P. Preston Reynolds

Reaffirming Professionalism through the Education Community

Professionalism in medicine is often examined by considering the effect of the corporatization of medicine, the regulation of medical care, and financial conflicts of interest. Attention should also be focused on the clinical training environment because the rules of professional conduct are learned primarily during medical school and residency. This article considers the importance of an education community in fostering medical professionalism among physicians-in-training and faculty. An education community is one in which the assimilation of knowledge, skills, and values and the development of individuals personally and professionally are priorities. In medicine, this must be done with the delivery of patient care in a context where many competing demands work for and against the existence of an education community. This paper argues that reform of residency training, mentoring, a curriculum on professionalism, and the evaluation of professional conduct are essential to building an education community that enhances medical professionalism. Defining Professionalism Political, academic, and business leaders have recognized the importance of professionalism and described its characteristics. Justice Louis Brandeis [1] believed a profession had three features: training that was intellectual and involved knowledge, as distinguished from skill; work that was pursued primarily for others and not for oneself; and success that was measured by more than the amount of financial return. Other writers [2-4] have emphasized the importance of self-regulation and autonomy in clinical decision making as hallmarks of the medical profession. Some have noted the existence of a code of ethics that sets forth a standard of conduct [5, 6]. This paper considers medical professionalism and its inherent dependency on a formative community. As a working definition, medical professionalism is a set of values, attitudes, and behaviors that results in serving the interests of patients and society before ones own [7, 8]. Honesty and integrity are values essential to medical professionalism. The professional physician has an attitude of humility and accountability to patients, colleagues, and society. Professional behaviors include a nonjudgmental and respectful approach to patients, the pursuit of specialized knowledge and skills with a commitment to excellence and life-long competency, and a collegial and cooperative approach to working with members of a health care team in the delivery of patient care. Lastly, community service and public leadership reinforce the responsibility of physicians to fulfill the goals set forth for the profession by the public. In exchange for putting the interests of the patient and public first, physicians are accorded trust, respect, and the confidentiality of patients. The Education Community Although many factors threaten professionalism in medicine today, perhaps most destructive is the gradual disintegration of the education community, which hinders the transmission of values and behaviors. Physician socialization requires the assimilation of values into a personal framework. Similarly, professional conduct is shaped through interactionsor the lack thereofwith faculty, peers, and patients [9-11]. Because the learning of values and behaviors best occurs in a community with explicit expectations, medical professional education requires role models. The traditional model of medical education implemented by Osler and Halsted [12] emphasizes active learning by students working in the clinics and on the wards under the close supervision of full-time faculty. Embedded in that tradition is a community of physicians who uphold similar values and behaviors. The presence of an education community in medicine is precarious, yet its existence is essential to the profession. John Gardner, former Secretary of the Department of Health, Education, and Welfare, recently described the future of a community: If the community is very luckyand few will be in the years aheadits shared values will be embedded in tradition and history and memory. But most future communities will have to build and continuously repair the framework of shared values. Their norms will have to be explicitly taught. Values that are never expressed are apt to be taken for granted and not adequately conveyed to young people and newcomers. Individuals have a role in the continuous rebuilding of the value framework, and the best thing that they can do is to exemplify them [13]. The loss of an education community in medicine and the threat to the assimilation of professional values, attitudes, and behaviors have been accelerated by the specialization of medicine, the service demands of residency caused by the economics of health care, and the faculty reward system. First, specialization has contributed to a diminishing sense of a shared value system and a weakening of the relationships among the faculty and