Medical professionalism continues to merit a great deal of attention, to provoke dialogue and debate, and to challenge practicing physicians, medical educators, and others involved with contemporary health care. During the past decade or so, important advances have been made both in understanding the nature of professionalism1–4 and in efforts to teach and assess professional values and behaviors in undergraduate and graduate medical education.5–8 A number of specialty boards and societies, such as the American Board of Internal Medicine, have focused on ways to foster and document professionalism among practicing physicians.9 On balance, however, less attention has been given to the practical challenges and expressions of medical professionalism in practice settings than in academic settings.
The Nature of Professionalism
An exhaustive discussion of medical professionalism is clearly beyond the scope of this article, or even this special issue of Academic Medicine. The complexity of contemporary medical practice drives the complexity of medical professionalism and confounds a simple, universally accepted definition. Medical professionalism has many dimensions, from a distinction between basic and higher professionalism,10 to the necessary competencies of a social contract,2 to conditions necessary for ethical practice.11 Each dimension is valid, but none is sufficient to fully define the nature of professionalism.
Professionalism and values
One fundamental dimension of professionalism relates to the values that have long shaped the practice of medicine. For the past few decades, the practice of medicine, as a profession, has come under withering fire from many directions. Physicians, individually and collectively, have felt threatened and besieged. The increasing focus on professionalism has been perceived as a defensive response, an effort to defend the bulwarks of the profession (my warlike allusions are chosen quite deliberately). Stevens11 (p359) has noted that professionalism has assumed, in some quarters, an almost mythic dimension to become a “powerful, formulaic way of thinking.” She notes, correctly, that “professionalism … can no longer be taken for granted as a core of behavioral expectations that are inherent in becoming a physician.”11 (p357) If those of us who are concerned about the future of medicine are to restore and maintain professionalism, we must—slowly, perhaps, but inevitably—abandon the current reactive and defensive posture and make professionalism a positive, lived expression of the values that have for so long characterized the profession of medicine. These values must infuse not only educational settings but also practice sites.
Professionalism, then, must be grounded in the long-standing values of medicine. The practice of medicine is a sacred trust; ideally, it represents not a contract but a covenant.3 A covenant connotes a relationship based on trust, and the covenantal nature of medicine has been reflected in medical oaths since ancient times. The Hippocratic oath addressed the physician’s duty to benefit the sick and keep them from harm and injustice.12,13 The Prayer of Maimonides states “in the sufferer let me see only the human being.”14 A more contemporary medical oath calls on a physician to “act so as to preserve the finest traditions of my calling.”15 Now, in the 21st century, we must endeavor to refresh the meaning of medicine as a covenant between physicians and those they serve by upholding these finest traditions and endeavoring always to see only the human being in those who suffer.
Professionalism and humanism
There is in medicine a critical nexus between professionalism and humanism. Both have long been “inextricably woven into the practice and art of medicine.”16 (p141) Scribonius, a physician in the court of the Roman emperor Claudius, is credited with the first written use of the word profession in a book of prescriptions from 47 AD. In defining profession as “a commitment to compassion or clemency in the relief of suffering,” Scribonius emphasized humanistic values such as benevolence and compassion.17 Many contemporary discussions of professionalism also address, explicitly or implicitly, such humanistic values.1–3,18
Just as the word professionalism carries many connotations, so, too, does the word humanism. The Gold Humanism Honor Society offers a succinct definition:
Humanism encompasses those attitudes and behaviors that emanate from a deep sensitivity and respect for others, including full acceptance of all cultural and ethnic backgrounds. Further, humanism is exemplified through compassionate, empathetic treatment of all persons while recognizing each one’s needs and autonomy.19 (p5)
Insofar as humanism addresses the question of what it means to be human, it must frame the practice of medicine. Insofar as professionalism has a moral core and encompasses values that are intrinsic to all humans, it, too, must frame the practice of medicine.
