The Subversiveness of Professionalism

This essay was the winner of the Andrew Puckett Essay Award at Duke University in 2014.

“I don’t know why everyone’s playing these silly games,” the man said, even before my preceptor and I walked into the room.  “I went to my surgeon and he said he wouldn’t operate unless I quit smoking.  What kind of treatment is that?”   Halfway through a busy surgery clinic, a patient like this was the last thing I wanted to see.  As he fidgeted and leaned forward in the chair, I could tell that he was exactly that sort of talkative patient that I still couldn’t figure out how to disengage from – at least, before I got a pocket lecture on the history of his illness, his parents’ health, and the nice old lady who comes by and looks after his dogs while he’s away at the hospital.

I was surprised to see my preceptor – who’d been all about efficiency earlier in the day – pull up a chair and level with the patient.  He explained clearly why his peripheral artery disease was uniquely sensitive to his smoking habit, and how surgery without any lifestyle change would have been useless to him.  In the end, the patient left not only satisfied but with a new resolve to quit smoking now that he understood its link with his disease.  When we got out, the preceptor remarked that we’d set ourselves back a good half hour on the clinic schedule.  “But in these situations, you have to do the right thing.”  I knew what he meant.  As a result of his decision, both he and the clinic staff would have to stay later.  But he turned around a patient who would otherwise inevitably lose control of his disease.  In the long run, this conversation with the patient was one of the most powerful prescriptions he could wield.  With a half-hour talk, he did more good for this patient than he could have in a whole afternoon in the OR.

A few weeks later, we had a lecture on professionalism in medicine.  Just as we were settling down into the gray seats in the auditorium, the speaker asked us for our own definitions of professionalism.  The answers were all over the place, from “being a team player” to “working hard,” – and the anodyne lecture did little to dispel our confusion.  As I existed I distinctly overheard someone guessing that professionalism simply meant whatever people wanted it to mean.  Yet as unsatisfying as I found the lecture’s exploration of the topic, I couldn’t agree with this cynical take.  I had seen, in that surgery clinic, a small example of what I admired most in medicine, and there had to be a foundation behind my preceptor’s stance.

So what was professionalism, really?  One way to approach a definition is to see what the opposite of professionalism is.  The obvious answer – the answer the lecturer would give – is that it’s sloppiness and indolence – various ways of not getting your work done.  But I don’t think that’s quite true; after all, those would be vices in any situation, not just in a job or a “profession.”  Instead, the true opposite of professionalism is being a company man.

A company man is someone who plays by the rules, who internalizes the values of his employer or the rewards system of the market and aspires to nothing greater than to play that game well.  It’s the kind of person – peaceable, flexible, capable – who can fit into any institution and make it grow.  Company men were what made it possible to build General Motors in the mid-1900s, and they’re what makes it possible to build large university health systems today.  Modern capitalism needs company men, and to be a company man is no bad thing.

But it’s a very different thing from being a professional.  A professional is someone who holds to values – whether the physician’s oath of Hippocrates or the lawyer’s reverence for the law – that transcend any other claims the world might have on him.  Professionals understand the system that surrounds their work, and are able to work with it, but do not let the needs of the institution displace their professional creed as their guiding value system.  And a profession is nothing more than a group of people who hold to a common creed.

It was a small act of professionalism that allowed my preceptor to spend the extra time it took to help that patient.  He may not have even consciously realized that he was making that choice – it may have been instinct by this point in his training.  But in that act was a small echo of the professionalism of Ignaz Semmelweis, who spent decades going above and beyond the call of duty to drastically reduce death in childbirth.  And of Barry Marshall, whose courageous self-experimentation overturned a century of dogma on the cause of stomach ulcers.  In the long journey from ignorance and folk medicine into the scientific medicine we practice today, every step was made possible only by an act of professionalism – of someone making the choice to actually help people when the easy answer was to keep doing things the way they’d been done before.

And that courage is still needed.  Scientific, evidence-based medicine may be enthroned today, but there are new challenges to providing patient care.  Distorted payment systems force doctors to spend less and less time with each patient.  The rigors of dealing with billing encourage doctors to give up independent practice and throw in their lot with ever-larger healthcare organizations.  None of these changes are bad in themselves – indeed they’re necessary defensive measures given the environment we practice in.  Yet at the same time, these changes are a recipe for turning professionals into company men.  It puts ordinary physicians under pressure to change their practice to suit the payment system or the organization’s needs, leaving them less flexibility to let their practice be guided by the dictates of their professional creed.

Perhaps the most ominous sign that professionalism is in danger is that it’s seen as a harmless bit of virtue, featured in inspirational posters and preached to medical students.  For professionalism, properly understood, is not a peaceful creed.  It’s a force that says that you must do what is right by the patient, no matter what hospital policy or your billing agent may say about it.  It says that fitting in matters much less than doing what’s right.  It is a force that topples orthodoxies, disrupts routines, and upsets accounting managers to no end.  If we had a truly vital ethos of professionalism, it would not be the kind of idea you put up on inspirational posters.  It would be the kind of ideology you furtively whisper to your close friends, and public agitation for professionalism would be a fireable offense.

Yet even if nobody’s pushing this robust, warlike professionalism, a humble, quiet version of it still lives on.  I caught a glimpse when I saw my preceptor take the extra time with that patient.  And once I started noticing it, I began to see it more and more.  I saw it in an administrator pushing for a costly quality improvement project; I saw it in the surgeon who took up precious OR time to teach the residents.  I even saw it in my classmates who chose to study important facts they will use in their careers, rather than cramming the minutiae that show up on tests.  Each of these, I knew, would pay a price – the administrator may have a harder time making budget; the students may score lower on their tests.  But it’s that willingness that made the virtue so striking.  And as long as physicians are willing to go that extra mile, I have great hope for the future of the profession.

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