housestaff and medical students. Over the past 30 years, the size of the clinical academic faculty increased more than 600%, in part to expand the delivery of specialized medical care [14, 15]. Feelings of collegiality and commonality among a core teaching faculty within a small department have been replaced by closer affiliations to and identification with the goals and values of a specialty division, a research team, or a clinical practice group. Specialization also has fostered self-interest and, at times, intense competition among physicians for patients, institutional resources, and control over diagnostic and therapeutic technology [16]. Furthermore, with the expansion of fellowship training, the specialty-oriented faculty in academic medical centers shifted the focus of teaching to fellows. In 1990, in internal medicine alone, more than 8000 fellows were engaged in subspecialty training [17]. The apprentice relationship that united the senior clinician and house officer now exists between the attending faculty and fellows. The layering of fellows between residents and faculty jeopardizes mentoring of residents and medical students, which is critical to fostering professionalism and sustaining an education community. Second, the faculty reward system that favors publication and presentation rather than teaching also has undermined the education community [18, 19]. Travel by airplane has facilitated the process, as has the continuous growth of medical journals. Before air travel and national funding of basic science research, faculty rarely left an institution. They wrote papers on the train and only occasionally submitted a grant application. Otherwise, they spent most of their time teaching residents and medical students, caring for patients, and leisurely doing research. Whereas residents face increased pressure to admit more patients, the faculty face increased pressure to do research and publish, to participate in national medical organizations and research conferences, and to accept visiting professorships. Lost from the hospital wards is the constant presence of the master clinician-teacher, a person essential to maintaining an education community [20]. Third, the service demands of residency, driven by the economics of health care and combined with the loss of senior clinician role models, have contributed to a lower standard of professional conduct on the clinical wards [9, 20-23]. Previously, the attending physician was both a master of the art of medicine and its knowledge base. Residents worked hard, yet the attending physician expected them to serve as exemplary role models to medical students. Today, the attending physician does not have time to conduct a thorough history and physical examination, including a social history, at the bedside. Similarly, residents spend between 17 and 31 minutes evaluating a new patient when on call at night and 25 minutes during the day [24-26]. Worse yet, physicians-in-training now often encounter a patient for the first time on the operating table [27]. That more acutely ill patients are admitted to and discharged from the clinical wards more quickly (sicker and quicker) means that residents experience the anxiety with less gratitude and positive reinforcement for their professional service [28-30]. In the context of lightning rounds and the demands of a busy clinical team, a substantial number of medical students reveal that they have documented in charts physical examinations of patients that were not done (unpublished data). Nearly all medical students report hearing residents and faculty refer to patients in derogatory terms, and usually think such terms are inappropriate ([31]; unpublished data). Confidentiality, and at times the desires of patients, go unheeded. When queried, residents reported that after they had made a mistake, only 24% notified the family, and only 54% told a supervising physician [32]. Physicians-in-training notice the professional and unprofessional conduct of more senior clinicians. This is how they learn the behaviorsgood and badof doctoring. Unlike the harried resident or burdened faculty, the master clinician regarded teaching and patient care as a calling. The relation between the loss of community and the deprofessionalism of medicine is best understood when considering the difference between a calling and a career. When one enters a profession as a calling, one assumes a definite function in a community and operates within the civic and civil rules of the community [2, 33, 34]. When a profession becomes a career, the orientation is to impersonal standards of excellence, operating in the context of a national occupational system. To follow a profession has come to mean to move up and away. Consequently, the goal is no longer participation in a local community but rather the attainment of success, and success (depends) for its very persuasive power on its indefiniteness, its open endedness, the fact that whatever success one had obtained, one could always obtain mo

