Professionalism is rarely taught formally. It is learned by osmosis through the hidden curriculum: a set of attitudes that each one of us transmits unconsciously to students, medical residents, and colleagues. All of us are a model or counter-model of professionalism through a series of values that have been the pillars of our profession since Hippocrates. Values that do not seem to be strong enough to pass our time.
There are specific factors of the 21st century such as the financial crisis, the highly technical nature of medicine, bureaucratisation or trivialisation of the medical process that could explain, but not justify, the decline in the values of our profession: Empathy, integrity, solidarity, the altruism, or confidentiality.
That is why, from the Bioethics Committee of the Spanish Paediatrics Association we establish the need to revive professionalism. Building and maintaining the values of our profession by training scientifically competent paediatricians, as well as being excellent from an ethical point of view, is part of our responsibility.
La profesionalidad apenas se enseña formalmente. Se aprende por ósmosis a través del currículum oculto: conjunto de actitudes que cada uno de nosotros transmite de forma inconsciente a estudiantes, residentes y compañeros. Todos somos modelo o contramodelo de profesionalidad a través de una serie de valores que han constituido los pilares de nuestra profesión desde Hipócrates. Valores que parecen soportar mal el paso del tiempo.
Existen factores propios del siglo XXI como la crisis económica, el excesivo tecnicismo, la burocratización o la banalización del acto médico que pueden explicar, pero nunca justificar, el declive de los valores de nuestra profesión: la empatía, la integridad, la solidaridad, el altruismo o la confidencialidad.
Por eso, desde el Comité de Bioética de la Asociación Española de Pediatría planteamos la necesidad de reanimar la profesionalidad. Construir y mantener los valores de nuestra profesión formando pediatras científicamente competentes, pero también excelentes desde el punto de vista ético, es parte de nuestra responsabilidad.
Professionalism is suffering, it does not withstand the passage of time well. It is going through a silent crisis that is structurally associated with the liberal professional model, which has excessively neutral values, and the model of society that we are all contributing to, in which many values (human, professional, social) that used to be solid and stable are becoming liquid and unstable.1
Today, when we try to visualise a good professional, the first thing that comes to mind is technical and scientific prowess, the ability to make brilliant diagnoses, to put novel therapies in practise, to perform complex surgeries or procedures. We do not think of the virtuous professional, committed and responsible in the performance of his role.2 However, an occupation is different from a profession in its moral characteristics,3 and it is possible to be wholly devoid of moral character and be a good technician, but not a good doctor.
On the other hand, we are alarmed to see that ethical aspects of medicine (the doctor-patient relationship, integrity, responsibility, empathy) are becoming less appealing when it comes to publishing, promoting a course or organising a roundtable at a congress compared to scientific or technical subjects. We have partly lost our vocation, the inner drive to fulfil an important destiny of our own choosing, as opposed to one imposed on us. We no longer seek excellence as a virtue, which, far from being a moralistic notion, means the complete fulfilment of our choice; if the virtuous violinist is the one who makes the violin sound good, then the virtuous doctor is the one that develops the qualities pertinent to the profession: benevolence, sincerity, respect, integrity, compassion, empathy, honesty. It seems clear that there is no general interest in ethics, and that they are considered a peripheral and incidental subject. For all the above reasons, we are compelled to think that professional ethics or professionalism, whose core continues to consist of timeless elements, is in need of resuscitation, if only basic.
The concepts of vocation, excellence, virtue and ethics are barely taught in formal education, but they are learned by osmosis through the hidden curriculum: the set of attitudes that is transmitted by any professional, whether a mediocre one, a true master or a thoroughly toxic individual4 (the kind that displays behaviours that go against professionalism, or whose words and actions do not match). The hidden curriculum shapes the environment positively or negatively, so that, whether we like it or not, each of us becomes a role model of professional or unprofessional conduct. This is a huge responsibility!
