined outcome, he chose to enter a hotel, consume 25 000 U of vitamin C daily, and watch old Marx Brothers movies. He believed he laughed himself well. This episode stimulated him to write a book titled Anatomy of an Illness: Reflections on Healing and Regeneration1 (it is still in print, and it is recommended reading for all physicians). On the dust jacket, Cousins wrote these words, "It all began, I said, when I decided that some experts don't really know enough to make a pronouncement of doom on a human being. And I said I hoped they would be careful about what they said to others; they might be believed and that could be the beginning of the end."1 His point, of course, was that physicians should not destroy the hope of patients. In his later years, Cousins served on the faculty of the University of California, Los Angeles, Medical School, reminding the students of these lessons.

Be careful what you tell your patients; they are fragile beings, wonderfully constructed, but words can damage them just like a knife, and they place great trust in you. No person has a right to destroy the hope of another person.

Use language that patients understand. This may be more difficult than you might imagine. I once undertook an unpublished study on informed consent. I would carefully explain to my preoperative patients what type of surgery was to be performed. I would then ask them to write on the consent form what they understood the procedure to be. Fully half could not name the procedure I had just explained to them. Patients will rarely admit that they don't understand, and they are often more frightened than they will admit. When they enter a physician's office, or are seriously ill, many are not very perceptive or receptive. Small wonder then, that some malpractice cases have been brought by patients who say they were not informed by the surgeon of what he or she was going to do in spite of a consent form in the medical chart, signed by that patient, that clearly outlined the procedure with all the possible risks and complications. One moral of this story is that keeping accurate, complete, and clearly written records is a must. If your handwriting is illegible, as with most physicians, have it typed. This is good patient care as well as preventive legal care.

Offer a compassionate, caring attitude to the patient. Many patients today complain about the care they receive or fail to receive. In fact, from a strictly scientific view, this "delivery of medical attention" today is perhaps the finest ever provided in the history of the world. However, aside from its significant cost, it is frequently perceived by the patient as not being delivered with care. The aloof, scientifically oriented, detached physician may be totally correct in his or her diagnosis and treatment but end up with a patient cured but dissatisfied that they did not receive the proper care.

HUMOR

I believe the physician should possess and exhibit a sense of humor. As Cousins showed,1 laughter is great medicine. There is some evidence2-3 that endorphin levels rise when one laughs and are lowered when one is dour or depressed. Without being flippant, you should always try to exhibit a positive attitude toward patients. I treated mostly head and neck cancer during my career, and when a patient was given this diagnosis, they were usually appropriately scared. Some would ask, "What are my chances? Am I going to die?" My response was always, "Yes." After the shock of this fairly brusque reply had passed, I would add, "Everyone must die sometime, but I am here to see that this doesn't happen to you on my watch." I would then outline what treatment plan the tumor board had recommended, and go on,

“This is what we are going to do for you. And here is what you are going to do for me. You are going to quit smoking and quit drinking. If you are unwilling to do this, you will need to find another doctor, because otherwise, you will just be wasting your money and my time. People who develop these cancers, usually because of smoking and/or drinking too much, even when cured by the therapy we recommend, if they continue to smoke or drink have a 50:50 chance of developing a new cancer within 2 years.”

All of my patients did not stop smoking or drinking, and I never turned any away, but many did quit, and all were surprised that I felt so strongly about these vices. Some said that no physician had ever "told" them to quit before. I found this hard to believe and most curious until I analyzed exactly what they were saying, "No physician told them to quit." The physicians would recommend or advise them to quit but did not order them to do so. Perhaps it was my military background, but it was not difficult for me to give an order. You can disregard a recommendation or advice, but you must disobey an order. Some of my colleagues have argued that we don't have the right to order patients in this fashion. Really? We write orders all the time for such picayune things as when a hospitalized patient can get up to go to the bathroom or not, what kind of diet they can have, and what drugs they should take. Why shouldn't we order them to cease something that is so deleterious to their health?