Design and Use of Performance Measures to Decrease Low-Value Services and Achieve Cost-Conscious Care

Improving quality of care while decreasing the cost of health care isa national priority. The American College of Physicians recently launched its High-Value Care Initiative to help physicians and patients understand the benefits, harms, and costs of interventions and to determine whether services provide good value. Public and private payers continue to measure underuse of high-value services(for example, preventive services, medications for chronic disease),but they are now widely using performance measures to assess use of low-value interventions (such as imaging for patients with uncomplicated low back pain) and using the results for public reporting and pay-for-performance. This paper gives an overview of performance measures that target low-value services to help physicians understand the strengths and limitations of these measures,provides specific examples of measures that assess use of low-value services, and discusses how these measures can be used in clinical practice and policy.

PROFESSIONALISM IN RESIDENCY

Residents are on the front lines of medical care. Although our experiences are rewarding, they are also stressful. The hours are often long and, at times, counterproductive to the learning process....

Hospitals and Civil Rights, 1945-1963: the case of Simkins v Moses H. Cone Memorial Hospital.

In the 1960s, the legacy of discrimination still existed for black persons seeking admission to medical schools, appointments to the medical staff of hospitals, membership in medical societies, and access to hospital care [1-3]. Hospitals that cared solely for black persons were inferior to those that cared for white persons [4-7], and facilities that were designated for black persons in mixed-race hospitals included and were sometimes limited to a basement, attic, or separate building behind the main hospital. Consequently, equality in health care remained an elusive dream for black persons until the stage was set for massive federal intervention. This historical analysis addresses several questions. Why did black dentists, physicians, and patients pursue the integration of hospitals as a means to improve health care for black persons? Why did leaders in the black community work through the court system in laying the foundation for the racial integration of hospitals? What were the consequences of judicial decisions about the use of federal funds on executive action and legislative initiatives? This analysis also describes the federal grant system and effect of racism in federal funding on hospital practices. The case of Simkins v Moses H. Cone Memorial Hospital became the landmark decision leading to the elimination of segregated hospital care through Title VI of the 1964 Civil Rights Act and the Medicare program. Hospitals: The Target for the Elimination of Discrimination in Medicine At the close of World War II, Dr. Paul Cornely, Professor of Preventive Medicine at Howard University, was acting as consultant to the National Urban League and surveyed the health and social services that were offered to black persons in five cities-three in the North and two in the South. Beyond the general absence of social services for black persons in every city that he studied, Cornely found a significantly lower ratio of beds per person for black persons than for white persons. Existence of hospital beds, however, was no guarantee that black persons would be granted access to those beds [8]. Two examples follow: Near Dalton, Georgia, a woman was injured in a car crash. The closest hospital advertised no Negroes, so an ambulance was summoned from 66 miles away to take her to the closest hospital that treated black persons. The woman, Juliette Derricott, died. She had been a national YWCA executive and Dean of Women at Hampton and Fisk College. A 70-year-old man with white skin and blue-gray eyes was hit by an automobile. The motorist who hit the man rushed him to Grady Municipal Hospital. The physician worked to save the patients life while the family was notified of the accident. The first family member to arrive was the patients son-in-law. When the physician saw the son-in-law, who was a nationally prominent black man, he declared, What! Have we put a nigger in the white ward? Still unconscious, the patient was wheeled across the street through the rain to the black ward in the old building; in the black ward, the patient died. He was the father-in-law of Walter White, executive director of the National Association for the Advancement of Colored People (NAACP). Walter White came to know Dr. Louis Wright, another opponent of discrimination, through the work of the NAACP. The NAACP and Louis T. Wright: Integration in Federal Grant Programs Louis Tompkins Wright experienced overt discrimination while he was a student at Harvard Medical School from 1912 to 1915. Wright learned that he was not allowed to rotate to the obstetrics ward at the Boston Lying-in Hospital because the patients were white. Arrangements had been made for Wright with a local black obstetrician. Wright refused this option and argued that his tuition payment and the curriculum promised obstetrics at the Boston Lying-in Hospital. Supported by his classmates, Wright succeeded where previous students had failed. The last painful incident came when Wright, graduating cum laude and fourth in his class, was denied the right to march in the order of scholastic achievement because he was black [9]. Wright later became the Chair of Surgery at Harlem Hospital and chairman of the national board of directors of the NAACP. He directed the policies of the NAACP from 1935 until his death in 1952 and steered the organization through its campaign against discrimination in professional and public education. During his tenure, Wright established the National Health Committee to spearhead the NAACPs fight against separate-but-equal policies in hospital care [10, 11]. The NAACP quickly identified the abuse of the distribution of state and federal tax dollars to public institutions. In parallel, the NAACP Legal Defense and Education Fund directed its litigation activities toward ending the system of discrimination in education, beginning with higher education in the 1930s with the case of Murray v University of Maryland, followed by Gaines v Canada in 1939, Sipuel v Board of Regents in 1948, McLaurin v Oklahoma State Regents in 1948, and Sweat v Painter in 1950. The NAACP Legal Defense and Education Fund ultimately succeeded with its litigation strategy in Brown v Board of Education of Topeka, Kansas in 1954 [12, 13]. The same strategy would be applied to achieve social change in health care. Before World War II, 27 major grant statutes provided federal assistance for agriculture, public health, public assistance (welfare), education, unemployment, compensation, and employment services. After World War II, federal grants expanded substantially. State agencies were chosen as the channel through which federal dollars would flow to communities. Regulations, second in importance only to the statutes themselves, specified who could receive grants, under what conditions, for what purpose, subject to what criteria, and with what exceptions. Before Medicare, the largest federal grant program in health care after World War II was the Hospital Survey and Construction Act of 1946, commonly known as Hill-Burton. The Hill-Burton Act was designed to increase the number of hospital beds throughout the country, particularly in rural communities. Its sponsors were Senators Lister Hill of Alabama and Harold Burton of Ohio. The act authorized

HIV Policy: The Path Forward—A Joint Position Paper of the HIV Medicine Association of the Infectious Diseases Society of America and the American College of Physicians

75 million per year for 5 years beginning in 1947 (for grants to state agencies for hospital construction) plus

Factors Influencing the Acculturation of Burmese, Bhutanese, and Iraqi Refugees Into American Society: Cross-Cultural Comparisons

