August 2007 | Back to Table of Contents

Perspective

Attitude and Action

Professionals set high standards and work to live up to them.

By David Hutchinson, M.D.

This article is based on a speech given in 2004 at the Gold Foundation’s White Coat
Ceremony for first-year medical students at the University of Minnesota Medical School, Duluth campus.

Professionalism is a grand and nebulous topic. We know it when we see it, yet it’s difficult to define precisely. Especially in medicine, professionalism is a vitally important springboard to excellence, drawing upon values and attitudes to create benevolence and effectiveness. The concept deserves study and illustration. Doing so should help us maintain humanism in medicine.

Professionalism is first about articulating our values. In medicine, we have a rich set of ideals that we profess and strive to maintain. We say, for example, that we treat all individuals with respect regardless of who they are, or what they think, or what they say they did, and that we’ll hold their confidences. We say that we’ll be wise enough to find a balance between being close to and too close to our patients. We say that no matter how fervently we wish to serve our patients or what we might gain from treating them, we’ll first guarantee that we’re not doing them harm. We say that we’ll strive to become caring lifetime partners in our patients’ health journeys, so that we’re granted their trust and can come to know them as individuals. We say that the patient’s needs shall be our focus.

Recently, I was reminded about this last point. One of the residents in my teaching program and I were caring for a 16-year-old who recreationally had taken an overdose of cough medicine. By 2 a.m., he was snickering as he recovered in the ER about his evening’s “project.” That didn’t foster feelings of empathy for him. His mother’s gratitude to us and forgiveness of him, however, did, and reminded us that 16-year-olds are egocentric. He and his mother needed to feel that we were content to offer our help. Professionalism enabled us to focus on his needs rather than his behavior.

Caring a Great Deal
Professionalism is also about attitudes and the behaviors and qualities that stem from them. In his book True Professionalism, David Maister explores what makes a secretary great. He concludes that great secretaries take pride in their work, reach for responsibility, show initiative, do whatever it takes to get the job done, get involved, do more than assigned tasks, find ways to make things easier, really listen, learn to understand those they serve, are team players, can be trusted with confidences, are open to constructive criticism, are honest and loyal, and seek to serve.

“In other words,” he says, “great secretaries care a great deal.” He highlights several points. The first is that these attributes apply to more than secretaries. The second is that the list doesn’t include technical skills. Great technicians may be highly skilled, but they aren’t professionals until they reliably demonstrate these other characteristics.

The list reminds us that professionalism both stems from and builds self-respect. It fosters trust, enhances reputations, leads to job satisfaction. It is why some people are willing to put forth the effort that leads to excellence. They care a great deal about being professional. So it is with medicine. Knowledge and technical skill are important. We physicians spend our academic lives trying to cultivate them. But greatness in practice comes from doing other things that constitute professionalism.

Patients, especially, understand that. They want us to have the qualities and attitudes that medicine itself says define professionalism: altruism—allowing the best interest of the patient, not self-interest, to guide our actions; accountability—to individual patients, within our own profession, and to society in general; excellence—a commitment to exceed expectations, to lifelong learning, and to the highest quality of care; duty—a commitment to serve; honor and integrity—the consistent regard for the highest ethical standards and the refusal to violate one’s personal and professional codes; and respect for others—patients, families, and colleagues, and their value systems, realizing that respect is the essence of humanism, is central to working with others, and enhances collegiality and success in all relationships.

In postgraduate medical training, we try to convey that professionalism means learning to be a servant as well as a leader; employing the skills that we’ve cultivated through society’s investment in us; working extended hours that sometimes are like those of dairy farmers and small business owners; respecting the circumstances, feelings, and advice of others; and attending to the care of ourselves. We hope residents learn, too, that it means honoring team decisions or a partner’s preferences, learning from failure as well as success, learning to respect and trust authority and structure but also to challenge it when necessary, being compassionate and thorough because somebody needs you to be not because someone is paying you or grading you, and being conscientious when nobody is watching, and doing the right thing not the easy thing or the profitable thing.

Any definition of professionalism ultimately means that we must care. We must care a lot to be good. We must care greatly to be great.

