… have patience with everything unresolved in your heart and try to love the questions themselves … the point is to live everything. Live the questions now. Perhaps then, someday far in the future, you will gradually, without even noticing it, live your way into the answer.
—Rainer Maria Rilke1
For physicians, professionalism expresses itself in all relationships, be they relationships with patients, with colleagues, or with society. As I write this each of those relationships is being challenged. Time constraints, issues of social justice, documentation requirements, interprofessional challenges, and a general and massive loss of societal trust in many institutions (e.g., governmental and financial institutions) have demanded clarity about what professionalism is and how medical practitioners and their related institutions can be both effective and faithful to the promises of professionalism.
In this issue, Wynia and colleagues2 report on their work with the American Board of Medical Specialties (ABMS) attempting to define medical professionalism. Their work offers a foundational understanding of medical professionalism—that is, a definition that transcends the speculative idealism of lists of values and desired behaviors and considers professionalism to be the reason such lists are created. In their view, professionalism is a belief system about the best way to organize and deliver health care. The main belief in this system is that the public is best served when both the medical profession as a group and its members as individuals are held accountable to standards of competence, ethical values, and interpersonal attributes developed, declared, and enforced by the profession itself. It is a set of promises about the trustworthiness of both the profession as a whole and the individuals practicing in it. It attempts to clarify what the public and individual patients can and should expect from the medical profession and its practitioners.
I agree with the authors’ definition and at the same time hope they are right. I use the word “hope” the way Parker Palmer3 used it when he said:
Hope is not the same as optimism. An optimist ignores the facts in order to come to a comforting conclusion. But a hopeful person faces the facts without blinking—and then looks behind them for the potentials that have yet to emerge—knowing that the human experiment would never have advanced were it not for the possibilities, however slim, that lie hidden behind the facts.
The potentials behind the facts in medical professionalism are compelling, yet the profession finds itself at a crossroad: Trust will either be eroded or strengthened depending on which path we take forward.
Hannah Arendt4 argues that humans by their very nature are unreliable and that their actions have uncertain effects. These two factors make for unpredictability. In her view, promises offer a stabilizing influence and create the ground for lasting relationships with others; however, “(t)he moment promises lose their character as isolated islands of certainty in an ocean of uncertainty … they lose their binding power and the whole enterprise becomes self-defeating.”4(p244) It is important to get the promises right. If medicine is to survive as a profession, it is important that its promises be clear to all and that both individuals and relevant medical organizations be held accountable for the promises.
But what constitutes a good promise? Good promises plan for the forgiveness that will be needed when the promise is broken.5 In Arendt’s view, promises have a companion faculty: forgiveness. Forgiveness, like promises, should be taken seriously. It can repair human relationships and can help manage the irreversibility of some human actions. In the absence of forgiveness, promises remain vulnerable ideals. Progress has been made on forgiveness in medicine. Best practices, such as transparency, disclosure policies, formal apologies, analysis of error, and redesigning systems to be safer, help to make forgiveness possible, and, in some systems, to allow forgiveness to achieve the status of promises. The authors’ definition of professionalism is silent on forgiveness and lacks specificity in its call for accountability. That task is left to ABMS as it develops a workable plan for clarifying the promises and preserving trustworthiness when those promises are broken.
As for the rest of us, what can we do to restore and preserve medical professionalism? Perhaps we can begin by accepting Rilke’s1 advice that we “learn to love the question” and over time to “live (our) way into the answer(s).” Living our way into the answers requires an appreciation of the organic nature of professionalism. Professionalism is not organically expressed by answering multiple-choice questions correctly, or even by responding correctly to simulated challenges, as helpful as those tools are. It is expressed in relationships with real patients and in the particular contexts in which practitioners work and learn.
A Hasidic story is relevant. This story was related by Jacob Needleman and published by Parker Palmer6:
A disciple asks the rebbe, “Why does Torah tell us to ‘place these words upon your hearts’? Why does it not tell us to place these holy words in our hearts?” The rebbe answers, “It is because as we are, our hearts are closed, and we cannot place the holy words in our hearts. So we place them on top of our hearts. And there they stay until, one day, the heart breaks and the words fall in.”
Medicine is full of heartbreaking experiences for patients and their families, and for its practitioners. One thing we can do when confronted with human suffering is to “break our hearts” in ways that open the heart to professional values, in ways that let “the words fall in.” Suffering can either harden the heart or, alternatively, can open and expand the heart’s capacities for compassion.
How can we develop the heart in our work? We might begin by working with human nature. All humans come equipped with three faculties: the intellect, the will, and the imagination. The object of the intellect is truth, of the will goodness, and of the imagination beauty. This applies directly to the work of medicine. The task of the good physician is to discern and tell the truth, to seek what is good for the patient and place it above what is good for the doctor, and to find beauty (i.e., harmony) in clinical judgments, harmonizing the best generalizable science with a deep understanding of the particular context of a given patient and making a judgment that is in fact creative and beautiful. Good professionalism is a habit, a habit that can be fostered by systematically answering three questions at the end of each day: how good a job did I do discerning and telling the truth, doing what was good for the patient, and making clinical judgments that were practical and wise?
To develop the habit of professionalism we need both solitude and community—solitude to reflect on and clarify what we did, and community to see if our conclusions hold up under peer scrutiny. We are all busy, and the demands of clinical productivity have compromised both our ability to reflect on and to have good conversations about our practices. Yet this gets right at the heart of our work: Reflective practice is not an option; it is integral to professionalism. In promising professionalism, we are in fact promising how we manage our time. It turns out that we each have 24 hours a day, and if we fail to align our time with our values we are destined to spend our time on an ever faster treadmill and will lose touch with the wisdom that makes our work fruitful.7(p86)
We can pay more attention to the work of professional formation. I favor the word “formation” over the word “education.” Education implies the transfer of information; formation acknowledges the important role of context in shaping our professional development. Internal and external forces have profound effects in shaping our competence, values, and interpersonal skills. Most gardeners would argue that it is overly simplistic to say that phosphorus fosters the development of roots while nitrogen fosters good foliage; nonetheless, there is some truth in the statement, and the analogy works in the case of professional formation. In medicine, foliage might be thought of as grants, publications, titles, learning new clinical skills and procedures, etc. Roots might be thought of as consisting of deeply held values and beliefs. Having spent most of my professional life engaged in the professional formation of residents, it seems to me that we spend most of our time encouraging good foliage while the roots are assumed to take care of themselves. We may need to examine the phosphorous/nitrogen ratio of our formation work.
Learning the right way to break our hearts, to deepen reflective practice, to find time for solitude and for good conversations, and to nourish our roots as well as our foliage both as individuals and as a profession requires that we recognize and create nourishing communities. We must develop an ecology that supports life—one that nourishes the deeply human in all of us, patients as well as practitioners. To do that, we must design systems that make it easy to develop these habits.
Medicine does not begin with ideals, but begins with the sensory observation of reality. From these observations a construct of professionalism can be developed. If the belief that professionalism offers the best approach to organizing health care is to make for a good promise to society, we must carry our observations and conclusions into the larger social conversation. Meanwhile, we can practice those conversations in our own hearts and in our own house. We can then live our way into the answers.