Professionalism involves the combination of three elements: the health care professional, the patient and the institution. However, in this article we will focus almost solely on the professional, as ethics are philosophy in practice and must be applicable to our practice. In this sense, we can develop, teach and promote professionalism with zero costs. To resuscitate, or, to put it another way, to re-animate our devalued medicine, to halt the demotivation cultivated by administrators and to flee from our own corruption is largely up to us. However, getting entrenched in sterile complaints about inexistent idealised patients or utopian institutional improvements that will never come to be (and do not depend on us) brings people together and causes indignation, but does not promote change. Indulging in victimhood is infantile, indolent and cruel because it usurps the position of true victims.5
A basic history of professionalismWe have existed as a profession from the times of Hippocrates (V century B.C.), to which the Hippocratic oath has been attributed, a fundamental text in Western ethics that provides a code of conduct in pursuit of the best interests of the patient as well as the good reputation of the physician and the profession. The Oath remains an ethical and deontological standard today, as rather than being a mere contract, it establishes a bond that entails the moral obligation to devote one's life to the service of humanity. It postulates an ethics of the duty as a physician that goes beyond patient rights, and upholds a central tenet: health care professionals can aspire to nothing less than excellence, as any lesser aspiration must be considered insufficient.3 In the same period, Confucius (V century B.C.) stated that medicine is an art, and must not be conceived of solely as a means to heal, but also as a moral commitment to prevent suffering.
Since then, numerous testimonies have recognised the humanitarian aspect of medicine. For instance, Thomas Percival (XVIII century) believed that clinicians had to place the interests of patients and society above their own. We could cite many others, but we would like to highlight that in contemporary times, the authors that have best analysed the subject of professionalism are thinkers in the field of bioethics, such as James F. Drane, Pellegrino, Thomasma or Marc Siegler. In Spain, it is Diego Gracia that has made a decisive contribution to the bioethical education of several generations of privileged students, conveying a concept that pervades his teaching: the need to develop values, including those that apply to our profession.6
It goes without saying that Hippocrates is the antithesis of the infamous Dr. House, the protagonist of a popular television series, a doctor addicted to drugs, contentious and irreverent who is invariably forgiven on account of his assertiveness. He guesses diagnoses and saves lives without giving a thought to patients, and even less to their values. Someone who says “treating illnesses is why we became doctors. Treating patients is what makes most doctors miserable” or “everybody lies, symptoms don’t lie” is clearly a fictional caricature of our profession. He objects to physicians having to be empathic, arguing that what patients need from a doctor is not “compassion” but professional competence (“What would you prefer—a doctor who holds your hand while you die or one who ignores you while you get better?”). He keeps highlighting the dilemma between scientific competence and ethics, as if they were mutually exclusive.
Still, we can easily identify many of the undesirable attitudes represented by Dr. House in our field: many studies have described and measured high rates of professional burnout among paediatricians,7 paediatrics residents spend more time at the computer than with patients and their families,8 altruism is on the decline,9 and empathy is exhausted before the completion of medical education.10
What has happened to us? The economic crisis, the state of corruption or the allure of technology may explain, but cannot justify, the decline in the values of our profession, the collusion with the current attitude of mediocrity, or the noxious and addictive tendency to self-pity that brings us together in a new culture of victimhood and dissatisfaction.
To be or not to be a good professional todayIf we asked a new graduate in medicine or an inexperienced resident how they would define a good professional, they would probably give the generic answer of “someone who does their job well.” The same question posed to an administrator would probably be answered with “one capable of achieving the objectives set for our portfolio of services.” However, patients, who presuppose that physicians do have technical skills, would say that it is “an empathic doctor that listens and is compassionate and kind.” These happened to be the most frequent answers to the question that Ashish Jha, a Harvard professor, posted on Twitter: “In one word: What makes a good doctor?”.
Ultimately, it is the patients that aim unerringly at the definition of professionalism, which is essentially a virtuous attitude towards fulfilling a professional role that stems from a vocation, that drives us to seek excellence and is motivated by a sense of responsibility towards patients and society. A collection of duties and commitments of an ethical nature11 that have nothing to do with meeting administrative objectives or the specialisation of the expert that is satisfied with being a good technician and operates in an increasingly narrower universe, renouncing excellence as a virtue.
