Professionalism: Paging Dr. Hippocrates

Barry Egener’s daily schedule is packed. An internal medicine physician in Portland, Ore., he spends more than 30 hours per week in clinical practice, teaches at his group’s residency training program, is the medical director of Portland’s Foundation for Medical Excellence, and serves as a peer reviewer for five medical journals. It was 8 a.m. on a Monday when we spoke to him, yet he’d already had two patient consults.

But Egener isn’t heading toward burnout. To the contrary, 20 years into practice, he says he draws largely on the tenets of professionalism to continue to feel good about being a doctor. To some harried physicians dealing with an unforgiving healthcare economy, “professionalism,” a concept they first learn in medical school, may seem a quaint, academic notion that simply does not work within a modern practice. To Egener, however, “trying to maintain those values in the face of the pressures of everyday medical practice is how I prevent myself from burning out, and also how I maintain good quality care for my patients.”

What does he know that you don’t?

“First, do no harm.”

Before you dismiss Egener as a workaholic freak of nature, it may be helpful to explore the idea of professionalism within the context of modern medical practice.

Christine Cassel, an internist and geriatrician who is also the president and CEO of the American Board of Internal Medicine (ABIM) and the ABIM Foundation, jokingly refers to the core principles of professionalism as “the high-falutin’ values that medical students enter school with and that we very efficiently beat out of them in four years.”

Indeed, the concept of professionalism is defined for medical students repeatedly; they are taught to put their patients’ interests above all others, including their own, and that altruism should be at the heart of all patient encounters.

But many young doctors become hardened by residency programs known for their grueling hours and crushing patient loads. Then they enter private practice. The lofty tenets of professionalism quickly become a distant memory. Now their prime concerns are securing fair pay for their work, squeezing in more time for patient interactions, achieving a work/life balance they can live with, and retaining control over their decision-making capabilities when they are questioned by third-party payers.

Professionalism? Why should they consider themselves professionals when it often seems no one else does?

One-third of physician respondents to a recent Physicians Practice poll said that they would choose some other profession if they had a chance to do it over. That’s no surprise, says Cassel: “Feeling that you’re not living up to the professional values you were taught can lead to great cynicism and disillusionment. Doctors are left wondering, ‘What is this game I’m in, anyway?’”

Although widely thought to be so, the famous directive, “first, do no harm” is not explicitly stated in the original Hippocratic Oath. Still, it has long been considered a tidy summation of a physician’s primary duty to place their patients’ welfare above all other considerations. It is, therefore, the oldest, and perhaps still the best definition of professionalism within a medical context.

But Hippocrates certainly never had his medical directives second-guessed by insurers unwilling to pay for treatments that he considered medically necessary. He never begged bean-counters for payment. So today’s physician cynicism is understandable. But is it necessary?

The professionalism paradox

So then what exactly is professionalism? Egener defines it as “a large concept that includes things like altruism, integrity, [and] a commitment to excellence of practice.” But, he acknowledges, “It can be challenging to maintain within the everyday practice of medicine.”

Not a surprising answer from a physician whose work week frequently exceeds 60 hours. But Egener maintains that truly applying the tenets of professionalism as they are generally understood actually works to his benefit.

“I think that the potential conflicts of interest that professionalism addresses … [are] less about financial conflicts of interests than [they are] about time tradeoffs,” Egener explains. “It’s more about quality of life, time with family, and the temptation to do a less-than-thorough job with patients because of your personal well-being issues. The paradox is that it is exactly that professionalism is the key, I believe, to not burning out in that environment.”

Almost all physicians go into medicine with the best intentions, says Egener, but they soon find themselves with too little time and too many patients, which tempts them to cut corners. When they yield to that temptation, they violate their own values, Egener argues, “and that is what I think causes burnout. It’s a sense of, ‘This is not why I went into medicine; this is not what I thought I would be doing; I feel like I’m not as valuable to my patients as I would like to be.’”

Dave Davis, a Toronto family physician who recently retired after 40 years of practicing, doesn’t buy the too-little-time, too-many-patients theory. Rather, he thinks physicians fail to deliver optimal care when they are less than fully present during the time they do have with patients.

Davis typically saw between 32 and 40 patients daily, sometimes more, while he was in practice. Such visits, he says, usually lasted 15 minutes or less. But Davis doesn’t think that lengthier visits would have meant better visits.

“Some of us believe that professionalism cannot exist in the culture of 10-minute visits or in a managed-cared environment, when in fact the two are not incompatible at all,” Davis maintains. “I think it’s just a matter of finding a way to adhere to the principles of professionalism while you are doing the clinical and business-oriented tasks in front of you. … Time is not a factor in forgetting the principles of professionalism like respect, compassion, and integrity. Those are all innate to us, and we can operate in a 15-minute or even a five-minute time span while adhering to them.”