Some have expressed concern that, at least in undergraduate medical education, professionalism is supplanting humanism, or that professionalism is conflated with humanism.20 I would argue that the two are not mutually exclusive. Far from it: each can enrich the other. A professional education must address specific knowledge, skills, and expertise, as well as attitudes and what Thomas Green21 (p109) has called an imaginative conscience, through exposure to the “poets and … literary giants of our experience.” Humanistic values, as well as pedagogical methods drawn from the humanities, can be used to help convey the values of professionalism. Conversely, the values of professionalism can help convey the importance of humanism, perhaps especially to doubting, cynical students who consider time spent discussing professionalism or humanism an unnecessary distraction from what they need to learn for their next exam. In an almost analogous fashion, practicing physicians too often complain that the current health care environment and the pressures of contemporary practice leave no time for other pursuits. Medical educators and leaders must find ways to integrate and suffuse both professionalism and humanism throughout the curriculum, in basic science and clinical settings, and in practice sites as well as academic health centers.
Professionalism Outside the Academic Health Center
The values of professionalism are the same inside and outside the academic environment. Appropriately, most of the efforts to understand, inculcate, and assess medical professionalism have occurred within institutional settings such as schools of medicine, residency review committees, or professional organizations such as specialty societies. Daily expressions of professionalism occur most frequently not in the academic health center but in physicians’ offices and in the communities they serve, reflecting simply the numbers of physicians in practice versus the number in academic medicine. One element driving the concern about a loss of professionalism has been the rapid advances in medical science and technology that have come to characterize contemporary medical practice. When expertise drives professional work, expertise then becomes the norm against which professionalism is judged,22,23 even though professions, especially medicine, respond to a “fundamental human need or social good whose advancement is already a moral aim.”21 (p79)
The resurgent interest in medical professionalism has also been driven, in part, by a growing sense of alienation and loss of meaning among practicing physicians, as well as the transformation of medical practice from a professional to a business model.24 The cauldron of practice can erode or, less likely, stimulate professionalism. We must find ways to minimize the erosion and maximize the stimulation. It is critical, therefore, to incorporate into practice settings activities that are explicitly designed to restore, promote, and advance professionalism and humanism in medicine. Such activities can occur in at least three spheres: with students, with patients, and with our communities.
Professionalism and students
There is a long-standing debate about whether values can be taught. Although one can argue that an individual’s ethical and moral foundations are well established by the time he or she enters medical school, there are, nevertheless, opportunities to foster the further development of such foundations during undergraduate and graduate medical education. Professionalism must be taught.25 Although efforts to embed professionalism in schools of medicine and academic health centers are key, so too are efforts to do so in practice sites.
Medical educators must ensure that medical students and residents are prepared for the world in which they will practice and the communities they will serve. As Stern and Papadakis8 (p1797) have noted, “students need to see that professionalism is articulated throughout the system in which they work and learn…. The challenge becomes even more daunting when the goal is to institute an attitude of professionalism in multiple organizations.”
Students considering a career in medicine not infrequently spend time in a physician’s office to “shadow” the physician and gain exposure to contemporary medical practice. Such experiences convey powerful messages about the nature of medicine as a practice and the roles of the physician. Hence, practicing physicians can begin to mold humanism and professionalism in a very early stage of a medical student’s professional development.
In most medical schools, a certain amount of formal clinical experience now occurs at sites remote from the academic health center, including defined experiences with community physicians during the early stages of medical education, as well as formal clerkships during the clinical years. As more and more teaching of both students and residents occurs in such locations, it is critically important that community physicians demonstrate those behaviors that resonate professionalism and humanism. As teachers, they must be committed to being role models for what physicians should be. Nonacademic settings such as physicians’ offices and community hospitals can be excellent venues to address professionalism, but only if one can engage practicing physicians as effective mentors and role models. Students are very sensitive to inherent conflicts between what is taught and what is observed, and “efforts to teach the ideals of professionalism can be easily overwhelmed by the powerful messages in the hidden curriculum.”8 (p1797)
Another feature of the nonacademic setting is that there can be, by the nature of the learning environment, many opportunities to nurture professionalism without the constraints imposed by formal assessment. In recent years, great strides have been made in assessing the professional behaviors of medical students.7 We know that negative faculty judgments are associated with later disciplinary action by state licensing boards.26,27 Nevertheless, many clinical volunteer faculty may feel uncomfortable making summative judgments about a student’s professionalism after limited interactions, even though they are willing to make useful, constructive formative assessments. I do not say this to detract from the critical importance of evaluating professional behaviors or from the need to train all faculty to make those evaluations, but rather to emphasize the importance as well of informal, formative feedback that can derive from modeling and discussing the professional and cultural values that students encounter in clerkship settings away from the academic health center.
