Another major catalyst in the erosion of professionalism is the complex issue of money and income. Many physicians, including hospitalists, are “judged” by their relative value units, an indicator of the quantity and complexity of patients seen. Services not “billable” are generally delegated to others, or they go undone. Such services include communicating tirelessly with all the stakeholders in the patients’ care, including family members, primary care physicians, other physician specialists, and other disciplines. Untoward behaviors, such as “upcoding,” selecting funded patients for care, creating patient streams for highly lucrative services, and under-resourcing care provisions that “lose money”—regardless of the value to the patient—are inadvertently incentivized on individual and system levels to enhance revenue. Many hospitalists are strapped with student loans early in their careers, requiring them to earn enough to pay back these loans in a timely fashion. These perverse incentives can and often do confound our ability to act solely on behalf of our patients.2
How Do We Overcome These Threats?
The first step in reviving professionalism is to define it by what it is, not by what it isn’t. Professionalism is not the absence of bad behavior. Professionalism is the “commitment to carrying out professional responsibilities and an adherence to ethical principles.”3 Professionalism is the pursuit of the tenets of the Hippocratic Oath. As a litmus test, read and reread the oath, and honestly reflect upon your practice.
Another step is to continuously work in multidisciplinary teams, a skill that comes naturally to most hospitalists. In order to fulfill the oath, you should not work as a social worker, but you should advocate for your patients’ social work needs. You need a plethora of other disciplines to help you fulfill your role as a patient advocate. Know and respect the roles that your team members are playing, all of which are invaluable to you and your patients.
An additional step in helping you fulfill your role as a professional is to get the education and skills you need to function effectively within the complex systems in which we currently work. You should incorporate business and management education into your continuing medical education so that you can help patients traverse a system that is complex. You should know and understand the general concepts of value-based payment, insurance exchanges, federal-state-private insurances, and the basic tenets of health systems. You should know how to recognize and reduce waste and unnecessary variation in the system, and know how to measure and improve upon processes.
In the words of Emanuel Ezekiel, MD, PhD, “Learning clinical medicine is necessary for making patient well-being the physician’s primary obligation. But it is not sufficient. To promote professionalism and all that it entails (reducing errors; ensuring safe, consistent, high-quality, and convenient care; removing unnecessary services; and improving the efficiency in the delivery of services), physicians must develop better management skills … Becoming better managers will make physicians better medical professionals”.2
For those entering medical school, nine core competencies can predict success in medical school and later in practice; we should all commit to excellence in these, which go beyond clinical knowledge:
- ethical responsibility to self and others;
- reliability and dependability;
- service orientation;
- social skills;
- capacity for improvement;
- resilience and adaptability;
- cultural competence;
- oral communication; and
- teamwork.
Lastly, a critical step in preventing the erosion of professionalism in medicine is self-regulation. External regulation comes to those who refuse or are unwilling to regulate themselves. Professionalism is a set of skills that can be taught, learned, and modeled. As a new specialty, we all own the success or failure of the reputation of hospitalists as consummate professionals.1