Medicine: Still an Honorable Profession in 2010

Well, has this been a heck of a last year or what?  Who would have imagined the direction and bumpy road our politicians were going to take us on in healthcare.  And the angst, frustration, and fighting…for what we believe in as well as with others and even amongst ourselves.  After all that has transpired and getting a sink or swim on the job education in politics, I confess that this job isn’t exactly at the top of my list of where I would have chosen to be right now.  I much preferred telling Beth that “rhetorical” stab wound didn’t really look that bad and the shot gun blast in her side wasn’t really that big.  Now I’m in the line of fire and I’m sure this next year will carry much of the same frustrations and challenges in “reforming” healthcare.  The train you can say has left the station, but there’s still a lot of track to be laid down to determine the direction it takes and we have to be there at the front lines swinging that hammer.

First I want to applaud Beth for what I learned from her leadership of ArMA through the maze of this past year.  She was even tempered, smart, knowledgeable, and put in more time reading through all of the rhetoric than I could ever hope to.  She always answered the scores of e-mails, some supportive, and some far from it, as your president of ArMA and, if you know her at all, clearly not as Beth Purdy, citizen and surgeon.  She’s a pretty tough act to follow, so I can only try to emulate her approach and work with ArMA staff to keep us focused, directed, and going in the direction you all want us to go.

When a sea of change like this past year happens, I think you need to take a step back, regroup and see what you can learn from the trip itself; your victories, losses, and mistakes, and then figure out where you go from here.

You cannot go back much farther than the Father of Medicine, Hippocrates.  Hippocrates earned that title by rejecting superstition in favor of observation leading to classifying diseases, and by creating a set of moral and professional standards for physicians.  The medical texts and writings attributed to Hippocrates and his students, the Corpus Hippocraticum gave incredibly detailed descriptions of many diseases, progression of diseases, and epidemiology of diseases.  There were no treatments to realistically offer, only knowledge and solace because you knew the likely outcome.  The original works were probably written between 350-450 B.C. and first officially published somewhere in the early second century A.D.

Although Hippocrates was wrong in his theory of diseases being caused by an imbalance of the four humors, his descriptions of diseases and their course were incredibly detailed and accurate and still applicable today for many of the diseases he described.

As the Father of Medicine, despite 70 plus works on disease and medicine attributed to him, he is still remembered by most laymen (and many physicians) as the author of the Hippocratic Oath.  Many medical schools still require a modernized version of this oath, which, ironically, is no longer believed to have even been written by him.  Why does it continue to be used?  Because people want to see us, physicians, as moral, ethical, and above reproach, in addition to all-knowing in medical knowledge. 

Another of history’s more famous physicians, often called the Father of Modern Medicine, Sir William Osler, was known as a superb diagnostician and clinician.  He was held in high regard by his peers throughout Canada, the U.S., and Europe.  He is perhaps the most influential physician in fundamentally changing the way medical students were and are taught in the U.S.  He brought students to the patient’s bedside in their third and fourth years of medical school and while at Johns Hopkins established the concept of a full-time sleep in residency system upon which our current residency training system is based.  Osler liked to say “He who studies medicine without books sails unchartered sea, but he who studies medicine without patients does not go to sea at all.”

His students also frequently heard him stressing “if you listen carefully to the patient, they will tell you the diagnosis” when trying to bring home the importance of the history of the patient.  These principles still hold true today in the practice of medicine.

Osler was a prolific writer and authored what was considered the textbook of medicine which was used for over a century of teaching medicine.  Yet, his most famous writing was his Valedictory and farewell address at the University of Pennsylvania in 1889 when he left to become the first Chair of Clinical Medicine at Johns Hopkins.  His address, which became a published essay, was titled Aequanimitas, and lectured on what the graduating resident physicians of the day needed to succeed.  Osler described two things they desperately needed to possess.  First, imperturbability, which he meant as “coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness….  It is the quality which is most appreciated by the laity though often misunderstood by them; and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients.”
He considered the second thing you needed to succeed a “mental equivalent to go with this bodily endowment”; namely, the “desirable attitude” he called a “calm equanimity”.