Don't take yourself too seriously. We physicians, working long hours, dealing with disease, death, and dying (or worse, growing paperwork), sometimes put on a long face and walk around like Digby O'Dell, the friendly undertaker. When things go wrong, as they sometimes will, try to be a little detached and find the humor in the situation. I used to tell myself in such circumstances that someday I would look back at this and laugh. At that moment, however, it didn't seem very funny. Being cheerful at such times is not always easy to do. Allegedly, Winston Churchill's wife, trying to console him after he had led Great Britain during World War II as prime minister only to be voted out of office once the war was over, said, "Don't worry, Winston, this may well be a blessing in disguise." Harrumphed Churchill in reply, "Right now, it is very effectively disguised." Keep smiling; it will confound your detractors. It is, of course, important to always project appropriate gravitas in interactions with seriously ill or dying patients.

One of my pet peeves is the physician who talks down to a patient with a very loud voice. Although a loud voice may be indicated with someone who is partially deaf, in most cases, it is not. It is as though the physician feels that the louder the voice, the truer the words will be, and the more the patient will comprehend. Talk in a normal tone of voice, and treat the patient with respect. You do not have the right to call patients, especially older persons, by their first names unless you also wish to be called by your first name. Elderly people, of whom there are more and more each day and of whom I am one, deserve the respect of you young "whippersnappers. "

PRIORITIES

Where you place your values and priorities tells a great deal about a person. I was told early in my career to first be a husband, then be a father, then be a physician, and then be a specialist. It is good advice, and good priorities, that I tried to follow. Medicine is a very seductive mistress. It is very easy to get caught up in doing good and forget about other important things in life such as family, friends, and enjoying pursuits outside of medicine.

It is also important that one take control of one's life and practice. Understand early on that there will never be enough time in the day to see all the patients who would like to see you, especially if you are a devoted physician. You must be efficient, be on time, and try to adhere to a clinic schedule; do not allow yourself to be lured into a trap of seeing more patients in a given time period than can reasonably be managed. You will "burn out," and the patient will not be happy. Try not to keep the patients waiting. It would probably come as a revelation to some physicians that other people's time is just as valuable as their own. I have always said (and practiced) that if I had an appointment, I would not wait an hour to see a physician unless I was unconscious.

In short, exhibit integrity, honesty, and fidelity. Care for and about your patients, maintain good humor, and don't take yourself too seriously. Speak quietly and with respect in language the patients can understand, and never destroy their hope. Concern yourself with the whole patient. If we physicians do this, we won't have to worry about our place in society; it will be there.

Editor's Note
Robert W. Cantrell, MD, had a long and illustrious career in otolaryngology– head and neck surgery, culminating as the vice president and provost of the University of Virginia Health System for 7 years. Despite his retirement from his leadership roles, Dr Cantrell still maintains a keen interest in the practice of medicine and the maintenance of professionalism and ethical behavior.
This is an abbreviated version of a talk that he has delivered, and continues to deliver, to the University of Virginia resident staff as well as prospective residency candidates. Because of its popularity and cogent focus, I requested he put on paper that which he has so eloquently delivered verbally. I do hope that you find it as cogent and poignant as we have.

AUTHOR INFORMATION
Correspondence: Dr Cantrell, University of Virginia Health System, 1925 Owensville Rd, Charlottesville, VA 22901 (rwc@virginia. edu).

REFERENCES
1. Cousins N. Anatomy of an Illness as Perceived by the Patient: Reflections on Healing and Regeneration. New York, NY: WW Norton & Co; 1979.
2. Hoare J. The best medicine. Nurs Stand. 2004;19(14-16) :18-19. PUBMED
3. Weisenberg M, Tepper I, Schwarzwald J. Humor as a cognitive technique for increasing pain tolerance. Pain. 1995;63(2):207- 212.