Dr.Paul’s Clinic: Professional Values

PROFESSIONAL VALUES — Dr. Francis W. Peabody’s often-quoted address on “The Care of the Patient” speaks eloquently to the value of clinicians’ respect for humanity and the value of the clinician-patient relationship to treatment itself. “The significance of the intimate personal relationship between clinician and patient cannot be too strongly emphasized, for in an extraordinarily large number of cases both the diagnosis and the treatment are directly dependent on it. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is caring for the patient” . Carl Rogers studied and taught about the beneficial outcomes for learning and health that result from approaching a learner/patient with unconditional positive regard.

The American Board of Internal Medicine has placed increasing importance on humanistic qualities as it considers candidates for its examination. It requires program directors to evaluate residents’ personal integrity and their respect and compassion for patients. The Pew-Fetzer Task Force on Advancing Psychosocial Health Education carefully considers areas of knowledge, skills, and values that support effective patient-practitioner relationships. They emphasize the following values: importance of self-awareness, self-care, and self-growth; appreciation of the patient’s life story and the meaning of the health-illness condition; respect for the patient’s dignity, uniqueness, and integrity (mind-body-spirit unity); respect for self-determination; respect for a person’s own power and self-healing processes; and the importance of being open and nonjudgmental.

In addition to the above observations, we would highlight the importance of ascribing value to several other features of clinician-patient interactions:

Clinical curiosity

Attention to decision-making preferences

Attention to cultural issues

Attention to accountability

Attention to professionalism

Clinical curiosity — Respectful curiosity about the person in front of you and about medicine brings energy, vitality, salience, and meaningfulness to medical visits. It is healthy for the encounter and critically important to the sustenance of the clinician’s dedication to his/her work.

Explicit attention to decision-making preferences — Patients vary in the degree to which they want to share in medical decision-making. Many older patients prefer the clinician to hold most of the authority, while younger patients are apt to want to play an active role in shaping diagnostic and therapeutic plans. No rules hold, however, so the operative value needs to be one of respecting each individual’s preference for the extent to which decision-making is shared, and the operative behavior must be to check explicitly about that preference.

Attention to cultural issues — We have alluded to the importance of knowledge about cultural differences between patients and clinicians. For this knowledge to be of real use, to effect medical outcomes of care, the clinician must move beyond cognition of cultural differences to truly valuing and respecting the beliefs of each patient to whom s/he provides care.

Attention to accountability — Much of medical training inculcates clinicians with a strong sense of responsibility. “The buck stops here” is a feeling well known by every intern. While this can greatly benefit patients when the clinician is personally executing every aspect of care, that is now rarely the case. It is not an effective point of view when the clinician is part of a team. Clinician arrogance about “who knows best” is unfortunately another well-known phenomenon. The clinician must hold responsibility for his/her part in the team’s work but must also appreciate each team member’s role and skills. All team members are responsible for respectful collaboration in the work and participation in a system that monitors outcomes of care and provides clear and timely feedback about each team member’s performance.

Attention to professionalism — Effective interactions between each clinician and patient depend, at their core, on mutual trust. Survey data show that the levels of trust and respect that were formerly extended to the profession of medicine have substantially eroded over the past 40 years. Societal skepticism about the trustworthiness of medicine has many legitimate sources and is a cause for concern.

What can we do to restore the public’s trust in our chosen profession? While there is no straightforward solution, we can begin by being aware of this challenging situation and mindful of the foundational values that can guide our behavior with each patient we approach.

We must learn to use and balance our values when navigating particularly difficult situations with patients (eg, breaking bad news, withholding an unnecessary and costly technology/test).

We must openly reveal to our patients (and students) the basis for the professional judgments we are making.

We must actively take patients’ preferences into consideration and be prepared to change our opinions when new information becomes available, including the basis for patients’ opinions.

Only by making this “juggling act” explicit will we regain trust and avoid perpetuating some of the most damaging situations of all, ones in which we contribute to racial, ethnic, and other disparities through our implicit processes of stereotyping and misperceptions.

CONTINUOUS LEARNING — As Hippocrates observed, art is long and life is short. No one of us truly “masters” skillful approaches to all patients in all situations. We mature, grow in our professional experience, and hope to improve our capacity for this most fundamental of clinical tasks.

We owe it to our patients and ourselves to continue to reflect and improve our interactions.

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