by Morley Evans
TEXAS MEDICAL BOARD BULLETIN
The newsletter of the Texas State Board of Medical Examiners
Fall 2004 Volume 2, No.1
On the Sagging of Medical Professionalism
by Herbert L. Fred, MD, MACP
For the past two decades, medicine has been a profession in retreat, plagued by bureaucracy, by loss of autonomy, by diminished prestige, and by deep personal dissatisfaction. These ills would be bad enough by themselves. But another malady confronts us — the sagging of our professionalism.
Medical professionalism defies precise definition. Fundamentally, however, it boils down to service in the patient's best interest. Among its central elements are (1) commitment to excellence; (2) altruism, with service before self-interest; (3) avoidance of harm; (4) trustworthiness; (5) pursuit of truth based on scientific and humanistic criteria; (6) close cooperation with others in the health care field; and (7) humility. 
In this essay, I address our sagging professionalism and offer my thoughts on its clinical manifestations, consequences, causes, and cures.
Clinical Manifestations and Consequences
To me, the most common, and yet most subtle expression of betrayed professionalism is serving ourselves before serving our patients. By doing so, we sacrifice the very core of doctoring humanism. And as a result, the patient-physician bond becomes weakened-or never even forms. Additional manifestations include abuse of power, arrogance, lack of conscientiousness, and conflicts of interest.  Certain other types of behavior deserve special attention because they are sometimes interpretable as being dishonest.  Failure to take charge is a common example. In such cases, the attending physician shirks his or her responsibility, deferring to an army of consultants, each managing a part of the body with no one managing the whole.  Buck-passing frequently leads to a host of ill-advised activities — more consultations, inappropriate testing, undocumented diagnoses, over-prescribing of medications, uncalled-for procedures, needlessly prolonged hospitalizations, and unnecessary office visits. The consultants in these cases commonly shirk their responsibility as well. Although ideally positioned to halt this medical merry-go-round, they ride it instead. Moreover, those with a "gimmick" use it, even when they know it isn't indicated. And let us not forget the fraudulent reimbursement claims to Medicaid and Medicare or those physicians who, attracted by remuneration and perhaps by a desire for public recognition, serve as expert witnesses even though they clearly are not qualified for the role.
Finally, most physicians simply remain silent when they know or suspect a colleague to be emotionally disturbed, a substance abuser, or just plain incompetent. This reluctance to get involved is particularly deplorable when they know or suspect that an associate is cheating or lying.
Clearly, numerous factors contribute to our sagging professionalism. Heading the list in my opinion is a change in society's overall priorities and values. Old-fashioned hard work, devotion to duty, and pursuit of excellence have taken a back seat to an emphasis on limited work hours and quests for financial and other types of personal gains. As a result, people at all levels — including many physicians — are satisfied with mediocrity. In fact, mediocrity has become the standard. Given this environment, no wonder our professionalism sags.
External forces largely beyond our control also play a role. Examples are the myriad constraints imposed by insurance companies, the incessant pressures resulting from federally mandated regulations, the glut of "for-profit-not-for-patient" hospital administrators, the lawsuits lurking around every corner, and the reams of paperwork required. Attending to these various demands cuts deeply into the time we could otherwise spend attending to our patients. And complicating the picture are human frailties; especially ignorance, greed, fear of being wrong, and the need for aggrandizement.
Can we remedy our sagging professionalism? Only insofar as we are willing to be role models of integrity and honesty for each other. Only if we show commitment compassion, competence, candor, and common sense. Only if we understand and believe that medicine is a calling, not a business. Only if we strive diligently to restore, preserve, and promote the human element in medicine. Only if we look at, listen to, and talk with our patients, working as hard and as long as it takes to ensure their welfare. Only if we always put our patients first.
I leave the reader with a quotation from Bela Schick (1877-1967), renowned Hungarian pediatrician and bacteriologist: "First, the patient, second the patient, third the patient, fourth the patient, fifth the patient, and then maybe comes science. We first do everything for the patient."  Not only do his words capture the essence of this essay, but they serve to remind us of the ruling principle of our profession.
1) luger, A. Dissatisfaction with medical practice. New Engl J Med 2004; 350:69-75.
2) Bryan CS, Brett AS, Saunders DE Jr, Khushf G, Fulton, GB. Professionalism. In: Medical Ethics and Professionalism: A Synopsis for Students and Residents. Center for Bioethics and Medical Humanities. University of South Carolina; 2004: 13.
3) ibid, p. 14.
4) Fred HL, Robie P. Dishonesty in medicine. South MedJ 1984; 77:1221-22.
5) Fred, HL. Passing the buck. South MedJ 1982; 75:1164-65.
6) Strauss MB. Familiar Medical Quotations. Boston, Mass: Little, Brown and Company; 1968:374.
Dr. Fred is a Professor, Department of Internal Medicine The University of Texas Health Science Center at Houston. He received the American College of Physicians Distinguished Teacher Award for 2004. The Board thanks Dr. Fred for providing this essay.