Professionalism and patients
The ultimate beneficiary of a physician’s professionalism and humanism is the patient. This seems an almost unnecessary statement of the obvious, but in today’s challenging health care environment, when physicians are beset with multiple and often conflicting demands, it is important to remind ourselves that humanistic and professional values truly do continue to shape the healing relationship between patient and physician.
William Osler,28 (p274) the first professor of medicine at the Johns Hopkins University School of Medicine in the late 19th century, and an acknowledged avatar of professionalism, said in a 1903 address to students who were about to embark on careers as practicing physicians:
Yours is a higher and more sacred duty…. To you the silent workers of the ranks, in villages and country districts, in the slums of our large cities, in the mining camps and factory towns, in the homes of the rich, and in the hovels of the poor, to you is given the harder task of illustrating with your lives the Hippocratic standards of Learning, of Sagacity, of Humanity and Probity…. Of a humanity, that will show in your daily life tenderness and consideration to the weak, infinite pity to the suffering, and broad charity to all.
More than a century later, the grammar and syntax may seem a bit outmoded, but the message is as pertinent as ever. In this brief statement, Osler alluded to several of the dimensions of professionalism, including competence, a sense of social contract, and humanistic values, and he acknowledged the difficulty of exemplifying those dimensions in the daily life of a physician.
Physicians must be advocates for their patients. So, too, patients can become advocates for their own physicians. Patients, like physicians, may sense acutely the loss of the intense, personal relationship that impels healing, if not always cure, and wish there were some way to restore it. Patients, then, can speak up for physicians who nurture a personal, healing relationship, and such physicians can play an active role in restoring an environment of professionalism in practice; in doing so, they will increase trust and strengthen the covenantal nature of medicine. The ultimate beneficiaries of the patients’ advocacy will be not only individual physicians but also the profession.
Professionalism and community
Traditionally, physicians have served as much more than caregivers; they have long been seen as integral members of their communities. Despite the challenges of the current health care practice environment, certain dimensions of medical professionalism—such as its implicit social contract—demand that physicians be active, participating members of the communities in which they live. The use of the plural communities is deliberate, because we are all members of many communities—not only a city or town, but also a neighborhood; not only a specialty society, but also the profession; not only a scientific community, but also a social and cultural community.
Physicians’ professionalism, then, must be expressed not only in their daily interactions with patients and other health care professionals, but also in their manifold responsibilities as members of their communities. This expression can take many forms, and it need not take a great deal of time. Perhaps it is the family medicine physician who plays in the local community symphony orchestra, or the general surgeon who serves on the medical staff quality committee. Perhaps it is the orthopedist who volunteers as team physician for the high school football team, the internist who serves on the board of the local YMCA, or the pediatrician who helps coordinate a local food drive. Perhaps it is the pathologist who sings in a community choir, or the infectious disease specialist who is a consultant to the local county board of health. By making time to be active in their communities, physicians demonstrate professionalism. Communities respond by welcoming physicians as an essential element of life beyond simply the world of illness.
A Few Practical Ideas
Within academic settings, there are clear opportunities to integrate issues of professionalism and humanism into the curriculum, although doing so successfully can be most challenging.6,29 Many medical schools now have formal programs designed to foster professionalism and to introduce students to the importance of the humanities. Other articles in this special issue of Academic Medicine address some of the innovative approaches that have been used. Outside academic health centers, how can physicians and other health care professionals best promote their professions’ values and the attributes of professionalism and humanism? There are many ways to do so. The following examples are empiric rather than evidence based, but most cite real, personal experiences. They are meant simply to exemplify the concepts and stimulate additional ideas.
Ideas for structured humanities programs
The Institute of Medicine and Humanities (IMH), a joint program of The University of Montana and St. Patrick Hospital and Health Sciences Center in Missoula, is one effective model of how professionalism and humanism can be promoted in educational, health care and public settings outside an academic health center.30 For the past 20 years, the IMH has endeavored to better understand the human dimensions of health care by using the humanities to address health care issues that challenge our understanding of what it means to be human and by advancing scholarship in the medical humanities. Courses and lectures for undergraduate, graduate, and health professions students at the University of Montana, seminars specifically designed for health care professionals, and at least one major public conference each year offer settings in which to explore issues at the nexus of medicine and the humanities.
