A Word From the President

Ensuring the Triumph of Professionalism over Self-Interest

There's much talk these days about the importance of inculcating professionalism in our students, and how, in theory, physicians' adherence to medicine's ethical principles is critical for maintaining public trust in the profession. As compelling as the theoretical link is between professionalism and public trust, it's hard to come by persuasive data that would convince the hard- boiled skeptic.

That's why the recent study led by Maxine Papadakis, M.D., professor of clinical medicine and associate dean of student affairs at the University of California, San Francisco (UCSF) School of Medicine, deserves close attention. As you will read on page 11 of the current issue of the Reporter, this study found a strong correlation between recorded displays of unprofessional behavior in medical school and subsequent disciplinary actions by a state medical board. Although this finding may not be surprising, it represents the first clear evidence that faculty can identify students whose behavior in medical school is indicative of serious shortcomings in their understanding of and/or commitment to the tenets of professionalism.

Fortunately, much effort is currently being directed at bolstering the commitment to professionalism among medical students. A good deal of that effort has been stimulated by the "Physician Charter on Medical Professionalism," which was promulgated by the American Board of Internal Medicine Foundation (ABIM), the American College of Physicians Foundation and the European Federation of Internal Medicine in 2002, and which has now been endorsed by over 100 organizations (including the AAMC).

Last year, the ABIM Foundation awarded small seed grants to five medical schools and academic medical centers to see how the charter might be implemented in an educational environment. The participating institutions were McGill University Faculty of Medicine, New York University School of Medicine, UCSF School of Medicine, the University of Michigan Medical School and the University of Texas Medical Branch. Selected faculty from these medical schools engaged in efforts to incorporate the charter into the fabric of their academic environments while promoting professional values to improve access and quality of care for patients.

At the AAMC annual meeting last fall, the grantees presented their work to an audience of some 125 physicians, educators and healthcare professionals. Their efforts covered a wide range of activities, including circulating copies of the charter to medical students, residents and faculty; hosting lectures and group discussions about the charter's admonitions; establishing mentoring and peer assessment programs; and implementing curriculum changes. At NYU, for ex-ample, faculty implemented an innovative new curriculum designed to foster the progressive development of professionalism in students over the medical school years and to improve their students' ability to recognize unprofess- ional behavior. The other grant recipients engaged in similar activities. (Visit www.abimfoundation.org to get more detailed information and to obtain a copy of the charter.)

Physicians have always found it difficult to live up to professionalism's expectations and for good reasons. First of all, human nature is hard wired for self-interest; eons of evolution have endowed us with strong instincts to look out for number one. And then there's the ease with which doctors can exploit the power gradient that characterizes their relationship with patients. Opportunities - often undetectable to out- siders - abound for physicians seeking private gain at patients' expense. In addition, there's peer pressure; if those around us choose to violate their oath, the temptation to follow suit can be awfully hard to resist.

Compounding these threats to professionalism, each of which has existed from the time of Hippocrates, is the mounting intrusion of commercialism in the affairs of medicine. By turning to the commercial marketplace in the hope of restraining the rising costs of health care, medicine has learned some useful lessons in sound business practice, but has suffered some huge body blows in its age-old battle against self-interest. Witness how frequently the popular media calls attention to doctors succumbing to self-interest. Examples range from conflicts of interest in dealings with the pharmaceutical industry, to gain sharing with insurance companies, to the provision of unwarranted services, even to outright fraud.

Whether or not you agree with me that the fabric of professionalism is in danger of disintegrating under the relentless pressure of commercialism, I hope you will accept the premise that medical educators have an overarching duty to ensure that the next generation of physicians is braced to withstand the threats, both old and new, to the profession's fundamental values. Starting with careful attention to the character of those we admit to the profession, to emphasizing professionalism in the formal curriculum, to assessing achievement of explicit learning objectives that exemplify the attitudes and behaviors we value, to celebrating those who epitomize the virtues we espouse and, above all, to modeling professionalism by mindful attention to its responsibilities in all of our everyday dealings with patients, students, colleagues, and staff.

Yet another reminder of the solemn responsibilities we as medical educators have as stewards of our profession's future.

Jordan J. Cohen, M.D.
AAMC President

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