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© 1996 The Journal of Bone and Joint Surgery, Inc. Professionalism—Where Are All the Heroes? , CHAPEL HILL, NORTH CAROLINA*First President-Elect's Address. Read at the Annual Meeting of The American Orthopaedic Association, Colorado Springs, Colorado, June 11, 1996.
President Dick; Past Presidents Urbaniak, Leach, and Amstutz; members and guests; ladies and gentlemen: Many of the former presidents of this organization have spoken about the humility that they felt as they assumed office of this grand association, the oldest orthopaedic association in the world! Several spoke of their surprise at being elected. All spoke of the pride that they felt in being given the opportunity to represent this organization. I am no different. I must first give thanks to those people who have been very instrumental in my life—namely, my parents, who provided me with excellent role models for maintaining a work ethic; my many educators, teachers, and coaches, who inspired me to work hard, to try my best, and to adopt a never-give-up attitude; my children, who have taught me what life is really all about; and, especially, my wife, Mary Ann, whose love, support, and understanding frequently have been stretched to the limit. While preparing for this address, I did the usual and customary reading of past presidents' addresses, searched through Bartlett's Book of Quotations and Roget's Thesaurus, and had my son help me go online to get material. The topic that I have chosen is professionalism. The word profession is defined in Webster's Ninth New Collegiate Dictionary as: "1: the act of taking the vows of a religious community 2: an act of openly declaring or publicly claiming a belief, faith, or opinion ... 3: an avowed religious faith 4 a: a calling requiring specialized knowledge and often long and intensive academic preparation b: a principal calling, vocation, or employment c: the whole body of persons engaged in a calling."13 John Racy, in an essay on professionalism, suggested an alternative definition: "A profession is a socially sanctioned activity whose primary object is the well being of others above the professional's personal gain."9 This definition, while clearly biased toward medicine, can also be applied to law, teaching, and in some ways to the raising of children. The mark of a professional is the practice of doing the right thing not because of how one feels but regardless of how one feels. To paraphrase Sir Thomas Browne from his Religio Medici3: I desire rather to cure his infirmities than my own necessities. This sounds grand and glorious, but what about the physician's needs? Doesn't the doctor have the right, in fact the duty, to take care of himself or herself? How is it possible for anyone to undertake and sustain an activity that points in the opposite direction? Of course, the answer lies in human altruism. As social animals, we appear to be programmed not only for individual service but also for the survival of the group. A profession in the best sense of the term is a moral undertaking. There are those unusual individuals who give of their skills, learning, and energy without any apparent reward. They are cherished, revered, and sometimes sacrificed. They are the saints and the martyrs among us. There are too few of them. In order to support professionals, society has provided certain rewards, such as wealth, status, and power, but even then both society and the professionals understand that the reward must follow the service and that the rewards are secondary to the service. Professionals are supposed to do a good job under all conditions, not just when they are well rewarded. They do so because a good job is expected of them and because doing a good job defines their behavior. While societal rewards are necessary, they are, unfortunately, insufficient. Most professionals regard the internal rewards of their profession as much more important. Without these internal rewards, neither the amount of pay nor social recognition will suffice. Internal rewards include the well being and gratitude of the individuals who have been served, an involvement in the lives of others, a sense of mastery, the satisfaction of curiosity, the acquisition of wisdom, and the esteem of fellow professionals. Clearly, a profession is much more than a job; it is an identity. Individuals give much of themselves to their professions, and they receive much in return. The giving, however, always precedes and supersedes the receiving. In other words, to be a professional is to assume and to maintain a lifelong role of dedication to the welfare of others—a role that confers dignity, status, and power. Inherent in professionalism is a commitment to excellence. Destructive to professionalism are exploitation for personal gain and neglect of the self-discipline and learning that are required to sustain professionalism. Having thus attempted to define professionalism, I share the concerns of Bruce Spivey, who wrote in 1990: "I am anxious about the fate of physicians as a caste that was once highly respected, even priestly; now physicians seem to be losing not only the respect of the community but respect for each other and the profession as well."11 While the mounting evidence of the medical profession's estrangement from the public is disturbing, I am equally concerned about the loss of solidarity within the profession—in other words, the estrangement of physicians from one another. More precisely, my concerns are with the apparently inevitable consequences of specialization and competition and with the way in which we relate to our patients and to society. There can be no doubt as to the future of medical technology. It will continue to flourish, but high-tech achievements will not necessarily ensure that our patients will view us in a positive light or improve the way in which we view ourselves or the way in which society views us. Why should we be concerned about our image? Why should we worry about how society perceives us? The reason lies in my belief that the way in which physicians are viewed by