In the context of today’s busy, frenetic practice environment, are the humanities anything more than “a leisurely distraction from the real work of diagnosing and curing”?31 (p94) Emphatically, yes! The humanities can serve to enable dialogue between physicians and patients, as well as other health care providers. Edgar and Pattison31 (p98) have noted that “the humanities … allow a community to scrutinize its own values and meanings, whereas the arts … make those values and meanings explicit and attractive.”
Seminars for health care professionals.
In 1997, the Maine Humanities Council launched Literature and Medicine: Humanities at the Heart of Health Care, a series of seminars for hospital staff facilitated by a humanist scholar.32 Bringing together a broad range of hospital personnel, from medical staff physicians and nurses, to laboratory technicians, to members of the administration, these seminars employ selected works of literature to stimulate an engaged dialogue that crosses the usual boundaries of health care hierarchies. The program’s success is attested to by its extension to 79 health care facilities in Maine, as well as hospitals in 13 additional states. In 2005, I introduced and led a literature and medicine seminar series at St. Patrick Hospital and Health Sciences Center in Missoula. One evening a month for six months, 20 hospital staff and physicians came together for informal but provocative conversations that centered on common experiences of illness and healing, using themes found in short fiction, poetry, and drama. Everyone, whether or not they were engaged in direct patient care, made valuable contributions. The seminar was repeated in 2006 at St. Patrick Hospital, using all new readings, and a similar program was created for two smaller hospitals in other Montana communities. In each case, the specific readings were selected to target issues that were pertinent for the particular hospital, to ensure relevant discussions.
Literature can be a powerful way to convey the values of professionalism and humanism. Especially useful, in my experience, are works by physician writers—individuals who maintained an active practice, as academic physicians or private practitioners, as specialists or generalists, while also pursuing their careers as writers. They become the poets and literary giants of our experience. Several physician writers have acknowledged that one career nurtures the other. Anton Chekhov33 famously noted that “medicine is my lawful wife and literature my mistress. When I grow weary of one, I pass the night with the other … neither of them suffers because of my infidelity.” Works by physician writers offer insights not only into the experience of being a physician, but also into the human condition and the experiences of illness and suffering. The Appendix offers a small, personal, and very selective list of works that I have used in various settings to provoke reflection and insight about the very human nature of the practice of medicine.
Public conferences can help express the values of professionalism and humanism by addressing topics of importance to the community. For example, in the fall of 2006, the IMH sponsored a series of conferences called Taking Missoula’s Pulse: Steps Toward a Healthier Community. One evening a week for four weeks, local authorities addressed issues such as violence, addiction, mental illness, and the uninsured, highlighting common threads of stigmatization, shame, poverty, and social justice, and the impact of these issues on all of us. Examples drawn from the humanities often enriched the presentations, and panels of patients added a powerful and personal perspective. Although such IMH conferences are designed for the public, they attract health care professionals as well. One senior internist commented after the session on violence that she had never heard patients speak so openly, emphasizing how much insight she had gained into problems that confronted some of her patients. Other recent IMH conferences have addressed topics such as depression, body image, and ethical implications of recent advances in genetics.
Ideas for professional organizations
Professional organizations can promote professionalism in ways that are both direct and indirect. The recent 36th Critical Care Conference of the Society of Critical Care Medicine (SCCM) stressed the importance of education. In hallways and meeting rooms throughout the meeting site, posters containing brief epigrams highlighted the roles of the physician as teacher and learner. Examples ranged from Nelson Mandela (“Education is the most powerful weapon which you can use to change the world”), to Michelangelo (“I am still learning”), to Herbert Spencer (“The great aim of education is not knowledge, but action”), to B.B. King (“The beautiful thing about learning is that nobody can take it away from you”). These and similar brief statements engaged the participants’ interest and stimulated informal conversations among the physicians in attendance, even though they did not deal directly with the medical and scientific aspects of critical care. The SCCM was thus able to highlight two important professional responsibilities of physicians—teaching and lifelong learning—without a great deal of energy or expense (Diane Scott, SCCM, personal communication, 2007). It is easy to envision similar approaches at meetings of other professional organizations, using examples that quietly but powerfully express various dimensions of professionalism and humanism in practice.
