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MD Consult: Books: Goldman: Cecil Medicine: APPROACH TO THE MEDICAL PROFESSION

Goldman: Cecil Medicine, 23rd ed.

Copyright © 2007 Saunders, An Imprint of Elsevier


In a profession, practitioners puts the welfare of clients or patients above their own welfare. Professionals have a duty that may be thought of as a contract with society. The American Board of Internal Medicine and the European Federation of Internal Medicine have jointly proposed that medical professionalism should emphasize three fundamental principles: the primacy of patient welfare, patient autonomy, and social justice. As modern medicine brings a plethora of diagnostic and therapeutic options, the interactions of the physician with the patient and society become more complex and potentially fraught with ethical dilemmas ( Chapter 2 ). To help provide a moral compass that is not only grounded in tradition but also adaptable to modern times, the primacy of patient welfare emphasizes the fundamental principle of a profession. The physician’s altruism, which begets the patient’s trust, must be impervious to the economic, bureaucratic, and political challenges that are faced by the physician and the patient ( Chapter 5 ).

The principle of patient autonomy asserts that physicians make recommendations but patients make the final decisions. The physician is an expert advisor who must inform and empower the patient to base decisions on scientific data and how these data can and should be integrated with a patient’s preferences.

The importance of social justice symbolizes that the patient-physician interaction does not exist in a vacuum. The physician has a responsibility to the individual patient and to broader society to promote access and to eliminate disparities in health and health care.

To promote these fundamental principles, a series of professional responsibilities have been suggested ( Table 1-2 ). These specific responsibilities represent practical, daily traits that benefit the physician’s own patients and society as a whole. Physicians who use these and other attributes to improve their patients’ satisfaction with care are not only promoting professionalism but also reducing their own risk for liability and malpractice.

TABLE 1-2   — 

   Commitment to

   Professional competence
   Honesty with patients
   Patient confidentiality
   Maintaining appropriate relations with patients
   Improving the quality of care
   Improving access to care
   Just distribution of finite resources
   Scientific knowledge
   Maintaining trust by managing conflicts of interest
   Professional responsibilities

From Brennan T, Blank L, Cohen J, et al: Medical professionalism in the new millennium: A physician charter. Ann Intern Med 2002;1136:243–246.

An interesting new aspect of professionalism is the increasing reliance on team approaches to medical care, as exemplified by physicians whose roles are defined by the location of their practice—historically in the intensive care unit or emergency department and more recently on the inpatient general hospital floor. Quality care requires coordination and effective communication across inpatient and outpatient sites among physicians who themselves now typically work defined hours. This transition from reliance on a single, always available physician to a team, ideally with a designated coordinator, places new challenges on physicians, the medical care system, and the medical profession.

The changing medical care environment is placing increasing emphasis on standards, outcomes, and accountability. As purchasers of insurance become more cognizant of value rather than just cost ( Chapter 11 ), outcomes ranging from rates of screening mammography ( Chapter 208 ) to mortality rates with coronary artery bypass graft surgery ( Chapter 74 ) become metrics by which rational choices can be made. Clinical guidelines and critical pathways derived from randomized controlled trials and evidence-based medicine can potentially lead to more cost-effective care and better outcomes.

These major changes in many Western health care systems bring with them many major risks and concerns. If the concept of limited choice among physicians and health care providers is based on objective measures of quality and outcome, channeling of patients to better providers is one reasonable definition of better selection and enlightened competition. If the limiting of options is based overwhelmingly on cost rather than measures of quality, outcomes, and patient satisfaction, it is likely that the historic relationship between the patient and the truly professional physician will be fundamentally compromised.

Another risk is that the same genetic information that could lead to more effective, personalized medicine will be used against the very people whom it is supposed to benefit—by creating a stigma, raising health insurance costs, or even making someone uninsurable. The ethical approach to medicine ( Chapter 2 ), genetics, and genetic counseling ( Chapter 38 ) provides means to protect against this adverse effect of scientific progress.

In this new environment the physician often has a dual responsibility: to the health care system as an expert who helps create standards, measures of outcome, clinical guidelines, and mechanisms to ensure high-quality, cost-effective care and to individual patients who entrust their well-being to that physician to promote their best interests within the reasonable limits of the system. A health insurance system that emphasizes cost-effective care, that gives physicians and health care providers responsibility for the health of a population and the resources required to achieve these goals, that must exist in a competitive environment in which patients can choose alternatives if they are not satisfied with their care, and that places increasing emphasis on health education and prevention can have many positive effects. In this environment, however, physicians must beware of overt and subtle pressures that could entice them to underserve patients and abrogate their professional responsibilities by putting personal financial reward ahead of their patients’ welfare. The physician’s responsibility to represent the patient’s best interests and avoid financial conflicts by doing too little in the newer systems of capitated care provides different specific challenges but an analogous moral dilemma to the historic American system in which the physician could be rewarded financially for doing too much.

In the current health care environment, all physicians and trainees must redouble their commitment to professionalism. At the same time, the challenge to the individual physician to retain and expand the scientific knowledge base and process the vast array of new information is daunting. In this spirit of a profession based on science and caring, the Cecil Textbook of Medicine seeks to be a comprehensive approach to modern internal medicine.

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