society and the way in which they see themselves will have a major impact on the quality of individuals who choose to enter medicine and subsequently on the quality of medical care for generations to come. Although I am speaking today about the medical profession, and about orthopaedics in particular, this dilemma extends to all three of the learned professions: the clergy, law, and medicine. Medicine is only the most recent to undergo what might be called demystification. More than two decades ago, Roy Branson identified the process as "the secularization of American medicine."2 In an essay by that title, he wrote: "Medicine faces a crisis as challenging to its authority as the Renaissance and Enlightenment's diminished faith in the efficacy of prayer and miracle. Just as men's reliance on their own ability to think and act during that time undercut the influence of priestly physicians, so today's demand for self-determination in every sector of society threatens medicine's independence of action."2 Long ago, similar pressures undermined the special status of the clergy and the mystique of the law. The Reformation changed the unique role of the clergy as an intermediary between mortals and the divinity. Lawyers came down from their pedestals when they entered the courts as paid advocates of contending parties rather than as defenders of some universal truth. The lawyers remained as learned individuals respected for their special knowledge but nonetheless were diminished because their expertise was for hire. Medicine has preserved its special mystique longer than any other learned profession perhaps because, as Branson put it, "... medicine is expected to transmute science into therapy, knowledge into action ... [It] not only conforms to what has been the fundamental perspective of modern, scientific culture, but energetically follows some of the guiding principles of pragmatic, American society. It is no wonder that medicine has enjoyed enormous prestige in America."2 The same scientific advances that have made medicine and our society so prosperous also have liberated and equalized the people in general. When relief is spelled with the name of an over-the-counter antacid, it is no longer the unique property of a healing priesthood. When health is acquired by dressing in a spandex bodysuit and putting on a pair of Reeboks, it is perceived by the public as a commodity like any other product. Those who purvey that commodity are no longer elite; they are no more unique than an aerobics instructor. These realities, in addition to the patient's expectation of a great result in every case and our entire society's loss of respect for authority, have changed the public's view of its physicians. These examples may appear trivial and frivolous, but they are only the more visible manifestations of a steady process that has transformed the healing profession into the health-care industry. Lewis Thomas noted this trend in 1974 when he wrote: "... it provides the illusion that [healthcare] is in a general way all one thing and that it turns out, on demand, a single, unambiguous product, which is health. Thus, healthcare has become the new name for medicine. Healthcare delivery is what doctors now do, along with hospitals, and other professionals who work with doctors, now known collectively as the health providers. The patients have become health consumers. Once you start on this line there is no stopping."12 It has been more than two decades since Thomas wrote those words, and the phenomenon has only accelerated since then. The current terminology that can be applied to all caregivers has placed all professionals on the same level and has confused the public into equating physicians with others who would like to be physicians but lack the requisite training or experience. This trend definitely has eroded our status and perhaps our self-esteem as well. How have these changes taken place? How can we go from being a profession one day to an industry the next? Spivey, in his essay on professionalism, blamed the pressures of specialization and competition for the passage of the physician from the hallowed grounds of the temple to the marketplace11. Because of the rising number of orthopaedic surgeons and of physicians in general, competition is especially keen. In our response to competitive pressures, in our desire to reduce overhead costs and to make our practices more efficient, we risk both appearing and being much like business executives. Instead of holding our place as exceptionally well trained professionals who perform an essential and valued service, we have become more like merchants than like ministers. Medicine has come to be viewed simply as another commodity, and those who provide medical care are perceived less as respected professionals than as competitors in a service industry. Perception! Perception is everything in this life. How much better to be perceived as a kind, caring, and competent orthopaedic surgeon than as a provider in a service industry. Our loss of the monopoly in judging illness and its treatment and cure is self-evident. Now we are seeing an erosion of our responsibility for the quality of the care that we provide. We can still perform the miracles of joint replacement, meniscal repair, and scoliosis correction, but we will be increasingly prevented from determining who will benefit. When care is rationed by cost and when third parties perform the economic triage, we hardly can claim full responsibility for our patients or, in fact, deserve their trust. We as physicians and surgeons have a very special mission: to heal many and to provide solace, understanding, information, counsel, and support to those we cannot heal. We now have more and more powerful tools with which to carry out that mission. We as physicians and surgeons have been entrusted with the privilege of caring for others—a privilege earned by virtue of our knowledge, experience, and technical skill. But equally important are the power of our personal and professional values and the close relationships that we have with our patients, not clients!