Ideas for individual physicians
To make my points more vividly, in this section of my article, I speak not about physicians but as a physician.
Using patients as advocates.
Many patients are concerned about the current state of health care in the United States, and that concern can be harnessed to make our patients advocates for medical professionalism. Recruiting patients as advocates does not mean whining about the frustrations we feel about contemporary practice—the constraints and restraints, the hurdles and the stumbling blocks that interfere with our ability to care. Rather, as members of a profession, we can engage patients by consciously exemplifying our own professionalism. In doing so, we can help establish and maintain several of Stevens’11 conditions for ethical practice, conditions such as building trust, insisting on high standards of care, or participating creatively in improving the health care system. We can work to ensure that every patient is treated with dignity and respect. We can, whenever appropriate, openly stress the importance of the profession’s values and the erosion of those values in the current environments of health care. When patients—and, more broadly, the communities in which we practice—see that we are willing to take leadership positions based on medicine’s values and moral foundation, they will be more likely to support our profession’s efforts to improve health care by, for example, improving access to care and ensuring conditions of social justice in medical practice. For example, the IMH conference mentioned earlier, Taking Missoula’s Pulse, provided a forum to challenge the audience to consider the consequences of lack of access to care for underserved populations or those with mental illness. Only if we physicians, individually and as a profession, demonstrate high standards of professionalism and humanism will we be able to reassert the moral core of medicine and restore the trust that is at the heart of the patient–physician relationship.
Using the humanities to show our own humanity.
Our professionalism as physicians can also be exemplified by sharing with patients our own humanity and, hence, our own vulnerability. Practicing physicians can use simple vignettes drawn from the humanities (broadly defined) to help explain otherwise difficult issues. Doing so reveals us not as technicians or scientists, but as individuals with broader interests and dimensions and concerns. The specific vignettes will necessarily depend on an individual physician’s interests. Most of the following examples are not hypothetical or imaginary; they are drawn from actual incidents.
A rheumatologist might share Renoir’s struggle to cope with rheumatoid arthritis as a patient sees her own capabilities shrinking with the progressive gnarling of her hands.
An ophthalmologist could tell a patient with progressive and irreversible vision loss about Rembrandt’s decreasing vision and its influence on his later paintings, to give that patient some hope for the future.
An internist might cite John Stone’s brief poem “Grief,” or suggest Mozart’s Requiem to comfort a grief-stricken family.
An oncologist could chat with a patient undergoing chemotherapy about the patient’s impressions of a recent symphony concert both attended, and hence encourage the patient’s continuing social engagement during a difficult time.
A family practitioner might help explain to third-year medical students the complex emotions evoked by patients by giving them a copy of “Case History” or “The Doctor” by Dannie Abse.
A neurologist might use Abse’s “The Stethoscope” during a white coat ceremony to convey to entering medical students the awesome privilege of being a physician.
A medicine residency clerkship director could echo Franz Kafka’s34 (p152) observation in “A Country Doctor” that “to write prescriptions is easy, but coming to an understanding with people is hard.”
Drawing on the humanities will not only be healing for the patient, but it will also enrich the physician’s own sense of satisfaction with practice.
Medical professionalism and humanism have long been integral to the practice of medicine, and they will continue to shape practice in the 21st century, in part because both reflect a moral imperative to serve. Although professionalism must continue to be the focus of formal educational efforts in undergraduate and graduate medical education, so, too, must it become a focus in the practice environment. Continuing to foster professionalism outside the academic health center is critical to efforts to rebuild the traditional values of medicine, the putative loss of which many now bemoan. There are many opportunities to foster professionalism and humanism in a busy practice environment, despite the harried and hurried lives of physicians. If the medical profession is to recapture and preserve the rich tapestry of professionalism and humanism that have, for so long, reflected the ideals of medicine, then those of us who are physicians must, individually and collectively, strive to express these qualities not only in clinical settings but also in the other communities we serve. It is a challenge we should embrace willingly.
1 Swick HM. Toward a normative definition of medical professionalism. Acad Med. 2000;75:612–616.
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5 The Medical School Objectives Writing Group. Learning objectives for medical student education—guidelines for medical schools. Report 1 of the Medical School Objectives Project. Acad Med. 1999;74:13–18.
