Fulfilling a Social Obligation

There was a time, not that long ago, in fact, when some leaders of the medical profession regarded health care not as a right, but as a privilege for those who had the financial, geographic, and sociologic means to access it. Thankfully, that time has past. No one disputes any longer, at least not openly, that a fundamental obligation of the medical profession is to address the health care needs of everyone, including those not covered by insurance or other payers.

Unhappily, the contemporary realities of medical practice pose significant impediments to fulfilling this obligation. Financial and time pressures, and not infrequently, peer pressures all serve as counterweights to the best intentions of doctors to live up to their profession's lofty ideals. That is precisely why it is so important for medical educators, particularly graduate medical education faculty, to repeatedly reinforce and explicitly model the behaviors that exemplify medicine's expectations of its acolytes. That is also why the Accreditation Council for Graduate Medical Education has been widely and appropriately commended for its recognition of this key role of medical educators by including professionalism among the 6 core competencies residents must demonstrate to justify program accreditation.

Exhortations and role modeling of expected behaviors are critically important for the professional development of future physicians, and I would be the last to suggest otherwise. But I would also suggest that behaviors emblematic of professionalism, no matter how well students and residents may display them while in training, are susceptible to being extinguished by the hard realities of medical practice, unless they are tethered to something strong enough to withstand the dispiriting pressures so often encountered by today's doctors.

As critically important as it is, professionalism is, after all, a way of acting. It comprises a set of observable behaviors by which physicians fulfill their responsibilities as professionals, ie, to meet the expectations of patients and the public.1,2 In other words, professional behaviors are outward manifestations of an individual's inclination to comply with external standards, and that inclination may or may not be sufficiently powerful to resist the many forces at play that would undermine those standards.

It follows from this reasoning that doctors with a solid foundation in humanism, those who have a truly deep-seated passion to help other people, who have an unflinching instinct to be compassionate, empathetic, and caring, are best positioned to remain steadfast in fulfilling their professional responsibilities despite ever-present temptations to do otherwise.3 Professionalism and humanism are not separate attributes of a good doctor but, rather, are intimately linked. Without a solid foundation of humanism to animate it, professionalism is overly dependent on good intentions, and it has little chance to prevail under the intense pressures rife in contemporary medical practice.

It is from this vantage point that I found the article by Wieland et al4 in this issue of JGME somewhat comforting. Judging by the survey responses of a select group of residents, the authors conclude that US residents have generally favorable attitudes, perhaps even a passion, toward serving underserved patients and, more important, that those attitudes are strongly correlated with volunteerism. As the authors note, their study suffered some from a rather low response rate to the survey (52%) and from the possibility that those who did respond were more representative of residents with an interest in serving disadvantaged patients. Moreover, residents in internal medicine were disproportionately represented among respondents, which may also have skewed the results toward a more comforting conclusion.

So, although one might wish the data from that study were more robust, at least the findings support the notion that the next generation of physicians is not only aware intellectually of the medical profession's obligation to address the health care needs of the underserved but is also motivated by a set of attitudes that may predispose them, once they are in practice, to volunteer their services to help meet that need. Indeed, that's what 84% of resident respondents said they were planning to do.

Let's hope that the results of this study are in fact indicative of a resurgence of humanistic care among young physicians. Given the increasing pressures they are likely to experience during an era of transformation in our health care system, physicians will need all the passion humanism can muster to maintain their commitment to professionalism.