"Thoughts on Professionalism and Patient Care"
August 22, 2001
Munsey S. Wheby, M.D., F.A.C.P.
It is an honor and a great opportunity for me to welcome the class of 2005. 2001, your entry year, celebrates the 100th anniversary of the University of Virginia Hospital, a place where you will be spending a considerable amount of time over the next four years. It is a place with a great history where excellent care has been provided many, many patients over these 100 years.
Along with you, 2001, is highly significant to me. It brings back vivid memories, since exactly fifty years ago, 1951, my class numbering 72 white males entered the University of Virginia School of Medicine. How times have changed and for the good! It is exciting to have witnessed the progressive improvement of our school.
I think that I should also describe for you how much the welcoming and orientation process for first year medical students has changed.
When we came here in 1951, the Dean may have said hello before we were assigned a wooden crate containing all the bones of a human skeleton. We were then told to come back in a week for an examination in which we were expected to know all of the articulations and muscle and tendon insertions.
It was not an entry designed for, or conducive to, exciting us about learning nor to introduce us to the wonderful profession of medicine. In fact, some students were immediately discouraged and at least one quit in the first week.
We believe we have made progress since then, particularly under the leadership of Dean Carey. The educational environment at the University of Virginia School of Medicine is better than it has ever been. Along with a number of other medical schools, our school has devoted attention to developing a more supportive environment for welcoming new medical students. From day 1, we hope to generate in you a feeling of excitement and anticipation that you are truly entering the medical profession.
Each of you is idealistic, well motivated, and has a mental image of being a physician even though you may not yet know what this entails. You have been preparing yourselves and have been chosen, in part, based on our perception of your character and accomplishments. In other words, we regard you as being intelligent, well-motivated and possessing high ethical standards. It may interest you to know that this was not always the image that medical students projected. Let me give you a surprising example.
You will soon learn that there is a national honor medical society called Alpha Omega Alpha. This is a prestigious honor society into which medical students are selected for membership based on their academic and other accomplishments. The organization was founded in 1902 by William W. Root, a 38-year-old medical student at the University of Illinois in Chicago. Root started the society because the name "medical student" was associated with "rowdyism, boorishness, immorality and low educational ideals".
Root was appalled at the behavior of his fellow students and proposed starting a group to foster scholarship and high medical ideals. At the time Root began AOA, only three medical schools even required college work for entry.
So, even though we venerate tradition here at Mr. Jefferson's School of Medicine, and even though we want you to enjoy life, we will do all we can to keep you from returning to that older behavior pattern of medical students.
Today, we begin your orientation and initiation into the great profession of medicine. I have referred repeatedly to profession. This year, in one of our small group discussions, I was shocked by the comments from one of our medical students who expressed a very negative impression of professionalism.
Let's spend a few minutes on the concept of professionalism to see if there is any reason for that negative reaction.
Profession: The occupation which one professes to be skilled in and to follow.
A profession has the following qualities:
- it possesses a discrete body of knowledge and skills;
- it requires a long period of education;
- its members determine educational requirements and admission to the profession;
- it evaluates and disciplines its members.
In a profession:
- one expects to earn a reasonable living...
BUT- one is expected to value performance above reward;
- one is held to higher standards of behavior than nonprofessionals;
and,- one is expected to behave in an ethical fashion.
Professionalism:
- the core of professional behavior is ALTRUISM;
- one is expected to place the interests of those served above self-interest;
- a Profession is expected to place societal interest above the interest of the profession.
Aren't these qualities worthwhile? Aren't they ones to strive for? Perhaps you can see why the student's negative comments were surprising to me. Our profession should engender in you a sense of fulfillment that you are helping others.
Maintaining professionalism requires constant attention. Many medical organizations have a reference to professionalism in their mission statement. For example, the American College of Physicians-American Society of Internal Medicine, to which I belong, is the organization for internists; i.e., those who practice internal medicine. It has as its mission "to enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine". This is by no means a new concept. The Royal College of Physicians of London was chartered in 1518 by Henry VIII "to resist the endeavors of wicked men and especially to repress the audacity of those who profess medicine rather because of their own avarice than in any assurance of a good conscience".
