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Profession in Health Care Lies Dormant, Not Dead
By David A. Fleming, MD, MA, MACP

The act of profession by physicians is through the sacred promise or oath taken when first entering the field of medicine as a student or trainee, and is repeated many times thereafter. Physicians are required by their profession to assume special responsibilities in relationships they form with patients and to put their patients first. This commitment has been a foundational reality for physicians and other health care providers, including those managing health care systems, for more than 2,500 years.

There is a general sense, however, that health care and the medical profession have been dehumanized by expensive technical advances, the business of health care, and the loss of relationships with physicians that patients have depended on, especially during the most vulnerable times of their lives.1 There is also a general sense that physicians, other health care professionals, and health care organizations are becoming too impersonal and bureaucratic.

In the present demanding culture of health care, the means and goals of medicine, in both practice and training, have been compromised by market influences, fear of legal and regulatory reprisal, and physician burnout; the author has been published on this subject.2 Market forces in academic medicine have also posed an unprecedented threat to the goals of the medical profession—particularly the physician's primary obligation to serve their patients' interests first.3

The sense of profession and precepts that underpin its universal importance for all health care professionals have been dampened, but not supplanted by these powerful forces. A careful look at the policies and mission statements of physician and other health professions' organizations, health care organizations, and even payer groups will reveal mission statements and policies that remain very much patient centered and focused on seeking the social good. Other resources have also been developed and deployed to recapture a sense of profession in every domain of health care.

Fifteen years ago the "Physician Charter on Medical Professionalism" was published to define and encourage professional behavior for physicians in the rapidly changing health care environments in which they practice,4 and has been widely accepted and deployed by physicians in education and training programs. But it has been recognized that the impact of physician behavior on health care quality and the patient experience are increasingly interwoven with the policies and practices of the health care organizations in which they practice.5

A subsequent resource available is the "Charter on Professionalism for Health Care Organizations."6 The charter provides guidance by outlining the tenets of professional commitment and encouraging professional behavior within health care systems in order to create a more inclusive, welcoming, healing environment of care, alleviate burnout, and provide ethical guidance for model hospital operations. While not denying the need for profitability, the charter shifts the organizational focus toward employees, patients, and the community.

The working group that drafted the charter represents health care systems, patients, community advocates, and health care professionals. The purpose of the charter is to encourage core principles and professional behaviors that are applicable to all health care organizations that see themselves as patient centered and progressive in their desire to improve.

The core principles that support the charter remind mission-based health care organizations that they should be patient centered, reasonable, and fair in offering access to services, constantly seeking to learn and improve, and practicing wise stewardship of resources.

The charter has four domains, each with specified commitments, as follows:

• Patient partnerships. Model organizations should be patient centered and partner with patients to ensure outcomes that reflect patient values and beliefs.

• Organizational culture. Seek an environment of shared values, beliefs, attitudes, and behaviors that reflect concern for patients, employees, quality of care, safety, and shared trust.

• Community partnerships. Collaborate with other health care organizations, the community, businesses, and policy makers to ensure community safety, quality of care for everyone, elimination of disparities, improvements in population health, and a work force (including leadership) that is inclusive and reflective of the diversity of the community.

• Operations and business practices. Ensure patient safety, clinical excellence, transparency, evidence-based practices, high-value care, professional competence, and fiduciary responsibility using sound ethical business practices.

The charter sets a high bar for organizational performance; it will be a challenge to fully embody all behaviors and commitments. Those developing the charter also recognize that adopting an aspirational model such as this based on the charter's domains and commitments may challenge well-entrenched attitudes and behaviors within many organizations. There is evidence, however, that implementing behaviors encouraged by the charter will improve health care, the work environment, and the patient experience.

These are challenging times professionally; however, most health care organizations and professionals want to find ways to meet those challenges. Now, there are means available to foster that effort.

— David A. Fleming, MD, MA, MACP, is president emeritus of the American College of Physicians, emeritus professor of medicine at the University of Missouri, and codirector of the Center for Health Ethics at the University of Missouri School of Medicine in Columbia.

References
1. Dehumanization. Encyclopedia of Death and Dying website. http://www.deathreference.com/Da-Em/Dehumanization.html. Accessed February 16, 2017.

2. Fleming DA, Moss L. Mentoring profession part I: the history and tradition of medical profession. Ann Behav Sci Med Educ. 2011;17(2):7-13.

3. Ludmerer KM. Instilling professionalism in medical education. JAMA. 1999;282(9):881-882.

4. ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians—American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Int Med. 2002;136(3):243-246.

5. Lesser CS, Lucey CR, Egener B, Braddock CH 3rd, Linas SL, Levinson W. A behavioral and systems view of professionalism. JAMA. 2010;304(24):2732-2737.

6. Egener BE, Mason DJ, McDonald WJ, et al. The charter on professionalism for health care organizations [published online January 10, 2017]. Acad Med. doi: 10.1097/ACM. 0000000000001561.