So, we ask again: What is professionalism, then? Its precise meaning within the context of private practice is a hot topic among practicing physicians and academics. It’s been written about and discussed endlessly in professional journals, association publications, op-ed pieces, and at medical conventions. Yet most agree that its principal tenet is selfless concern for patient care based on a physician’s sense of integrity.

Cassel, whose foundation has published a charter (below) addressing the principles of professionalism in modern practice, agrees that today’s physician is “really kind of stuck” between the legacy of medical practice as an altruistic vocation and the hard fact that physicians are businesspeople who must keep their eyes on the bottom line.

Which begs the question: Can physicians adhere to the directives of professionalism and still run a successful practice? Cassel maintains that they can. It starts with an understanding of how healthcare delivery systems, including your own practice, operate, she says.

“How can you create systems, even in a small practice, that can help you become more efficient, that can help you spend more time on the tasks that the doctor ought to be doing - not filling out all of those forms, not performing office tasks - but using the highly costly and highly valuable skills that doctors learn to actually be the doctor?”

ABIM-certified internists are trained to examine aggregate patient outcomes and put into place systems that can improve them. Cassel says she often hears from physicians after they’ve completed ABIM training that they feel they’ve “finally” been given the tools to “do the right thing.”

“You have to be able to measure your quality,” she explains, “and you have to know something about the science of quality improvement in order to help you perform better, and thus feel better.”

According to Cassel, it’s the sense that they are failing their patients that leads to physician discontent. “People are becoming demoralized because they don’t feel like they are doing the right thing; they don’t feel like they are doing what they were trained to do. And they understand that they are losing some of that professionalism.”

The altruism albatross

One reason the concept of professionalism often gets a cool reception from busy physicians is its association with altruism - which in this context is understood by most physicians to mean volunteerism. That’s not to say that physicians oppose volunteerism; quite the contrary, many are already performing so much under- and unreimbursed care that they sometimes feel like involuntary volunteers. Others give of their time in purposefully charitable ways.

James Naughton, a general internist in a 14-physician group in Pinehole, Calif., says volunteerism is a noble pursuit, but for physicians who are using all of their emotional and physical reserves in daily practice, it’s simply impractical. Besides, Davis adds, “I don’t think professionalism and altruism are synonymous. One can treat their patients with compassion and commitment to ethical principles - those are the traits of professionalism. … I think most docs are trying the best they can.”

Yet some physicians find volunteer work energizing, though not necessarily by offering their medical expertise for free. Egener, for instance, mentors a medical student. Others may choose to become advocates for healthcare reform. Regardless, volunteering is not a necessary component of professionalism, which many experts agree addresses treating your own patients with compassion and competence. In fact, if you are already overloaded, you need to shore up your own reserves for the patients in front of you; you do them no favors by burning yourself out.

Frustrated incorporated

But why all this talk about professionalism to begin with? Do we perceive physicians as having become so jaded by a faulty healthcare system, or so corrupted by conflicts of interest, that we must continually remind them via charters and journal articles that they are indeed “professionals”? Who precisely needs to be reassured of this fact?

Apparently, physicians themselves do. Those most actively contributing to the growing number of voices articulating the principles of professionalism are physicians themselves. What do they know that their patients do not?

“If you’re in primary care, you’re the accessible base of a failing healthcare system,” says Richard Baron, the founder and co-owner of Greenhouse Internists, a five-physician, Philadelphia-based family medical practice. Baron believes that the root of much of the discontent widely noted among physicians today - particularly primary-care docs - is, in a word, failure.

“I think it’s about coming to work and reliably and predictably being unable to meet reliable and predictable patient expectations,” says Baron. “And every time that happens, it costs you and your patients.”

So what options do deluged-but-dedicated physicians have left? Charles Kilo, the CEO of seven-physician GreenField Health, a primary-care practice based in Portland, Ore., maintains that physicians must abandon the “victim mentality” that he perceives as clouding their capability to advocate for themselves, and, by extension, for their patients.

“Most physicians will tell you that they are just the victims of all this bad stuff that’s happened in healthcare,” says Kilo. “And in part, that situation may well be true. I think they are the victims. But the reality of the situation today is that the victim mentality is inconsistent with leadership.”

If the majority of physicians who’ve seen their patients - and their own well-being - suffer from a dysfunctional healthcare system don’t assume leadership roles that will position them to make widespread change, their future is indeed bleak, says Kilo.

“Most physicians would say, ‘Not my responsibility,’ but the reality is that if it’s not their responsibility, whose responsibility is it?” asks Kilo, who recently founded a nonprofit organization to promote the political advocacy efforts he believes are necessary to reform healthcare. “As the group that ought to claim the main stewardship for health and healthcare in [this] country, physicians are, in aggregate, largely sitting on the sidelines.”