The medical education system is being undermined by increased specialization; by the service demands of residency, which are driven by the economics of health care; by a faulty faculty-reward system; and by the loss of senior surgeons as role models. First, specialization has contributed to a diminished sense of a shared value system and a weakening of the relationship among the faculty, house staff, and medical students. Over the past thirty years, the size of the academic faculty has increased more than 600 per cent, in part to expand the delivery of specialized medical care10. Specialization also has fostered self-interest and, at times, intense competition between physicians and surgeons for patients, institutional resources, and control over technology. In some institutions, the specialty-oriented faculty has shifted the focus of teaching from the students and the residents to the fellows. The apprentice relationship that united the senior surgeon and the house officer now frequently exists only between the faculty and the fellows. The layering of fellows between residents and faculty jeopardizes the mentoring of residents and medical students, which is critical to the fostering of professionalism and the sustaining of an educational community. Second, the service demands of residency, driven by the economics of health care, have contributed to a lower standard of professional conduct on the wards. How many times have you heard that the resident saw the patient for the first time in the preoperative holding area or that the student never got to see the patient until he or she was on the table? How frequently do you hear a student say that the attending physician was too busy to answer his or her questions? How many times does the attending physician do a cursory examination and place his or her interest on the images rather than on the examination? Teaching rounds have been replaced by so-called lightning-work rounds to get the job done, frequently on sleeping patients. Surgeons-in-training notice the professional and, unfortunately, the unprofessional conduct of the attending surgeon and such conduct cascades down to the students. Third, the faculty reward system that favors publication and presentations rather than teaching also has undermined the educational community. Faculty members face increased pressure to do more research, to publish more papers, to participate in more national meetings, and to accept more visiting professorships. How many months a year do those activities take us away from the business for which we are primarily here—the education of students and residents? In education today, we need more good role models and more mentors! On a personal note, I would not be an orthopaedic surgeon today had it not been for the role model of George Joseph Garceau. I was started down the road to becoming a pediatrician—in fact, I had signed on for a straight pediatric internship—when I found that I had a three-month block of time that I could spend away from the university. I chose to get a job as an extern at St. Vincent's Hospital in Indianapolis. When asked what I wanted to do, I said that since I would not get any time in orthopaedics at the university, perhaps I could spend a month in orthopaedics, a month in the emergency room, and a month in general surgery. My first month was spent with George Garceau and his residents. What a kind, gentle, caring, compassionate human being he was. He worked long, hard hours but truly enjoyed his work. On Thursday evenings, he would invite me to his home so we could "read some orthopaedics" and study pathology slides. He was always a positive individual. He was available; he was caring. He was not just a role model; he was a mentor. The term mentor comes from Homer's Odyssey. As Odysseus's trusted friend, it was Mentor who, in Odysseus's absence, nurtured, protected, and educated his son, Telemachus. Mentor introduced Telemachus to leaders and guided him in the assumption of his rightful social and political place. Mentor's instruction went far beyond the teaching of special skills. It encompassed personal, professional, and civic development—that is, the development of the whole person to full capacity and the integration of that person into the existing community. The characteristics of a modern-day mentor are derived from the original Mentor's relationship with Telemachus. A mentor should help the protégé to define goals and to develop the talents that will enable him or her to reach maximum potential, teach the protégé the skills and knowledge of a discipline, help the protégé to cultivate social and professional values and behaviors, and protect the protégé until he or she can sustain autonomous work. Other traits of a mentor include experience and empathy8. Experience, particularly the introspective understanding gained through successes and failures, breeds wisdom. Wisdom then enables the mentor to help the protégé to sift through difficult professional and personal issues and to clarify a life's direction. Empathy, on the other hand, reminds the mentor of the need for support during the educational process. Mentoring takes time and energy and should be rewarded in the faculty promotion system. I have tried to follow George Garceau's example: first, as an orthopaedic surgeon and teacher and then, as chairman of the Department of Orthopaedics at Indiana University School of Medicine. Dr. Garceau established the Department in 1948 and was its first chairman. Interestingly, Dr. Garceau served as a director of the American Board of Orthopaedic Surgery and as its president in 1957, and now I find myself as executive director of that organization. Dr. Garceau was my first role model in orthopaedic surgery. There have been several others, but he was the first. He became my mentor and, in fact, was a hero to me. Have you been a hero to someone recently? In medicine, there is no greater role model than Sir William Osler14, perhaps the greatest physician of all time. A Canadian by birth, he became chief of medicine at McGill University at the age of twenty-five years. He subsequently moved to the University of Pennsylvania to succeed Dr. Pepper as chief of medicine and ten years later moved to Johns Hopkins, where