Now, I'm sorry but I must interject a warning to you. While I do not want in any way to dampen your enthusiasm for the career you have selected, you should know that physician unrest is rampant. Physicians today are experiencing a sense of frustration as changes in the health care delivery systems in virtually all industrialized countries threaten the very nature and values of medical professionalism.
There is dissatisfaction both with practice and with academia. Much of this dissatisfaction is due to the fact that physicians are currently facing a hostile workplace. Many components contribute to this tumultuous state. Some include:
- managed care with change in practice patterns and decreasing reimbursement;
- increasing paperwork;
- government interference; e.g., unreasonable documentation requirements which result in decreased time for patient contact;
and, - a feeling by physicians that public respect for the profession has declined.
We must find ways to lessen those factors interfering with the enjoyment of the practice of medicine. It is important for us to focus on the positive aspects of being a physician. We should experience great personal satisfaction in practicing medicine and caring for patients. We cannot let the many hassles overshadow the satisfaction we should feel when we help patients cope with illnesses.
As you begin medical school, you will see that our curriculum is designed to provide you with patient contact very early on. We hope this early contact with patients will not only help you to see that you really are moving toward your goal of being a physician, but also will provide the understanding that attaining a firm base in science is essential for you to keep up with the rapid changes in medicine.
In preparing this talk for a receptive but captive audience, one of the temptations I had to resist was the urge to tell you about many of my experiences gained over a lot of years. You will be happy to know that I did successfully fight off this urge. Nevertheless, what I really hope to accomplish is to sensitize you to what I consider to be the most important part of being a physician. I want to leave you with some thoughts on patient care and caring for patients, the essence of practicing medicine.
When one is young and healthy, and perhaps has never experienced a serious illness, nor perhaps has experienced a serious illness in a close family member, it is difficult to comprehend and feel the emotional and physical impact of illness on patients.
After many years of practice, and teaching, and enjoying good health, I recently gained much more insight into patients' feelings when within the recent past, I had two illnesses from which I recovered completely quickly.
During each of these illnesses, I had a high fever and felt terrible. Some might call what I experienced "toxic delirium", or fever-induced alteration of brain function, but during the fever, my mind revolved continuously through my file of patients. Faces flew by. In sharpest focus were those who had died. I was overwhelmed with admiration for these brave patients. How many of them had presented an optimistic, even smiling presence during our short time together in the office or hospital only subsequently to endure fear and uncertainty during long, often lonely nights! In my feverish discomfort, I wondered how they had summoned the inner strength to deal with greater suffering and far more serious illnesses than my limited one. In fact, I became so overwhelmed by this feeling that during one of the fever bouts I asked my wife to take notes on my ramblings. It was a surprise to me when I read her words following my recovery. The notes rang true with the feelings I had experienced.
In more than thirty-five years of practice, I have cared for patients with serious blood disorders; my patients often required toxic chemotherapy and many had a far-from-certain outcome. In my feverish state, I kept wondering how my patients dealt with the terrifying uncertainty that is often at the heart of their illness, and I wondered too whether I had done enough to ease their discomfort and help them maintain hope. Even with this fever-induced "examination of conscience," it was reassuring to recall that many patients, and family members of deceased patients, had told me that our relationship had helped them cope with the struggle.
I don't read poetry very often but recently I read a short poem which was extremely powerful and which concerned the doctor-patient interaction. The poem affected me deeply because it was written by a good friend of mine about her late husband who was an even closer friend, a physician-colleague, and a graduate of our medical school. The poem is called "The Sentence". It was written by Joyce Butterworth and was published in the Spring 2000 issue of the Pharos, the journal of Alpha Omega Alpha which I mentioned previously. Pay careful attention to the description and behavior of the physician.
I hope sincerely that none of you will ever leave a patient or family member with such feelings. Listening, touching, kindness, warmth, sensitivity to patient and family needs, in addition to excellent clinical skills---these are the hallmarks of a caring physician---and, they provide the base for developing those relationships that are the source of satisfaction in practicing medicine. Bringing out these qualities in you is what our school is about. To the extent that we promote the development of these qualities, we are successful as a school.
In closing, if the University of Virginia's magic wahoo genie were to give me the power to have two things from this talk stick with you through your career, they would be:
- Remember that the essence of professionalism is ALTRUISM.
- Remember that feeling for the patient is an important part of caring for the patient.