Elementary concepts of medicine: X. Being a good doctor: professionalism

A practising physician is supposed to be good in his/her doctoring – and also in whatever intervening (s)he carries out. Otherwise put, being a representative of a learned profession, he or she is expected to exhibit genuine ‘professionalism’ in his/her practice, to be a good doctor in this meaning. While, very notably, neither one of our medical dictionaries (Dorland 1994; Stedman 1995) defines professionalism (medical or whatever), a charter on medical professionalism has just recently been published. It is the result of a joint project among the European Federation of Internal Medicine, the American College of Physicians and the American Society of Internal Medicine (Participants in the Medical Professionalism Project 2002a,b). The closest that this charter comes to defining medical professionalism is: Professionalism is the basis of medicine's contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advise to society on matters of health. Even more recently, with the advent of the report of the Royal Commission on the Future of Health Care in Canada imminent, the Canadian Medical Association (CMA) published a ‘document [that] outlines the major features of and challenges to medical professionalism and suggests responses to these challenges’ (CMA 2002). This policy document ends with an invitation: ‘The CMA welcomes opportunities to engage in dialogue with others as to how professionalism in heath care can be preserved and enhanced for the benefit of patients and society in general.’ We responded to that invitation, but our response was not accepted for publication in CMA's own journal, in which the invitation appeared; but instead in the Journal of Evaluation in Clinical Practice (Miettinen & Flegel 2003). That CMA policy document, without any definition of medical professionalism, merely specifies the ‘three major features of medical professionalism [that] benefit society’: ‘the ethic of service, clinical autonomy and self-regulation’. We began our development of a proposed concept of medical professionalism with a dictionary definition of professionalism in general; and consistent with it we ended up positing that (Miettinen & Flegel 2003): Medical professionalism is acting (in health-care and related matters) with all of the desirable qualities that can reasonably be expected of a physician, given his/her speciality and the circumstances; it thus is acting in all respects in accord with good practices, engagement only in normative practices (as most recently collectively defined or otherwise understood within the health-care jurisdiction in which the physician practises). We remarked that insofar as the physician acts in this way, (s)he indeed is ‘placing the interests of patients above those of the physician’ and is being true to ‘the ethic of service’; and we noted that (s)he thus is ‘acting with distinctive competence based on technical know-how selflessly applied’ (Blumenthal 2002). We believe that this attitude and behaviour is what the client expects of a good doctor, one who adheres to the imperatives of medical professionalism. Meaningful apprehension of the concept of medical professionalism presupposes, as well, clarity on what the principal components of health care are generically, so that the imperatives of professionalism and the challenges to, or in, these can be understood in their respective contexts. Neither the charter nor the CMA document specifies these. But as must have become apparent from the preceding essays in this series, we distinguish among three principal components of the practice of health care in general. Pivotal to all else in health care is the pursuit of knowing about the client's health – of gnosis. This knowing is the basis for actual ‘doctoring’–teaching the client about their own health, including how it might be changed for the better. Insofar as the decision to adopt an intervention is taken (in the light of the prognosis that concerns intervention effects), the actual intervening commonly does not, as we have argued, involve a role for the doctor involved in the knowing and teaching antecedents to the intervention decision. Regarding the pursuit of gnosis, we wrote this (Miettinen & Flegel 2003): ‘two generic types of action are involved: acquisition of “facts” (possibly mere factoids) about the client, and translation of the resulting gnostic profile to the corresponding gnostic probability. In this, professionalism has in the main the quality of arriving, at each stage of the gnostic pursuit, at good gnosis: a probability as close to the correct one as can reasonably be expected, given the practitioner's specialty – the correct probability, and thus the correct gnosis, corresponding to a proportion that characterizes situations like this one (per the profile) in general’ (Miettinen 1998; 2001). And as for the teaching component of health care, we said that (Miettinen & Flegel 2003): ‘the beginning of professionalism naturally is that the “doctor” actually does engage in this “doctoring” if at all possible. In actual teaching, then, professionalism is principally a matter of goodness/normativeness of its content, of the gnosis that the teaching purportedly conveys to the client. Teaching that is at variance with the doctor's actual gnosis – affecting gnosis in the context of de facto agnosis in particular – while common, scarcely accords with a doctor's professionalism.’ About carrying out an intervention our proposition was that (Miettinen & Flegel 2003): ‘the main imperative of professionalism [is] correct judgement about the physician's own qualifications for this. At issue is whether the physician can and will do it well, which naturally is a question of process (of surgery, say), not outcome. We thus disagree with the CMA policy that “physicians [are] accountable for . . . the outcomes they achieve on behalf of their patients.”’ The charter calls for patient autonomy in decisions about treatment, meaning that ‘[patients] must be empowered to decide on the course of therapy.’ But it does not explicitly say that professionalism calls for respecting the client's decision however contrary this might be to the physician's recommendation under the ‘principle of primacy of patients’ welfare.’ The CMA document says that ‘physicians are not morally obliged to provide inappropriate medical services when requested by patients despite their respect for patient autonomy.’ Much dialogue is needed on the boundaries of the possibly conflicting ideals of clinical autonomy (CMA 2002) and patients’ autonomy (Participants in the Medical Professionalism Project 2002a,b). About ‘clinical autonomy and self-regulation’ (Canadian Medical Association 2002) we wrote the following (Miettinen & Flegel 2003): ‘It was not the medical professions but society, through its government and despite broad and determined resistance from physicians, that introduced national health insurance in Canada and elsewhere. Shouldn’t the society, again through its government but now with all requisite inputs of medical and other expertise, also define good, normative health-care, care that is justifiable as a matter of balance of considerations that are not only medical but also economical and whatever else is societally relevant; and shouldn’t it see to it that societally sponsored health-care indeed is in accord with such society-benefiting professionalism? We think it should. Societal sponsorship of health-care without governmental assurance of its societal justifiability – of professionalism in societally sponsored health-care – we regard as irresponsible deployment of the society's resources.’ We still hold all that we wrote.

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