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The Paradox of Professionalism

Chang, Elaine MD

doi: 10.1097/ACM.0b013e31829a6855
Teaching and Learning Moments

Dr. Chang is a first-year resident, Department of Medicine, Baylor College of Medicine, Houston, Texas; e-mail:

I found my patient in the “shock hallway” of the emergency department (ED), on a stretcher in the orange uniform that we see at our county hospital multiple times a day. His chief complaints were chest pain and shortness of breath, and he had a history of severe congestive heart failure.

His lab results, EKG findings, and physical exam did not suggest acute coronary syndrome, and his initial volume overload resolved with diuresis in the ED. A quick scan of his medical record revealed that his story and workup that day were a reenactment of his visit two weeks ago. Additional chart-sleuthing uncovered six visits in the past three months with the same presentation.

He asked for Dilaudid. Any other pain medications “don’t work for me,” he said. He refused nitroglycerin as well. Yet, I happened to walk past his bed when he wasn’t looking, and he was the model of relaxed comfort. Still, he kept asking for Dilaudid.

“What do you take for your chest pain at the jail?” I asked him.

“The doctors used to give me Norco, but I ran out a week ago,” he responded.

My inner cynic wondered, “Perhaps they stopped giving you more because they figured out that you’re a drug seeker.”

In this kind of situation, what does it mean to be professional? The Accreditation Council for Graduate Medical Education (ACGME) defines professionalism with terms like respect, altruism, integrity, honesty, compassion, accountability to patients and society, professional commitment to excellence, adherence to confidentiality, respect for autonomy, and sensitivity to gender and disability.

Although this definition sounds ideal, professionalism is not so easy to define in practice. Some employ it as a tool based on using shame to shape identity. Whenever a resident’s behavior is remiss, whether it is a lack of punctuality or showing up to work intoxicated, we are chastised as being unprofessional, a catch-all criticism. The underlying message is: “Next time, remind yourself that you spent four years in college and four years in medical school, and have earned the MD behind your name. If you really deserved that title, you wouldn’t do [insert the sin].”

On the flip side, if I am following all the rules, I can pat myself on the back because of my professionalism. My goal becomes earning as many gold stars as I can, shifting my focus away from patients towards myself.

During my rotation in the ED, I was faced with this paradox as I encountered numerous patients insistent on receiving Dilaudid. Handling malingering patients was uncomfortable, and my goal often was to discharge them without feeding their narcotic dependency for too long or saying what was really on my mind. My compassion and altruism were running low, especially as my frustration grew at the resources being wasted.

The day after I met my patient with severe congestive heart failure, I went to church. I realized that, ironically, when I came to work with my identity as a Christian at the forefront, I was more professional. I would ask myself, “How can I help this person make progress towards well-being?” I still ordered the tests, examined the patient, and thought about the differential just as thoroughly, but it was for the sake of the patient. If I had walked into that shock hallway a day later, I might eventually have had the courage to say that I truly did want to help him get better, especially in the long term, and I did not think that narcotics were the answer.

Patients still ask me for Dilaudid, and I still avoid feeding their narcotic dependencies. Thankfully, I am able to do so while keeping their best interests at heart and, just as important, without letting my frustration and cynicism engulf my own life. My hope is that others also can embrace this altruism and compassion, like I did. Or professionalism, as the ACGME would say.

© 2013 by the Association of American Medical Colleges