he lived and worked with the likes of Halsted. His final move was to Oxford, England where he was Regius Professor of Medicine. We could do much to emulate the qualities of Osler. He lived by three personal ideals: (1) to do each day's work well and not to be bothered about tomorrow (a phrase he frequently quoted was: "Our main business in life is not to see what lies dimly at a distance, but to do what lies clearly at hand"); (2) to live by the Golden Rule; and (3) to develop and cultivate equanimity1. Osler was not a dreamer; he was a practical man and a doer. He credited his success to what was once referred to as "The Master Word in Medicine." It was the open sesame to every door, a word that was capable of making the "stupid man bright and the bright man brilliant." The master word in medicine was simply W-O-R-K6. If Osler were alive today, I am certain that he would reject the current approach to medicine as simply another business selling a somewhat different commodity. Today, Osler surely would be a vigorous spokesperson for the profession against the external constraints that interfere with patient care. At the same time, he also would be critical of the profession for any self-serving or financially motivated initiatives. Osler thought that as physicians "we are here to add what we can to, not to get what we can from, life."6 We need to remember that happiness in our profession comes primarily from service to others. To Osler, the medical profession was honored above all others because it calls on the highest powers of the mind and brings the physician into warm and personal contact with his or her fellow human beings. Osler thought that the practical outcome of all of the long years of medical education was the glorious opportunity to spend one's career "in befriending the sick and suffering, and helping those who cannot help themselves, and in lessening the sad sum of human misery and pain."7
Several months ago, I came across a work by Joseph Campbell5, the author of The Hero with a Thousand Faces4. Perhaps the foremost authority on mythology of our day, Campbell made a life's work of studying the similarities and recurrent themes in myths and religion. He thought that these similarities pointed toward universal insights that have been reached in many different places at many different times—insights that have been cloaked in symbolism. Campbell's first book4, written nearly fifty years ago, recounted the hero myths from many cultures. There are many permutations of the hero plot, but according to Campbell the prototypical hero is simply someone who surrenders himself or herself to a larger goal. In a typical myth, there is a call to the hero, followed by an arduous journey. The hero's path is often beset by difficult trials. There may be dragons to slay, rivers to swim, or mountains to cross. There also may be seductive temptations. Ultimately, a great good is obtained, usually enabling the hero to benefit others. A captive princess may be rescued; a stolen treasure returned; or, as we heard in last year's Presidential Address, Prometheus may bring fire for the good of mankind. Usually, the return trip is also full of danger, and not all heroes survive. Those who perish often are resurrected, and they may enter an enchanted kingdom or may rule over some portion of the next world. Those heroes who return safely often bring a great boon to their people and subsequently are honored and rewarded. By surrendering their personal desires to a greater good, heroes find their own fulfillment. Campbell thought that hero tales have been a recurrent theme in many cultures because the hero is the universal role model. Life calls on all of us to be heroes. It is our mission to follow the hero path, which Campbell regarded as the conquest of one's own ego and the transformation of one's own consciousness through service to others. I believe that the practice of medicine and surgery is, by its nature, a heroic profession. Those of us who enter into it do so because we have been called to help others. The path to becoming a skilled surgeon is long and arduous. Along the way, there are temptations and even dangers. Those who persevere and become successful are not home free. In many ways, those who make it are in the most danger of succumbing to the temptations of affluence, pride, and greed. But those who hold firmly to the original goal and calling of helping the sick and injured and who remain undistracted by selfish goals have their hearts warmed daily by the help that they provide to others. Society richly rewards its true heroes. Respect and affection often come unsolicited. But the greatest reward to the true physician comes simply from the service itself. Many of us have become discouraged by the current hostile attitude toward doctors. We have lost sight of the basic heroism inherent in caring selflessly for others. If, however, you practice your art conscientiously, you are indeed a hero. You are a hero in Campbell's sense of having surrendered your personal desires to a greater goal, the welfare of your patients. Hero myth assures us that in serving others we also fulfill our own destiny. Somewhere, deep in our hearts, we sense that the myths and the major religions are right. When, as physicians and surgeons, we care for our patients in a selfless way, we experience a deep fulfillment. We can learn much from the lives of men such as William Osler and George Garceau. The formula for professional life is simple in concept but difficult in practice. We must first master our field and then maintain our proficiency through lifelong study. We must care for each of our patients as a unique human being. We must go beyond what is simply our duty, and we must always put the welfare of our patients above our own. Although few of our patients in orthopaedics face life-threatening illnesses, they still desperately need the emotional support of a caring, competent, and dedicated surgeon. If we can meet their needs, we will have succeeded not only as doctors but also as human beings. In a quiet and unassuming way, we will be their heroes.
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The Medical Education System
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