Profession

Pediatric critical care is a profession. To be certified and practice as a pediatric intensivist, one must master several bodies of special knowledge, complete apprenticeships in pediatrics and pediatric critical care, earn various educational certificates, pass examinations (the culmination of which is the American Board of Pediatrics certifying examination in Pediatric Critical Care), and be granted a license to practice by a state medical board. Our profession oversees that process much as a guild controls its members and membership. As a profession, we train ourselves, test ourselves, credential ourselves, and discipline ourselves. We derive many benefits from our status as professionals. We are paid as professionals, respected as professionals, and valued by society as professionals.

The autonomy of our profession is granted and allowed by society. There are, accordingly, unwritten contracts between our profession and society. In exchange for the benefits that “professionalism” confers and the autonomy, self-governance, and control of licensure that is ceded to us, society expects us to meet its needs within the boundaries of our expertise. We gain the advantages listed here because we provide the quality of service that society requires.

In the end, professionalism is the set of responsibilities and behaviors that fulfill our contracts with society. These characteristics exemplify the good and virtuous doctor because that is the model society would hold us to, not because virtue has intrinsic value (though it does), but because deviation from virtue breaks our contract.

The virtuous doctor

Most would agree as to what characteristics exemplify the good and virtuous doctor. We have watched exemplary characters portrayed on television over the years in dramas, comedies, and in advertisements. These are the professionals that our parents, our patients, and the rest of society expect us to emulate, imitate, dress like, and act like. We have long had a sense of the characteristics portrayed. However, over the past several decades, professional medical organizations have obsessed over defining, teaching, assessing, and understanding the behaviors that connote professionalism. Now, why is that?

Stakes

Healthcare now consumes (produces) about 17% of the US gross domestic product. It has become increasingly technology intense and engages financial giants in the form of insurers, pharmaceutical companies, device/equipment manufacturers, both freestanding and gigantic nationwide inpatient facilities, and information storage/management enterprises. Healthcare employs about 14,000,000 workers, some of whom are independent practitioners and many of whom are contracted to large enterprises. Two of the largest third-party payers in the United States are Medicare and Medicaid, which together expend 4.7% of the gross domestic product on healthcare. Those payments flow from the general tax coffers to physicians and other recipients. We now live in a medical marketplace, and hear patients referred to by administrators as customers or by insurers as covered lives . How physicians manage patients in this context is of great financial import; thus it should be no surprise that many of the traits characterized as professionalism have financial implications. Professionalism has, accordingly, received renewed attention and scrutiny.

Great paradox of the medical profession

A constant tension pervades medicine where principles of self-interest and altruism coexist. In most human endeavors, it is considered appropriate to identify one’s own best interests and make decisions accordingly. It is in one’s best interest to obey the law, brush one’s teeth, and to work for a living. Yet, it is in the best interest of society for physicians to treat patients altruistically, whether that benefits the professional or not. The physician’s pledge to society is to be altruistic in dealing with patients, to put the patient first, before oneself. These two principles, self-interest and altruism, are polarized and often conflict. With each medical decision comes the question: “Was this for the patient or for the doctor? Whose interest did this serve?” In its simplest sense, professionalism in medicine comes down to putting the patient first.

Here’s a concrete example: It is 4 am . I haven’t slept a wink and I’m hard at work in the pediatric intensive care unit (PICU) trying to finish my documentation so I can catch some shuteye. The emergency department (ED) resident calls. He has a child with a fever who looks sick (to him). Would I mind taking a look to see if he needs to come to the PICU? What should I do?

• 1.
  

  Go take a look.

  
  
• 2.
  

  Have him admitted to general pediatrics.

  
  
• 3.
  

  Hold him in the ED until 7 am when relief arrives for the day shift.

  
  
• 4.
  

  Just bring him up to the PICU.

  
  
• 5.
  

  Send him home; it’s just a fever.

Altruism says: “Go take a look.” That would be best for the patient. It could improve the quality of the triage decision and optimize patient care. Self-interest says: “2, 3, or 5 and it’s not my problem. I’m exhausted.”

The professionalism issue here is altruism, “patient first,” but look at the financial overlay. The PICU provides expensive care and is a costly resource. A decision to admit to the PICU should not be made casually. General pediatrics may not be able to safely care for the patient, and a bad outcome may mean patient suffering, additional hospital or patient expense, or a lawsuit. Don’t use the hospital if you don’t have to. It costs money. Holding the patient in the ED is a dissatisfier, will damage the hospital in the eyes of the community, and will interfere with the ED workflow.