In explaining this he said:  “Natural temperament has much to do with its development, but a clear knowledge of our relation to our fellow-creatures and to the work of life is also indispensable.  One of the first essentials in securing a good-natured equanimity is not to expect too much of the people amongst whom you dwell.”
He continued, “Deal gently then with this deliciously credulous old human nature in which we work, and restrain your indignation.”  I’m not sure if he means just his patients or if he had to deal with politicians similar to those that we had to deal with this past year.

Dr. Osler goes on to explain how man clings to hopes of all kinds in maintaining life and health that may make no sense to those of us educated and trained as physicians, but you cannot lose your resolve to be tolerant, to listen, and to take care of those whose health you are so charged to ensure, regardless of their attempts to circumvent your own medical wisdom.  In other words, put the patient first and take care of them regardless of their beliefs, failings, indiscretions, or what they may have read on the internet.

Now more than ever we need to bring these concepts to the forefront of our everyday practice of medicine as well as our fight for improving healthcare in the United States.  These two physicians whom history has called the Father of Medicine and the Father of Modern Medicine, placed strong emphasis on medical knowledge, but they placed just as strong of an emphasis on defining who we are as physicians and how we present ourselves.  Both of these historically renowned physicians are best known and remembered for their proclamation of the ideals for the physician as much as or more for their knowledge and skills as physicians in their time.  Can we and do we, as physicians, still provide the care we are trained to provide, in line with the ideals of Hippocrates, Osler, and others?  Of course we can, and do…and I think the general public not only wants and needs us to, they expect it of us.

Especially now, we need imperturbability and equanimity….the two traits Osler felt the graduating residents needed to succeed as physicians.  We need to reestablish ourselves as knowing more of what needs to be done in a medical crisis and medical care, and in healthcare reform as well, than any nonphysician.  We already know this, but the lay public may NOT.  We need to accept and forgive them for their inability to fully appreciate this concept.

I often remind myself that despite events of the past and present, medicine is still truly an honorable profession.  As Osler so eloquently put it, “our mission is of the highest and noblest kind.”  I sometimes wonder if our profession, as practiced in today’s world, is still viewed by others as honorable.  Maybe that is because we don’t always seem to treat it as honorable; particularly as we must negotiate the business aspects of billing or contracts with hospitals or insurance companies.  It certainly has not been treated, at least in my experience in meeting with our legislators in Washington this past year, as honorable by many of our elected officials.  In the general view of the public, our image is sometimes even presented in quite a tainted light.

Despite a theme of thinking poorly of doctors in general and our practice of medicine, if you ask any random “Everyday Joe” what they think of their own doctor; that is, if they have one, they still for the most part love their doctor.  If you ask them what dream profession they wish for their children, many of them will say doctor or physician.  Of course, there’s also some misguided soul that says lawyer in response to the same question.

My point is these parental aspirations should actually give us hope.  I think the public still respects us professionally.  We need to give them more reasons to be vocal about our irreplaceable profession.  Somewhere, maybe deep down, I think most others outside of our circle uphold medicine as an honorable profession.  From some perspective, most politicians even believe we’re still an honorable profession.  Unfortunately, especially given some of the shortcomings still needing to be worked out and the lack of an SGR fix, it seems they also want us to work for honor and not dollars and that’s not going to get my 6 kids through college.

We need to remember our beginnings and reaffirm ourselves as honorable professionals; to present ourselves as the best representatives of our patient’s and profession’s interests, because these are principles we, at least, see as self evident.  Because we were trained in medicine rather than business we are often left behind in deciding some of our fate.  We are also not trained experts in the legal aspects of our profession.

However, we are the true and trained experts in practicing medicine as physicians.

We are the experts in determining the minimum needs and standards for providing patient care and determining what best environment in which to provide that care.  If we, in our own eyes, in our hearts and souls, adhere to believing and being an honorable profession, I think the public can and will see us as honorable.

I’m not sure sometimes what to think of our politicians and will leave that discussion for another day.  But who knows…the faces of our politicians are always changing and we have a chance going forward to stand up, be heard, and still influence how healthcare in this country is not only conducted, but perceived and viewed by the general public, our patients, and let it be viewed as honorable here and across the country.