Temperance in Caring
When discussing professionalism, one can’t not mention Sir William Osler. Probably the most famous physician of the English-speaking world, Osler is often described as the ideal physician, a master of both science and art, a lover of humanity, and a champion of patients. Osler wrote extensively about diseases. But he also taught that it is the patient and not the disease that is the entity. He advised “temperance in caring,” which contributes to our modern notion of professionalism. In his graduation speech “Aequanemitas,” he said, “You must keep about you a physical imperturbability, an impassiveness, for this creates trust, invites expression and openness from others, and is much appreciated. … And you must maintain also a mental equanimity, an even-keeled clarity and contentedness—a dispassionate passion for your work and outcomes. This helps to avoid unbalancing your faculties and your reactions. To achieve this, live in the moment.…” Osler reminds us that being professional means more than managing our demeanor—that we should rise above tribulation and achieve balance in mood and countenance so that we remain approachable, receptive, and generous—and can be of good use to others.

No Free Lunch
I once asked my father, a learned and good man, what professionalism means. Without lowering the magazine he was reading, he peered over his bifocals and growled, “Tell ’em that there’s no free lunch.” At first, I thought he hadn’t answered my question. Then, I realized that in his brilliant, reductionist way, he was reminding me that you only get what you pay for, or that you get out of anything only what you put into it. He also meant that for what is given to you, something is expected in return. Receive and then give, learn and then teach. Expecting to give back to medicine, as well as to the public, is another part of professionalism. Hippocrates understood that.

Achieving Professionalism
How do we incorporate the values, adopt the behaviors, and arrive at the realizations that constitute professionalism? How do we come to care so much and so consistently? Simply, we practice. We aspire to the qualities that define enlightened professional behavior. Our thoughts become our actions, our actions become habits, and our habits define our characters. We think and act professionally in order to become professional. In training, we learn work habits that are intentional and focused; we try to help others, knowing that many hands make light work and that cohesive groups go further than individuals; we begin to see work as a calling rather than an assignment; we learn to bolster the morale of others; we learn to share knowledge, effort, resources, and thoughts; we learn to temper our reactivity; we strive for balance and restoration; we try to remain thankful for the work of others; and we strive to become a partner to patients and peers.

It may sound like circular logic to say that we become professional by acting professionally, but chickens lay eggs and eggs hatch chickens. Intent begets achievement, courage and preparation beget opportunity, and experience begets wisdom and humility. This last point I know well.

Hard Lesson
As a third-year resident, I was moonlighting at a rural hospital for a weekend. I was to work in the ER, provide coverage for patients in the hospital and attached nursing home, and take telephone calls from patients from the local clinic. It was a lot of responsibility. I arrived for my 48-hour shift feeling on edge. Soon, between other urgencies, I was called to the nursing home, where the staff had anxiously encircled the bed of an emaciated, unconscious woman. I later learned several were related to her. The atmosphere was charged. I was told her blood pressure was ominously low. Her heartbeat was barely audible. Her mouth lay in that O-shape that means impending death. She appeared to have only moments left, and the people standing around her bed seemed to expect intervention.

I scooped up her chart to find that she had end-stage metastatic breast cancer. This couldn’t have been unexpected. Anxious and angry at the mess that had been left to me by her attending physician, I asked brusquely, “Isn’t this patient DNR?” I saw several nurses slowly shake their heads no. “Why, on earth, not?” The patient, after a brief pause and without opening her eyes, moving her head, or gesturing, said in the clearest, most deliberate voice, “Because I don’t want to be!”

I responded lamely, “Well that was of course the right decision for you then.” Then humbly I added, “I guess I’m learning unexpected things today. You stick with us. We’ll work on this.” I’d like to say that there was a happy ending, but within minutes, she did arrest. We attempted an awkward resuscitation before we relented.

It is a challenge for all of us to become great enough in a professional sense to serve adequately. Those nurses and the patient herself, despite the inevitability of her destiny, weren’t ready for her to die. And I didn’t carry myself in a manner professional enough to accommodate that. I also didn’t have enough equanimity to stop worrying about my success or failure in front of an audience. Nor was I generous enough to “find the patient in the room, rather than the disease,” to quote Sir William.

As I reflect on my career, I realize that professionalism both gives me a sense of purpose and contributes to my successes. I am grateful for the traditions, mentors, family members, and patients who have taught me about being a professional. As I work with new physicians, I hope that I can pass along the lesson that professionalism helps us retain the sacred in medicine, provides a structure for our art, and helps us maintain the humanistic idealism we bring when we enter medical school. MM

David Hutchinson is the assistant director of the Duluth Family Medicine Residency Program.