The notion of commitment as an obligation that has been voluntarily assumed is key to professionalism. A commitment to the intrinsic values that give meaning and legitimacy to our profession: excellence, solidarity, sincerity, tolerance, honesty or integrity. Ceasing to pursue intrinsic goals to focus solely on extrinsic goals (social status, financial gain or power) is to succumb to our own specific form of corruption, the corruption that takes place when we change the nature of something and make it go sour, depriving it of the essence that characterises it, perverting it.12
There is no question that the current social and occupational climate is not good. It is only fair to acknowledge that there are multiple external factors at play that contribute to the crisis in professionalism13: the bureaucratisation of employment and the trivialisation of care delivery; the growing power of administrators and the undermining of the authority of health care professionals (a sinister negative association); patients that tend to perceive physicians as automatons that uphold policies for cost containment and rationalisation; medicalisation and the growing influence of the pharmaceutical industry; advances in technology that facilitate the detachment of doctor and patient, the increasing complexity of care delivery with the resulting conflicts of interest between patients and doctors, doctors and institutions, scientific and professional associations, and so on. One example of these conflicts is the ever-changing vaccine policies that force paediatricians every day to act as mediators between patients and institutions in order to avoid the development of mistrust. Another influential factor is the substantial boom of superspecialties, with the resulting fragmentation of the care received by patients, who are detached from the recognisable figures of the doctors or paediatricians with whom they usually communicate.
While the current social context is hardly good, we cannot but acknowledge that science and technology have never been better. Thus, the allure of this successful world is easy to understand, but still just as unacceptable that in exchange for its glories we are willing to sacrifice the soul of our profession, what has defined us since the times of Hippocrates: professionalism. Something that is valuable enough to be worth saving from the wreckage of time. So solid that no earthquake should be able to erode it.
As health care professionals we teach future doctors theoretical knowledge and oversee their practical experiences, but we do not always foster the development of the moral traits that give rise to professionalism. Traits that are learned through the hidden curriculum, as we noted above, using creative tools such as film,14 but which should necessarily include training on professionalism in the formal education of medical students and residents.
We must train paediatricians who are scientifically and technically competent, but also ethically responsible; paediatricians who develop traits such as honesty, integrity, dependability, respect, compassion, empathy, a commitment to continuing education, self-awareness and an understanding of one's own limitations, altruism, responsibility and the skills necessary to communicate effectively with patients and their families as well as coworkers.15
Professionalism, a heroic quest?To revive professionalism and overcome demotivation and corruption, understood as the loss of the drive to pursue the intrinsic values of our profession, obviously does not require superpowers. It is the task of realistic heroes16 who, far from being fictional characters, are individuals that assert themselves and their ideals against the prevailing social mores. It is the task of those willing to resist and who wish to transform the social order through wilful action. Of professionals who, in dark times, when “the public realm has lost the power of illumination”, do not renounce to offering “some illumination [that] may well come less from theories and concepts than from the uncertain, flickering, and often weak light that some men and women, in their lives and works, will kindle under almost all circumstances,” as Arendt said.17
We need not be pessimistic. There are people who are determined not to conform to reality.18 Virtuous human beings, universally acknowledged regardless of their political leanings, their beliefs or their ideology, who are models of moral conduct. Such as Stephen Hawking, unflagging researcher and excellent scientist despite his severe physical limitations; Nelson Mandela, who was awarded the Nobel Peace Prize at the end of a live during which he managed to evolve from violent activism to pacifist political leadership; Pope Francis, religious leader, an example of austerity and a pioneer in the fight against corruption and pederasty; or Mother Theresa of Calcutta and her extraordinary humanitarian work with the people most marginalised by society, the sick, the poor, and the homeless.
Interestingly enough, and perhaps because of its positivistic evolution and increasing detachment from the humanities,19 in a field as heavy with values as is medicine, there is no moral leader universally recognised for his or her values. But there are multiple nongovernmental organisations that embody the most humanitarian values of medicine, and numerous realistic heroes inside and outside these organisations. In developing countries and our public health system, we can find solid professionals that are still motivated by the intrinsic goals and values of medicine in spite of very adverse circumstances, and still do not neglect scientific excellence. Paraphrasing Borges, we can categorically assert that all of these anonymous professionals “that we ignore” are saving professionalism.
Conflict of interestsThe authors have no conflict of interests to declare.
Please cite this article as: Martínez González C, Tasso Cereceda M, Sánchez Jacob M, Riaño Galán I, en representación del Comité de Bioética de la AEP. Pediatras sólidos en tiempos líquidos. Reanimando la profesionalidad. An Pediatr (Barc). 2017;86:354.e1–354.e4.
