What is a professional?

Is a professional simply a method of lumping people in a similar job together? The short answer is NO. So why isn’t a car salesman or a plumber a professional?

I recently went to a conference in Newfoundland and attended a seminar on professionalism. The speaker opened his talk and addressed the crowd with a question: What is a professional? I was utterly shocked at what the overwhelming response was from a crowd of mostly seasoned emergency physicians. The themed responses included “dressing well in front of patients”, “being able to speak well”, and “how you carry yourself”; the theme being concentrated on superficial behaviors. Maybe it is because I have been trained at uOttawa U because I participated in ePortfolio meetings, but I am very glad that I realize that being a professional encompasses a deeper breadth of responsibility and action.

So what is a professional?  - The killer question. I know that it is so much more than how my colleagues described it but it clearly is not something that is easy to define.  Therefore, I will step up to the plate and attempt to claw away at the definition realizing that such a powerful word cannot be done justice in a simple written entry.

Let’s break it down into 2 aspects of being a profession I hold near:

                   1.   A professional is part of a profession with specialized educational training: As medical experts, we are entrusted with a wealth of knowledge of the human body and suffering. This knowledge has refined and nurtured over hundreds of years.  As professionals, we continuously advance the information passed down to us, we teach each other, and we regulate who gets accepted into our circle and carries the knowledge forth. Our profession is maintained and advanced by its entire membership. We have to work hard to get to and get through medical school, residency, and we are granted special qualifications that are rigorous to obtain – a HUGE commitment and sacrifice. We also protect our knowledge and abilities that enabled us to carve out a niche for ourselves in health care.

a.                  So is a plumber a professional? I would argue no. The knowledge and qualifications needed to become a plumber are vastly less. You have to be good at what you do, but you don’t have regulatory bodies ensuring quality of work and you don’t have major research or conferences advancing the science of plumbing. 

                   2.  A professional works entirely in the interest of others: This is why we got into the game! This is what we all said to the first question in our medical school interviews. Physicians dedicate a large amount of time in order to promote patient wellness. And within our profession, this is meant to be without intentional secondary gain. Some might argue that we do receive secondary gain, such as respect and financial compensation, but this is not intentional. We do not provide better service to one patient over another because we will still have the same amount of respect and money at the end of the week. This allows us to work in the interest in of each patient fully, hopefully improving their health status – a beautiful thing.

a.                  What about the car salesman? A car salesman knows that he could make a larger commission from a wealthier browser or may talk you into buying a car that you weren’t quite 100% about. It is clear that the car salesman is not fully in the interest of the consumer. It would be difficult to make the argument that his actions are not swayed by secondary gains.

I do have a confession to make. I find myself a very idealistic medical student. I stand at the doorstep of this profession with wide eyed wonderment of how I will become a part of in this profession. And I still strongly believe in the previous aforementioned ideals. However, sometimes I feel that these ideals are not completely upheld and maybe they, like me, are too idealistic.

Being part of a profession, with all of our qualifications, means that we should protect what we worked so hard to accomplish throughout history which is building this great profession, right? Not just anyone can do what we do. But in this day and age, we have allowed health care professionals take some of the burden from us. Nurse practitioners are prescribing and admitting to hospital, and we now have physician assistants performing some of our daily tasks. These ‘helpers’ came about because of the doctor shortage (which is a whole other topic in itself) and provide us with a valuable service so we are not worked around the clock.

-                     Let’s look at this in another light. Nurses do have a number of tasks as a part of their job that do not require a bachelor degree to perform. So to help the nurses out, why don’t we hire nurse technicians to accomplish their more menial tasks so that we can save money and time and they can concentrate more on their aspect of patient care? This is because the nurses would fight back to protect their profession and what they have built up together and might even feel threatened. 

I see this as the same for physicians, not all of our job requires 10+ years of education but I still find the more menial tasks important to our patients and to our identity as physicians and should protect them (if it remains in the interest of our patients).

Also, I mentioned earlier that physicians act selflessly in the interest of our patients with no secondary gain. Well, I can think of some situations where this is not always true. For example:

-                    A 40 year old female comes in with RLQ pain.  There are no peritoneal signs and the patient looks well. After a careful clinical exam, the patient is deemed to have idiopathic pain not likely related to GI or gynecologic origin. It is also noted in the chart that she has had prior CT scans and lower scopes and nothing has been found. The doctor opted for another CT scan to rule out any other pathology. 

How many physicians would trust in their skills enough to not reorder a CT scan on this lady just in case a new process is happening or something might actually surface this time? Possibly many, possibly few, but I have certainly seen it happen.

I believe that this might not always be in the patients’ best interest since we now know that radiation exposure is not harmless. But there is certainly an incentive and gain for physicians: in the off chance that something is there, we could catch it. Or if a different pathology appears there later on, we can say “look, I did the scan and there was nothing there”. We might just be saving our own butts on occasion instead of rethinking: “What is the best thing for this person?”

