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Quality Initiatives in Radiology

President’s Address from the Opening Session of RSNA 2006: Strengthening Professionalism¹

¹ From the American Board of Radiology, 5441 E Williams Blvd, Suite 200, Tucson, AZ 85711. Presented at the 92nd Scientific and Annual Meeting of the Radiological Society of North America, Chicago, November 26, 2006. Received and accepted August 21, 2007. The author has no financial relationships to disclose. Address correspondence to the author (e-mail: rhattery{at}theabr.org).

	Introduction

Top Introduction Why Explore Professionalism? What Do We Owe... What Is Professionalism? What Actions Can We... References

 
The focus of the Opening Session at the 2006 Annual Meeting and Scientific Assembly of the Radiological Society of North America (RSNA) is on "strengthening professionalism," a concept that we’ve been discussing a great deal in medicine and science. And we are not alone. From the most powerful corporations, to Congress, to your local school district, ethics and professionalism are on the front page of major newspapers. That’s the good news. The bad news is that many of our American institutions need to put ethics and professionalism on the front page!

As physicians, we are given the privilege, by the public, for credentialing, certifying, and maintaining ourselves as professionals. We have the freedom to determine our own destiny. We must forge a course that will ensure this privilege.

It is up to us to keep the house of radiology in order. If we abuse our freedom or fall short of our stewardship of trust in the eyes of the public, we risk losing this privilege. And I believe we are at risk. Bolstering our stewardship and protecting medicine’s privilege are the focus of this address. A renewed commitment to professionalism is a tool that can help us accomplish our goals.

I will share a few thoughts with you as a prelude to a wider discussion of professionalism. I hope to persuade you of three things. First, the very fact that we are talking about the urgency of professionalism is a sign: Changes are brewing in medicine that threaten our professional fabric. They are very real, and we need to pay attention. Second, each of us, as Francis Bacon put it, is a "debtor to his profession." The practice of medicine has provided many fruits, and we owe it something in return. As physicians and as leaders in our communities, we owe society something as well. In paying this societal debt, our profession and we as individuals become richer. Third, we cannot strengthen professionalism until we better understand it. For me, that means first acknowledging that professionalism is at the very core of what we physicians do. It also means recognizing that professionalism springs from the warmth and compassion of our hearts as much as it does from ethical, informed decision-making and intellect.

Professional attributes such as altruism, duty, honor, humility, and honesty are human virtues (Fig 1). Professionalism is guided by human virtues just as much as it is by the robust and carefully peer-reviewed research papers and scholarly articles that help shape our daily decisions. And professionalism grows from the shared sensibility of groups, with all of their attendant imperfections, not solely from individual action and adherence to one’s own personal standards. In short, professionalism is multifaceted, just as we humans are.

View larger version (30K): [in this window] [in a new window] [Download PPT slide]   Figure 1.  Attributes of professionalism.

	Why Explore Professionalism?

Top Introduction Why Explore Professionalism? What Do We Owe... What Is Professionalism? What Actions Can We... References

We are surrounded by disappearing safety nets, uncertain infrastructure, eroding trust, high cynicism, burnout, and, sadly, lowered prestige for those who find themselves in the middle of it all: health care professionals. There is pressure on all sides. Increasingly, we physicians find ourselves on the defensive. The higher calling of medicine is still there, but we cannot let it sound like an echo from a distant canyon. And that is the danger in extreme.

As pressures increase and physicians feel squeezed out, marginalized, and underappreciated, it becomes easier and easier to move our attention to professionalism to the back burner. However, if ever there was a time to look deep within ourselves, to renew our commitment to doing what’s right for patients, to fighting for better access to care, to fixing the broken wheels of our health care system, this is that time.

I am reminded of a study published earlier this year by Forbes that evaluated the professions and their public standing. You might be surprised to know that firefighters topped the list. Why? I believe it’s partly because on 9/11, millions of Americans saw the heart and soul of firefighters in a way they may not have been seen before. It was the ultimate demonstration of selfless dedication: that is, professionalism. Service and commitment to a wider community are two hallmarks of the firefighter’s credo, just as service and commitment to the welfare of our patients, and to the public, are at the very heart of who we are and what we physicians do.