6 Wear D, Bickel J, eds. Educating for Professionalism. Creating a Culture of Humanism in Medical Education. Iowa City, Iowa: University of Iowa Press; 2000.
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12 Edelstein L. The Hippocratic oath: Text, translation, and interpretation. In: Temkin O, Temkin LC, eds. Ancient Medicine: Selected Papers of Ludwig Edelstein. Baltimore, Md: Johns Hopkins University Press; 1967:2–63.
13 Miles SH. The Hippocratic Oath and the Ethics of Medicine. New York, NY: Oxford University Press; 2004.
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18 Misch DA. Evaluating physicians’s professionalism and humanism: the case for humanism “connoisseurs.” Acad Med. 2002;77:489–495.
19 The Arnold P. Gold Foundation. The Gold Humanism Honor Society. A Force for Humanism in Medicine. Englewood Cliffs, NJ: The Arnold P. Gold Foundation; 2005.
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21 Green TF. Voices: The Educational Formation of Conscience. Notre Dame, Ind: University of Notre Dame Press; 1999.
22 Brint S. In an Age of Experts: The Changing Role of Professionals in Politics and Public Life. Princeton, NJ: Princeton University Press; 1994.
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Appendix Selected Works by Physician Authors That Convey the Values of Humanism and Professionalism
Note: This very brief, very personal list only hints at the numerous works by these and other writers that reveal the human dimensions of the practice of medicine. The annotations are meant simply to provoke curiosity, with no pretense to literary analysis.
Campo R. Ten patients and Another. In: What the Body Told. Durham, NC: Duke University Press; 1996.
The case histories of 11 patients are related in language that slowly evolves from the medical to the lyrical, revealing the narrator’s own humanity.
Chekhov A. Objet d’art. In: Pilcher H. Chekhov: The Comic Stories. Chicago, Ill: Ivan R. Dee Publishers; 1999.
In contrast to the rather dark, pessimistic mood of many Chekhov stories, this is a lighthearted look at a doctor’s discomfort with a patient’s inappropriate expression of gratitude.
Mates S. The Good Doctor. Iowa City, Iowa: University of Iowa Press; 1994.
In this volume, the story “Laundry” evokes the multiple, conflicting demands of balancing professional with personal life, and clinical practice with research.
In the same volume, the story “The Good Doctor” addresses gender roles in medicine and the complex emotional and psychological issues sometimes embedded in those roles.
Sams F. Epiphany. New York, NY: Penguin Books; 1994.
This novella tells of a long, sometimes difficult relationship between a crusty older physician and a patient whose experiences with racism and injustice slowly emerge over the course of numerous visits.
Selzer R. Toenails. In: Letters to a Young Doctor. New York, NY: Simon and Schuster; 1982:66–69.
Selzer R. Imelda. In: The Doctor Stories. New York, NY: Picador USA; 1998.
Selzer R. Raising the Dead. East Lansing, Mich: Michigan State University Press; 2001.
Many of Selzer’s “doctor stories” offer powerful insights into the nature of healing. “Toenails” and “Imelda,” for example, challenge us to think about the experiences of the physician as a caring, empathic human being.
Selzer’s memoir, Raising the Dead, provides a patient’s perspective on life-threatening illness and hospitalization while revealing patients’ often complex experiences with caregivers.
Stone J. Music from Apartment 8. In: New and Selected Poems. Baton Rouge, La: Louisiana State University Press; 2004.
Many poems in this collection deal with the experiences of physicians and other caregivers. “Talking to the Family,” for example, addresses the complex emotions associated with giving bad news, and the reluctance that physicians sometimes feel in doing so. “Gaudeamus Igitur: A Valediction” celebrates the awesome privilege of caring for patients and the many uncertainties inherent in clinical practice.
William Carlos Williams
Williams WC. The Doctor Stories. Compiled by Robert Coles. New York, NY: New Directions Books; 1984.
Many of Williams’ “doctor stories” have become iconic examples used in medical education to provoke questions of medical ethics and physician responsibilities.
“Old Doc Rivers” challenges the reader to think about the impaired physician and the responsibility of professional colleagues to address the problem.
“The Use of Force” invites discussion of ethical responsibilities and limits, as well as the consequences of a physician’s inappropriate emotional response to patients.
“Ancient Gentility” reveals the rewards and satisfaction of compassionate practice.