Kilo also recommends that physicians work together (rather than at odds) with their payers to address the system’s shortcomings, a concept that he admits receives a frigid response when he brings it up to groups of physicians.

“But then I say, ‘Well, OK, your insurance company is Darth Vader. Have you ever actually invited them to sit down and talk about these issues?’ The answer is almost always consistently, ‘Well, no,’” says Kilo. “So we want to point fingers and we want to place blame without really taking the time to sit down and find the common ground with folks. … If we don’t do that, who’s going to do it for us?”

Little victories

Baron, for one, prefers not to sit out this game. He maintains that each time a physician involved in performing a task asks himself, “Why am I doing this?” he probably shouldn’t be. Mundane and repetitive office procedures eat into physicians’ valuable time, and Baron says doctors need to tap into nontraditional solutions rather than “throwing more money or more people” at their problems.

Of course, that involves a certain amount of risk-taking. But Baron thinks the alternative - maintaining the status quo within an inefficient practice - is untenable. He thinks that many physicians practicing in dysfunctional environments easily lose sight of their professional values because they work within systems that are set up to fail. And he says the first barrier to overcoming that mindset is to realize that you have more control than you think you do.

“One of the real privileges and opportunities of small practices is the amount of control you actually do have over the environment in which you work,” says Baron. “I know a lot of people feel they don’t have that, but I think they do.”

The most dramatic risk Baron ever took to restructure his practice was purchasing an EMR in July 2004. He admits that the first six months of implementation were “miserable.”

“I mean, you don’t know how to hold it, you don’t know where to sit, you don’t know how to type, you don’t know who to look at. …. It’s an experience that can globally make everyone unhappy in a practice. … But after that, you realize that this is a tool that can help you regain the real work of a physician having real patient interactions.” Now, says Baron, rather than spending half the day running around the office trying to locate information, he and his colleagues can make better use of their face-to-face time with patients.

“When patients ask you to fulfill simple requests, like refilling prescriptions or comparing their current weight to their weight at their last visit, and you either don’t have their dosage levels at hand or have to waste five minutes searching for a misplaced file, I think you spend a lot of time being unhappy,” says Baron. “And I think you spend a lot of time making painful decisions that you resent being placed on you. … And I believed that having an EMR would help us meet patient expectations much more reliably and with much less wear and tear on ourselves, and that’s been quite dramatically true for us.”

Greenhouse Internists’ EMR has heightened the productivity of Baron’s office physicians and staff, allowing them to expand their patient volume while also operating with three fewer full-time equivalent employees.

“Now when I’m sitting with a patient with pneumonia who I’m going to prescribe an antibiotic for, I can ask her, ‘Would you like me to send that prescription to the drug store for you?’ And she says, ‘That would be great,’ and I can do that without writing out a prescription, copying it, and handing it over to someone to fax,” explains Baron.
“I feel like I’m being a better doctor. I feel like I’m taking better care of that patient. And I’m doing it in a way that didn’t cost me at that moment.”

Tech to the rescue?

Tech-savvy physicians seem to agree that advances in IT can go a long way toward making it possible for them to return to the business of doctoring. Naughton says his practice’s EMR has allowed the physicians with whom he works to spend more time with their own patients, and, when necessary, with one another’s. Naughton says having at your fingertips access to information on a partner’s patient whom you’ve never seen before, particularly in an emergency situation, “is a remarkable change that’s made a huge difference for us.”

Kilo’s efforts to fully integrate his practice with technologies that allow for multiple methods of physician-patient communication have completely transformed the way his practice does business. GreenField Health boasts a fully operational EMR and a concordant registry that allows physicians to access information about their patients in aggregate, and thus better anticipate and respond to their needs. The practice’s physicians also regularly use e-mail and phone calls to follow up with patients after office visits.

“We work to promote the use of e-care,” explains Kilo, “and we have a couple of insurers in our area now, who, largely because of our work, reimburse for e-care. So our doctors are very happy, but we live a different life than many other practices do, because our day is a mix of face-to-face visits along with e-mail care and phone care. … It’s very different from the unforgiving fee-for-service environment in which most primary-care physicians work.”

Kilo says his physicians have learned to use IT to enhance their patient relationships: “It’s difficult to sustain any relationship based on two or three rushed 15-minute visits a year,” he says. “What e-mail and phone care do is give you a platform for more robust communication.”

Change your ’tude

“Mindfulness” is the term Egener uses to describe his efforts to assume a holistic view of his patients rather than simply treating the presenting disease. “If I can be present to a patient’s larger needs, that’s more professional,” he explains. “If I ask myself, ‘What does this person really need from me?’ as opposed to, ‘She came in for a prescription refill,’ I feel more like a professional because I’m looking at the larger significance of the visit. That helps keep me feeling valuable to the patient and also rededicates me to the reasons I went into medicine.”