Bottom line is WE’RE NOT PERFECT. There are going to be times that we look at our profession outside the confines of the definition of professionalism whether it is due to policy, external pressures or whatever else. 

But I do believe that we should, as the next generation of physicians, stand up and take the reins to continually redefine what professional conduct is and contribute to the advancement of our profession in general so that other aspiring physicians can have a professional framework under which to work and redefine.

And we should try not to forget why we find ourselves in this overworked, complex, and highly interesting profession – it’s all for the patients.

Medical error is often a touchy subject for many health professionals. Doctors are expected to perform all procedures with perfection and patients expect nothing short of this when they are undergoing any medical procedure. With extensive medical training, surgeons and clinicians are trained to become highly proficient in a specific specialty or set of procedures. Although medical training in Canada is considered to be amongst the best in the world, there is no physician that can achieve perfection throughout an entire career of medicine. As such, we must all become comfortable with handling errors in our medical practice, and we must be able to do so in a very respectful, honest and sensitive manner. Furthermore, while recognizing our own mistakes may be difficult, it is often even more difficult to recognize the mistakes of other physicians while maintaining respect for the physician that has erred.

During the course of a recent medical elective, I was exposed to many patients that had undergone cataract surgery one day earlier. Although the result was near perfect in almost all of the patients, I had the interesting experience of encountering a patient that had a more complicated procedure. Specifically, while completing the procedure, the posterior lens capsule ruptured, leading to vitreous loss and complication of intra-ocular lens insertion. As a result, this patient experienced much more severe post-operative symptoms, specifically increased redness, pain and blurred vision.

When the patient came in, my preceptor handled the situation very calmly and appropriately. He made sure to mention that the procedure was complicated and abnormal. He mentioned that some of the symptoms that the patient was experiencing were a result of this complication. However, he was very clear that he would follow the patient much more closely and frequently to ensure that more severe complications did not arise. Furthermore, he informed that patient that he would be willing to reexamine the eye within the next week if the patient felt that the symptoms were getting worse (something that he did not explicitly offer to any of the other patients). The patient’s response reflected this professional and sensitive approach, as the patient did not respond with any anger, but rather was very understanding and appreciative of the physician’s honesty and accommodation. I feel that this encounter would have been far different if my preceptor acted in a defensive manner or attempted to blame the mistake on other members of the surgical team (i.e. nurse, anesthesiologist).

On a similar note, I was exposed to a patient that had received a normal cataract surgery from my preceptor in the left eye, however, had evidence of a complicated procedure in the right eye following surgery from a different surgeon. As mentioned above, it is very easy to slander the errors of other physicians and to point out shortcomings in their results. However, my preceptor handled the situation in a similar fashion to his own error. I was impressed with his professional demeanor and feel that he made great efforts to point out that these procedures are technically difficult and are always at risk for potential complications.

These two clinical experiences have given me a great basis for developing my own personal strategy for handling medical error. In the future, I plan to handle my inevitable mistakes by acting in a sensitive, professional, honest, reassuring and accommodative fashion.

During a physician skills development session with my preceptor at the hospital, I had the chance to practice my medical interviewing skills with a man who had been in the hospital for several weeks. This man, whose ailments included heart failure and emphysema, was receiving a constant supply of 4 L of oxygen. He was admitted to the hospital not because of a change in his health status, but because the hospital had become the only place where he could receive the oxygen he needed to maintain his condition. He was accused of smoking around his oxygen tank. This led to his eviction from the seniors’ residence where he was staying, as well as the termination of service by the oxygen supplier. As a result, he had to go to the hospital, as it was the only place where he could receive oxygen for the moment. The primary ethical dilemma arising from this situation is the balance between managing the risk to the individual and the community (smoking can endanger the public, mainly due to the risk of an explosion) and a patient’s right to receive treatment that is necessary to his survival. The hospital is currently negotiating with the oxygen supplier to try to reinstate this patient’s access to oxygen in an outpatient setting, with certain conditions. This situation is further complicated by the discrepancy between the accusation of the seniors centre and what the patient said, as he claims he did not smoke during his oxygen treatment. The urgency of this case is also apparent when you consider the economic component and the burden on hospital services, since this man could be treated outside the hospital setting. At this point there are monetary costs on a daily basis, in addition to the use of a hospital bed that could be given to another individual in need. It is important to consider all options that strike a balance between the safety of the individual and the public, as well as this patient’s access to treatment. This could come about under an agreement to have this patient closely supervised by a long-term care facility. One component of the agreement might be to allow the patient to smoke, but under supervision and not during his oxygen treatment. Furthermore, a contract should be signed that would set out the consequences of a breach of the agreement, in which the refusal of oxygen therapy by the supplier, and also by the hospital, should be considered.