You can call it our moment of truth: The time when we must decide if a return to our individual ethos and responsibility as physicians can strengthen professionalism and thereby strengthen medicine. I don’t think there is any answer but yes, a resounding yes.

	What Do We Owe the Public and Our Profession?

Top Introduction Why Explore Professionalism? What Do We Owe... What Is Professionalism? What Actions Can We... References

 
The second of our three themes for exploration focuses on the debt we owe our profession—and the public. The latter emphasis is a key factor, because I believe that the real challenge of renewed professionalism isn’t only becoming better professionals ourselves, but also influencing those around us to do the same.

As some of the most well-educated, highly respected, and well-compensated individuals within our communities, we are very privileged. With this privilege comes a responsibility to give back: our time, energy, involvement, commitment, and financial support.

As long as we remember and act on our commitment to serve the public, rather than ourselves, first, we will be judged as professionals. When we are perceived as serving ourselves before the public, we will be seen as a service commodity: to be bought, sold, and traded.

Our commitment must trump schedules, economics, legal concerns, insurance policies, HMO rules, and regulations! Our service to a humanistic ideal above all else is what makes medicine unique among the professions. It is why Studs Terkel excluded physicians from his book, Working: Because, he said, "Physicians work not for daily bread, but for daily meaning and astonishment" (2).

The humanistic ideal does not stand on its own. It relies on the strength of all of us, who renew the ideal, day in and day out, and reinforce each other in the process. That’s the lifelong debt of the physician, and, more important, of the physician community. We share this debt together.

	What Is Professionalism?

Top Introduction Why Explore Professionalism? What Do We Owe... What Is Professionalism? What Actions Can We... References

 
If we can accept that we physicians are debtors, forever bound to serve, then we can move on to the third idea: We pay our debt by strengthening professionalism. But that means we must better understand what professionalism is.

There is no single definition of "professionalism." But here are some ideas that will perhaps encourage more discussion. Professionalism has no magic formula. We know professionalism when we see it, and I believe we feel it when we have achieved it. And it can only be sought out and absorbed, not coerced or forced upon anyone.

After more than 40 years as a physician, I’ve come to the conclusion that professionalism is at the core of the art, as well as the science, of medicine. It is the exercise of character and scholarship—a two-sided coin.

Let’s start with side one: scholarship. If we truly want to renew our professionalism, the first step for all of us should be getting reacquainted with our ethical codes. Medicine is grounded in the Hippocratic Oath (Fig 2) (3). The Oath lays out the basic principles that define our moral identity as physicians. It is not a glib and empty promise to oneself but an enduring framework for each day. The Oath is joined by the ethical code of the American Medical Association (4), which also is as relevant and useful today as when pen first touched paper almost 160 years ago.

View larger version (40K): [in this window] [in a new window] [Download PPT slide]   Figure 2.  Concluding statement from the Hippocratic Oath, with image of Hippocrates (460–370 BC) (3).

As you know, there is a nationwide emphasis on the six competencies in resident and fellow education, lifelong learning, and maintenance of board certification. Professionalism is one of the six, and the Charter provides an approach to this competency. The Charter suggests ten commitments that each of us can make, ranging from honesty with patients to managing conflicts of interest (Fig 3). These commitments provide a great cornerstone for professional conduct.

View larger version (44K): [in this window] [in a new window] [Download PPT slide]   Figure 3.  Ten commitments of professionalism.

That’s the scholarly side of professionalism. The art of professionalism is the flip side of our ethical codes—with all their careful wording and rational thought—and it comes from the heart. It is essentially the development of character. We learn the art from role models, from the people around us. Moreover, we have an obligation to pass it on to the generations who follow.