Professionalism is a larger issue than merely resolving the patient first medical paradox; the concept of professionalism received a much more thorough examination in the late 1990s and first decade of the new millennium. Many of the groups that regulate medicine on our behalf weighed in. Among them were the American Board of Internal Medicine Foundation, the American College of Physicians, the American Society of Internal Medicine, and the European Federation of Internal Medicine, all of which worked together to draft the document “Medical Professionalism in the New Millennium: A Physician Charter.”

Professionalism, the physician charter

The Charter adopted three principles and made 10 commitments to fulfill the medical profession’s contract with society:

• 
  

  Principle 1: Primacy of Patient Welfare . Altruism demands that the patient’s needs be given precedence over self-interest, market forces, societal pressure, and administrative exigency.

  
  
• 
  

  Principle 2: Patient Autonomy . Physicians must be honest with their patients and, whenever possible, empower them to make informed decisions.

  
  
• 
  

  Principle 3: Social Justice . There should be fair distribution of healthcare resources.

  
  
• 
  

  Commitment 1: Professional Competence . Each individual physician must ensure one’s own competence, and the profession as a whole must ensure its members’ competence. Professionals are responsible for putting mechanisms in place to ensure lifelong learning, competence, and skills.

  
  
• 
  

  Commitment 2: Honesty with Patients . Patients must be completely and honestly informed. Medical errors must be acknowledged. Mistakes must be analyzed to improve the quality of healthcare.

  
  
• 
  

  Commitment 3: Patient Confidentiality . Patient trust demands that confidences be protected. Trust is essential to the doctor-patient (patient-doctor) relationship.

  
  
• 
  

  Commitment 4: Appropriate Relations to Patients . Patients are inherently vulnerable. Professionalism demands that they not be exploited.

  
  
• 
  

  Commitment 5: Improve Quality of Care . Not only must we maintain clinical competence, we must work collaboratively to reduce medical errors, increase patient safety, minimize overuse of healthcare resources, and optimize outcomes of care.

  
  
• 
  

  Commitment 6: Improve Access to Care . Physicians must strive to reduce barriers to equitable healthcare and to foster uniform and adequate standards of care.

  
  
• 
  

  Commitment 7: Just Distribution of Finite Resources . The physician must make wise and cost-effective use of limited resources.

  
  
• 
  

  Commitment 8: Scientific Knowledge . Where possible, care should be evidence based.

  
  
• 
  

  Commitment 9: Manage Conflicts of Interest . To maintain patient trust, physicians must recognize, disclose, and deal with conflicts of interest that arise in the course of their professional activities.

  
  
• 
  

  Commitment 10: Ensure the Integrity of Professional Responsibilities . The profession must define, organize, and ensure the standards of its current and future members.

Pediatric intensive care unit as a site for medical education and lifelong learning

The renaissance of interest in professionalism has fostered an endeavor to weave the topic into medical education, build it into curricula, and focus on it in coursework. Despite that interest, medical student altruism, social interest, and other qualities of positive social value have been noted to decline as the student progresses through medical school and the early phase of clinical training. The altruistic freshman is transformed by clinical experiences into the cynical senior. It has been argued that this growth of cynicism reflects the gap between what we say as teachers (the formal curriculum) and what we do as practitioners (the hidden curriculum). When we do not “walk the talk,” we plant the seeds of cynicism and nonprofessionalism.

An example: Dr. Blunt and an impressionable medical student are suturing a central line in place. Their patient is in a chemically induced coma from self-medication compounded by subsequent hypoxia. His story is tragic and the student knows that the teenager deserves sympathy and respect. As Dr. Blunt ties the last knot he comments, “It would have been easier to get this line in if he hadn’t been so fat.” What did the student just learn about sympathy and respect?

In the PICU, doctors, students, and nurses are compressed into a very small, intense space. They are all engaged in lifelong learning as they play their separate roles in patient care. Life is, after all, an open-book test. Thus, throughout our development and maturation as professionals, we in the PICU are continuously learning professionalism and cynicism from our colleagues.

The team aspect of PICU care adds a dimension to professionalism. Not all care providers will be aligned in their views of each patient’s self-interest or society’s collective interest in distributing healthcare resources. A good example is care of the dying or severely disabled child. We may not all agree on limits of care, management of family members, or end-of-life issues. Transfer of primary responsibility at end of shift; division of responsibility among team members such as nurses, physicians, and consultants; and appropriate delegation of tasks (given our job-specific scopes of practice) all stress our ability to work together. Collaborative care necessitates that we share our ethical views among team members and include appropriate team members in the decision-making process.

We should clean up our act in the PICU, take care that our words and actions reflect the formal curriculum, fulfill our contract with society, and behave toward our patients—and toward each other—like the professionals we, at first, set out to be.