Much of what has transpired over the years in how we practice medicine may in part be our own profession’s fault...some of it by acts of commission and some by omission.  We can blame our lack of involvement leading to the demise of medicine as we used to know it on our being too busy trying to take care of our patients.  In some respects, that is actually very true.  However, in learning from past mistakes, which I admit, I am not always very good at, we, as a profession need to be and stay involved in an organized fashion.  We need organized medicine even more, not less.  We need to find a way to get more involvement from our colleagues despite the work and business environment we see working against that happening.  We, in organized medicine, at ArMA, need to step up and embrace the honor and privilege that it is to be a physician, and then propel ourselves and our profession forward with that in mind.

We’ve all heard the old adage “that which doesn’t kill you makes you stronger”…and I don’t think we’re anywhere near dead.  If we remember to conduct ourselves as an honorable profession, we will, we can, and we must, for our own sake and the sake of our patients, persevere, flourish and move forward as a profession.  We need to not only maintain, but improve healthcare in Arizona and the United States so that we are a model of what others should follow. 

I believe we at ArMA tried to do exactly that this past winter preceding the signing into law thousands of pages of legislation for healthcare reform, whatever that ultimately will come to mean.  The “eleven points” ArMA presented to our politicians are dynamic and by definition will be in need of revision or tweaking; however, we need to effectively communicate these and similarly held ideals to the masses in order to demonstrate our honorable approach, direction, and beliefs.  This includes our positions on personal responsibility and preventative medicine.  We need to stress that we put patient care first and then truly do that.  I question whether the AMA took that approach and they are still taking a lot of heat about the decisions they have made.  We need to remember that we represent all medical specialties and we have to go in one united direction.

This doesn’t mean we agree on every issue as we clearly do not…if we did Chic would get bored and David would have a clear vision of the path for all that he does at the Capitol and ultimately the staff here would think they were in some sort of Utopia. 

If you haven’t spent time reading what is available on the ArMA website recently, I encourage you to do so.  You’ll be proud of what ArMA professes to be and can confirm for yourself that ArMA really does hold to its ideals…and they are long standing.  Read Beth’s message from the president for this past year:

“ArMA has advocated for physicians and their patients for more than 114 years.  We support our members and their patients in many ways through effective communication, financial guidance and thoughtful legislative efforts.  The number one priority of our members is quality patient care – and we do all we can to ensure that happens here in Arizona.” 

The preamble to the ArMA Code of ethics, adopted from the AMA, reads ”The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient.  As a member of this profession, a physician must recognize responsibility not only to patients, but also to society, to other health professionals, and to self.  The following Principles adopted by the AMA are not laws, but standards of conduct which define the essentials of HONORABLE BEHAVIOR for the physician” (and our site goes on to list the nine principles you can read at your leisure).  These are some bold statements made on our own website…do we live up to them?  Do we, ArMA’s member physicians, live up to the ideals Hippocrates and Osler professed in the history of medicine and we also profess on our own website, as they are still relevant and necessary?  I certainly hope so and I believe we do. 

Let us be forward thinking.  We need to communicate our ideals so members are informed, and we can all share the value of membership as this will make us even stronger and more clearly heard and understood.  We need to remember politicians are POLITICIANS, and while their objectives may sound like ours, getting elected is their first concern.  We should strive to alter the mindset of many of our colleague physicians, so they want to hear and listen and be supportive of our efforts as much as they want to be heard.  If we truly mean what we say about patient care and that patients’ well being matters above all else, we are their colleagues in care, not their masters.

IF WE PUT PATIENT CARE FIRST, WE ARE ALL ON THE SAME TEAM.  We need to revive the notion that medicine remains an honorable profession and that “our mission is of the highest and noblest kind” as Osler said it was.

What we do matters for the future of healthcare in America.  Who other than us knows what is best for healthcare and the well-being of our patients.  As your president, my goal in the coming year is to advance our status and our principles.  I wish all of us great luck and fortune ahead in these endeavors over the next year and beyond.