Some of the deepest, most abiding principles of professionalism are rooted in our basic humanity, our day-to-day behavior as social beings, responsible and accountable to each other. I have consulted with 22 colleagues, who offered their input about recognizing professionalism—"knowing it when they see it" (Fig 4). I was struck by how often certain traits came up in their descriptions, such as (a) recognizing the sacredness of the patient-physician relationship; (b) being trustworthy; (c) understanding the seriousness and responsibility of the physician’s task; (d) commitment to protecting patients; (e) compassion; (f) listening well; (g) treating colleagues with respect and understanding; (h) recognizing that no job is unimportant; and (i) striving to be humble, not self-important or ego-driven. Notice anything in these descriptions? They are grounded in basic human respect and a set of values we were hopefully already well on our way to learning when we were in kindergarten. Indeed, one might boil much of our professional standards down to a single fundamental: Professionalism means never, ever doing anything you would not do in front of your mother!

View larger version (54K): [in this window] [in a new window] [Download PPT slide]   Figure 4.  Colleagues’ descriptions of a professional.

	What Actions Can We Take?

Top Introduction Why Explore Professionalism? What Do We Owe... What Is Professionalism? What Actions Can We... References

 
It seems to me that one of the great problems with professionalism is that too often it seems to dwell in the margins of our day-to-day lives: to be assumed, rather than understood, practiced, and measured. What can we do to keep it front and center in our lives? Let me leave you with five steps that each of us can take (Fig 5).

View larger version (59K): [in this window] [in a new window] [Download PPT slide]   Figure 5.  Action steps for incorporating professionalism in our daily lives.

Second, all of us should focus greater attention on teaching and mentoring both young and older individuals. We owe something to those who educated us. Contribute time and resources to your medical school and residency program. Focus as much as you can on inculcating the highest professional standards. Students, residents, colleagues, and patients will never forget how we make them feel. Exhibit exemplary behavior with the highest professional standards.

Third, we recognize that we must encourage professional behavior, but do we have the courage to root out unprofessional behavior? Professionalism will thrive in a socially connected environment, in which we influence one another. But just how influential are we? Not enough, it seems, when problem behaviors are present, and colleagues—including group leaders—rationalize, minimize, or compartmentalize them. In my years as a physician, department chair, and CEO, I always knew we had a problem when I heard the phrase "...yes, but he’s a good doctor." We must have the fortitude to identify unprofessional conduct and act. It’s that simple.

Fourth, explore professionalism from the perspective of you as a radiologist. I’m convinced that many patients are losing faith in the medical profession, not their individual physicians. That means we all should be thinking of what each of us can do to bolster the public’s confidence in radiology and medicine in general.

Fifth and finally, let’s take this conversation about professionalism from this annual meeting to the PACS workstation. That’s where we make connections as professionals. That’s where the mentoring, teaching, and learning moments occur. The more professionalism becomes a group responsibility, not just an individual one, the more successful we will be.

In this presentation, I have scratched only the surface of professionalism. The next steps are up to each of us. By acknowledging our professional debt and acting upon it, each of us can help strengthen medicine’s heritage of high ideals and shape the destiny of our profession.

	Acknowledgments

 
The author thanks Roberta E. Arnold and Paul Larson, who were both incredibly helpful in the preparation of the address.

	References

Top Introduction Why Explore Professionalism? What Do We Owe... What Is Professionalism? What Actions Can We... References

 

1. Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academies Press, 2000.
2. Terkel S. Working: people talk about what they do all day and how they feel about what they do. New York, NY: New Press, 1974.
3. The Hippocratic Oath. Modern version by Louis Lasagna, 1964.
4. Council on Ethical and Judicial Affairs, American Medical Association. Code of medical ethics: current opinions with annotations, 2002–2003. Chicago, Ill: American Medical Association, 2002.
5. The Medical Professionalism Project, the 2005 RSNA Professionalism Committee. Medical professionalism in the new millennium: a physicians’ charter. Radiology 2006; 238:383–386.[Free Full Text]

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This Article Figures Only Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hattery, R. R. Search for Related Content PubMed PubMed Citation Articles by Hattery, R. R. Related Collections Professionalism Quality Assurance/Quality Improvement