Such an attitude takes time to cultivate, but it can pay off in spades by heightening one’s job satisfaction. And, Egener adds, it’s “time-neutral.” It takes no more time to approach patients “mindfully,” he says, than it does to approach them “instrumentally.”

For his part, Davis says he has a 90-second secret that helps him make the most of time-constrained patient visits. He advises physicians to cultivate their listening skills and begin each office visit by asking the patient, “What do you think is going on?”

Davis explains that this technique can save both the patient and the physician a significant amount of time in the long run. “Spending that extra 60 seconds to ask the patient what they think the problem is will help you get to know the patient a little bit in a professional sense and can also avert unnecessary testing or repeated office visits.”

After addressing their immediate concerns, Davis advises physicians to give their patients the opportunity to set the agenda for the remainder of the visit themselves. “Tell them, ‘We’ve got 15 minutes today; how do you think I can help you most?’” Davis suggests.

A patient may list five or six items she wants to address, so Davis advises physicians to give the patient the opportunity to rank the importance of those items by candidly informing her that time constraints will not allow for addressing them all: “Ask [the patient], ‘Which one of those five things do you think are the most important?’” Patients will typically choose the items that are also of most concern to the physician. Once you’ve established with the patient your goals for a specific visit, politely ask her to make another appointment for her less pressing concerns.

Cultivating these communication techniques, which Davis says typically take less than 90 seconds, establishes a mutually agreeable template from which you can deliver targeted, quality care.

Be the change agent

Thomas Inui, MD, president and CEO of the Regenstrief Institute, a nonprofit informatics and healthcare research organization based in Indiana, suggests that physicians stay aware of the organizational alternatives that may benefit their practices. Among these are group visits, in which a group of patients who suffer from the same chronic illness, such as diabetes, come into the office for education and perhaps group counseling and support.

“You might write prescriptions in the beginning of the morning while getting acquainted with … as many as 20 patients, and toward the end of the session, if anyone needs to have anything checked, like their blood pressure, or have their feet looked at, you do that,” suggests Inui, who is also the associate dean for healthcare research and a professor of internal medicine at Indiana University School of Medicine. “So everybody has a visit, and everybody gets a chance to know one another. We know from a behavioral medicine point of view that this is an optimal way to educate and support change in behaviors.”

Instituting a “call hour” for patients at the end of the day is another way some physicians have enhanced their productivity, says Inui. And if you communicate with patients via e-mail, Inui suggests telling them that you reserve a specific time each week to reply to their messages. Knowing when to expect an answer, they’ll be less likely to clog up your in-box.

“We spend a lot of time having visits in which neither the doctor nor the patient knows exactly why they’re there,” says Inui. “In chronic disease management, that’s especially the case. … So we need to get more intelligent about what visits are for, what telecommunications can accomplish, and teach patients how to use the systems that we’re developing.”

The business of healing

Many physicians have adopted corporate business models to enhance performance. Inui says a model developed at Case Western Reserve University’s School of Management called “appreciative inquiry” is one example. It entails busy professionals reserving some down time to reflect on their work and identify one moment or circumstance in which they performed optimally and felt terrific about their profession.

Recounting such a moment and exploring what factors made that moment possible constitutes the very simple concept of appreciative inquiry. Once you’ve identified the elements that contributed to your success at that moment in time, explore how you can replicate those factors, and open yourself up to the possibilities of implementing change that promotes professional success.

Cassel adds that the concept of “lean management,” originated by Toyota to enhance production, has been adopted by practices both large and small to streamline services, often resulting in significant cost savings and better patient outcomes.

“Doctors are naïve about such things,” says Cassel. “When inefficiencies are brought to their attention, they often respond by thinking that they have to work harder rather than smarter.” And that’s a sure path to frustration and discontent.

Respect yourself

“Physicians who say they are too busy to think about professionalism are probably thinking about it all the time,” opines Naughton. Regardless of their legitimate frustrations, “they don’t lose the sense that their obligation is to the patient in front of them, and that is the essence of professionalism.”

The good news: Patients haven’t given up on you. Although some polls indicate that physicians collectively don’t rank as high in the public’s estimation as they once did, “Individuals still respect and trust their physician,” Cassel notes. “They feel that their own doctor is a really good person who has their best interest in mind. … Surveys show that patients want to trust us, and I think there’s a great hope to be gained from that.”

Barbara A. Gabriel holds an MA in English literature and is the associate editor of Physicians Practice. She has served as editor and writer for numerous healthcare publications over the past 10 years. Barbara can be reached at bgabriel@physicianspractice.com.

This article originally appeared in the October 2007 issue of Physicians Practice.