3 million per year (for state surveys of hospital facilities) [14]. As a federal-state partnership, state agencies were given an initial grant to survey hospital needs and to develop a plan to apportion construction funds on the basis of population distribution and existing hospital beds. Federal dollars without control was the guiding principle. The Hill-Burton Act sought to provide equal facilities for all citizens, but it allowed hospitals that were receiving federal funds to continue existing patterns of discrimination on the basis of a separate-but-equal provision in the legislation [15]. Regulations for the Hill-Burton legislation reflected congressional discussions. They allowed states to develop statewide hospital plans that included segregated institutions if the state health-planning agency considered these facilities adequate for the population served. Hospital facilities that were built for separate populations were to be of similar quality for each population group and adequate to meet the needs of that group [15]. Facilities that were not constructed as separate but equal had to ensure access to all persons without discrimination. The Hill-Burton Act, as interpreted by the General Counsel of Health, Education, and Welfare, meant that no person could be denied admission because of race, creed, or color to that portion of the facility for which federal funds were used; however, the patient could be denied admission to other sections. It was also interpreted to mean that no patient could be denied any service that was essential to his or her health; however, patients could be segregated in the facility by race, creed, or color, and professionally qualified persons could be denied staff privileges [15-17]. In practice, Hill-Burton funds were used by communities throughout the South to build hospitals that excluded black patients from admission and to prevent black physicians from caring for their patients once they were admitted to mixed-race hospitals. When such possibilities became real in Tallahassee, Atlanta, and Memphis, the NAACP Board of Directors required that the local NAACP chapters refuse support for the construction or expansion of a segregated Hill-Burton hospital. If this requirement was ignored, the national NAACP would revoke the local chapters charter [18]. Dr. Wright, as chairman of the NAACP Board of Directors, argued that the way to fight segregation in health care was to refuse to support its institutionalization, particularly when institutions were funded by tax dollars. Over the years, two strategies emerged among the leaders of the black community to improve health care for black persons. One was a strategy of accommodation whereby black leaders would request through well-established patterns of civility, from the white business elite, monies for black institutions, such as hospitals. In Durham, North Carolina, this form of negotiation led to the construction of Lincoln Hospital, an all-black hospital, in 1901 and three subsequent expansions. In terms of investments, however, the differential between Watts Hospital, the all-white hospital in Durham, and Lincoln Hospital grew with each decade. By 1950, Watts Hospitals assets totaled more than

A legislative history of federal assistance for health professions training in primary care medicine and dentistry in the United States, 1963-2008.

2 800 000, whereas Lincoln Hospitals assets reached only

Title VII and the development and promotion of national initiatives in training primary care clinicians in the United States

740 000 [4, 5]. The other strategy was one of integration. In developing this strategy, Wright established the National Health Committee of the NAACP and worked with two faculty members from Howard University: Dr. Montague Cobb, Professor of Anatomy, and Dr. Paul Cornely. The three worked together to orchest

Title VII innovations in American medical and dental education: responding to 21st century priorities for the health of the American public.

Christine Lubinski, Judith Aberg, Arlene D. Bardeguez, Richard Elion, Patricia Emmanuel, Daniel Kuritzkes, Michael Saag, Kathleen E. Squires, Andrea Weddle, Jennifer Rainey, M. Renee Zerehi, J. Fred Ralston, David A. Fleming, David Bronson, Molly Cook, Charles Cutler, Yul Ejnes, Robert Gluckman, Mark Liebow, Kenneth Musana, Mark E. Mayer, Mark W. Purtle, P. Preston Reynolds, Lavanya Viswanathan, Kevin B. Weiss, and Baligh Yehia HIV Medicine Association, Infectious Diseases Society of America, Arlington, University of Virginia, Charlottesville, and Virginia Commonwealth University, Glen Allen, Virginia; Bellevue Hospital Center, New York University Medical School, New York, New York; University of Medicine and Dentistry–New Jersey Medical School, Newark; Elizabeth Taylor Medical Center and American College of Physicians, Washington, DC; University of South Florida, Tampa; Brigham and Women’s Hospital, Harvard Medical School, Cambridge, Massachusetts; University of Alabama at Birmingham, Birmingham; Jefferson Medical College, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; Halle T. Debas Academy of Medical Educators, University of California, San Franscisco; Fayetteville Medical Associates, Fayetteville, Tennessee; University of Missouri Center for Health Ethics, University of Missouri School of Medicine, Columbia; Cleveland Clinic Medicine Institute and General Internal Medicine, Cleveland Clinic, Cleveland, Ohio; Coastal Medical, Cranston, Rhode Island; Graduate Medical Education Clinics, Providence Physician Division, Portland, Oregon; Mayo Clinic, Rochester, Minnesota; Central Iowa Hospital Corporation, Des Moines; American Board of Medical Specialists, Evanston, Illinois; and Johns Hopkins University, Baltimore, and Uniformed Services University of the Health Services, Bethesda, Maryland

Commentary: the teaching community health center: an idea whose time has come.

We examined the acculturation experiences of Burmese, Bhutanese, and Iraqi refugees living in central Virginia based on the model of acculturation developed by J. W. Berry. We identified themes in examining the effects of English language proficiency, level of social support, financial stability, and expectations about and satisfaction with life in the United States on acculturative stress. Language difficulty and barriers to accessing education, employment opportunities, and health care caused stress in all cultural groups. Nearly all refugees were happy they had immigrated due to the personal freedom, safety, and hope for the future they found in the United States.