Unprofessional professionals

“The public does not expect its professional servants to simply act according to the rules and it expects a different kind of behaviour and one where professionals are seen to act with honour and concern for the population they serve.”  
—Professor Averil Mansfield, former BMA president and Britain’s first female professor of surgery

A recent Canadian Institute of Health Information (CIHI) document[1] misguidedly blam­ed doctors’ fees as a major contributor to the rising costs of health care in Canada. In a previous editorial[2] I wrote on some financial issues facing doctors. Read both articles and you will, I hope, recognize that I was right and CIHI is wrong.

“When doctors talk ethics, they usually mean money.” That was the cynical viewpoint of one of my early Canadian teachers. Nowadays a plumb­er bills $180 for a house call, while a doctor is paid less than half that amount. Does the reality of medical reimbursement today explain some of the attitudes that prevail in modern medical practice? Perhaps.

Doctors have traditionally worked excessively long hours. Fee for service was a time-honored choice as the method of payment. Not anymore. In the last CMA survey on remuneration, only 23% of doctors favored fee for service as their preferred method of remuneration. Remember that fee for service is piecework and is a method that favors the employer and the consumer, not the employee. That is why unions wholeheartedly reject it.

I hope that the newer generation of doctors will be adequately rewarded for their work, but even more so, I hope they understand that they are different from many other workers in society. They are professionals. Medicine is a vocation. While I believe in market forces and fair financial re­wards for physicians, we nevertheless have a unique role in looking after those who have become victims of illness or injury.

A friend was recently hospitalized at a major BC hospital, suffering from a serious acute illness. Sadly, his experience was very poor. He was cared for by a so-called team, something that is becoming more and more the norm as our profession pursues a work-life balance (whatever that is), rather than the traditional patient-centred approach to care. The doctor with (nominally) primary responsibility changed several times during his stay. 

Astoundingly, none of the team leaders was available or responsive to requests from the worried and distressed wife of the patient. She did receive one rude admonishment from a resident after multiple requests for some information regarding the state of her husband. 

Having spent many years of my professional life in teaching and training residents, I felt bad for both my friend’s wife, who was subjected to inappropriate abuse, and for the resident who was clearly not being taught that respect and compassion were important qualities of a good doctor.

We sometimes fail to realize that what we consider routine is, to a pa­tient, a unique and frightening time. Physicians must treat patients the way they or their loved ones would like and ex­pect to be treated when they need care.

Some anonymous team leaders have forgotten their role. Perhaps they perceive the role of their fellows and residents as being to protect the leader’s time and privacy. Perhaps they are teaching medicine well in a didactic or academic sense. That is not enough. Young doctors need to learn professional behavior and the art of medicine. Clearly, some teachers are incapable of fulfilling this role.

Government policies enacted 20 years ago have produced a Canadian health system in which there is an extreme shortage of doctors. Those policies were based on the advice of now discredited health economists who apparently felt that the role of a health economist was to economize on heath. 

As a result, Canada now needs 26000 more doctors to equal the OECD average. BC has reacted better than most to this shortage, but the response is still inadequate as 5 million Canadian patients remain without a family doctor. Canadian specialists no longer have to build a referral practice and they develop instant wait lists. Family doctors can pick and choose their patients. In parts of Canada, patients put their name into a lottery in the hope of getting a doctor. Doctors don’t have to try too hard to please because patients have little choice anyway.

“Medical professionalism” is now taught in our medical schools. In placing it as just another part of the curriculum, we may have lost sight of what it actually represents. Professionalism cannot be taught in a didactic course. It requires a behavioral attitude that can only be learned by exposure to caring and compassionate physicians. Anonymous team leaders who fail to lead are not the role models we want. All of us will one day be patients. What kind of team leader do you want when you become ill?
—BD

References

1. CIHI [press release]. More physicians than ever; greatest percentage increase in physicians in 20 years. 2 December 2010. www.cihi.ca/CIHI-ext-portal/internet/en/Document/spending+and+health+workforce/workforce/physicians/RELEASE_02DEC10.
2. Day B. Who pays? BCMJ 2005;47:469.