Invited commentary: Professionalism in 21st-century medicine.

Medical professionalism is a complex and multifaceted subject. In 2002, “Medical Professionalism in the New Millennium: A Physician Charter” was published in the Annals of Internal Medicine and elsewhere (1). This document stressed the primacy of patient welfare, patient autonomy, and social justice. The charter is discussed in Dr. Kirk's excellent Kitchens Lecture given at Baylor University Medical Center (2). Dr. Lloyd Kitchens was an exemplary clinician who personified the finest qualities of a physician. His article on medical etiquette published in these Proceedings several years ago still rings true (3). What role does professionalism have in the current medical arena? Certainly patient welfare, autonomy, and social justice are core principles. Paradoxically, the challenges of delivering health care are becoming ever greater at the same time that scientific medicine is advancing as never before. How can we provide appropriate care for our patients in a universal, comprehensive, and equitable manner (4–6)? How can medicine fulfill its social contract with society? William Osler, the great clinician and educator who lived between 1849 and 1919, represents one exemplar of medicine as a noble profession and a calling (7, 8). His many aphorisms and essays speak eloquently to the heart of the doctor-patient relationship. His observation that “the old art can not possibly be replaced by, but must be incorporated in, the new science” is as true today as it was 100 years ago (9). Osler welcomed scientific advances in medicine because he knew they would enable him to take better care of his patients. He was at the forefront of medical science and no doubt would still be if he were alive today. In addition to his focus on science, he emphasized that doctors should pay special attention to the patient, not just the disease. His friendliness, generosity, and respect for others have had an enduring influence on generations of students and physicians. In an essay entitled “The Reserves of Life” he likened a medical career to a race through London and told students at St. Mary's Hospital Medical School that “in ordinary training you run the course over, but life's race is run but once; and, though the course may seem long to you, it really is very short, but very hard to learn. Fortunately, you are not alone on the track, as your brothers are ahead, and if you are willing there is always help at hand” (9). We should heed this counsel. Guidance from trusted colleagues is a valuable but sometimes underutilized asset. Many of William Osler's precepts remain applicable today. Perhaps the central pillar of professionalism is competence (6, 10, 11). Unless a physician is competent, he or she cannot be either professional or ethical. Kindness and compassion are other qualities which, though not mentioned in the physician charter, are fundamental to the care of ill people. Patients are cared for individually; whether in an office, clinic, hospital, or on a battlefield, the doctor-patient relationship is a one-on-one encounter. A physician must obtain a history, elicit pertinent positive and negative physical findings, and order selected laboratory tests. He or she must analyze these data in the context of an ever-expanding galaxy of scientific knowledge. What is the diagnosis? What constitutes the best treatment for this patient? What can be done to return this individual to as close to normal daily activities for him or her as possible? The answers to these challenging questions are sought every time a doctor sees a patient (7). In our current competitive and costly environment, finding these answers becomes daunting. We need help in responding appropriately and effectively (12, 13). This is our responsibility, and we must be accountable. So who is a true professional? Dr. Michael LaCombe describes a physician who represents the consummate example: I knew a doctor once who was honest, but gentle with his honesty, and was loving, but careful with his love, who was disciplined without being rigid, and right without the stain of arrogance, who was self-questioning without self-doubt, introspective and reflective and in the same moment, decisive, who was strong, hard, adamant, but all these things laced with tenderness and understanding, a doctor who worshipped his calling without worshipping himself, who was busy beyond belief, but who had time—time to smile, to chat, to touch the shoulder and take the hand, and who had time enough for Death as well as Life (14). Professionalism and being professional are core competencies now adopted by accredited residency and fellowship training programs. Their impact extends far beyond training, however. Dr. Kirk's fine address and the wisdom of role models such as William Osler, Lloyd Kitchens, and Michael LaCombe will help us follow the right path (15).