Professional, did you say?

Karl Erik Müller, Ingrid Neteland, Carl Tollef Solberg About the authors
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What does it mean to be an accomplished professional? The answer is not self-evident. What we define as our profession and what qualities we think an accomplished doctor should have reveal a great deal about us.

In issue 19/2016 of this journal, Hertzberg and colleagues describe how doctors themselves define a good doctor as a colleague with strong professional dedication (1). Our profession is defined both internally and to the outside world on the basis of what we ourselves claim the profession and professional accomplishment to be. The prevailing perception of what makes someone professionally accomplished, particularly among colleagues, informs us about at least three things: what medicine is, what it ought to be and what we as doctors demand of ourselves. In this way, professionalism reveals something about us.

What qualities does an accomplished doctor have? Some would argue that the lowest common denominator is that she has an academic knowledge of diagnoses, tests, and treatments. Knowledge and skills beyond this are a plus, but not something that we should demand of all. Thus, there is a linear relationship between how much you know and can do and how accomplished you are.

We would argue that this is far from sufficient. In the medical profession, we get to participate in very private spheres of people’s lives. Doctors have a special responsibility to take care of people in situations where they are vulnerable. Such consultations can be daunting, but also rewarding. Our ability to listen, show understanding, empathise and provide reassurance is key and must be practised (2). These qualities are challenging to acquire and cannot be measured as easily as technical competence. They are best learned in practice, on visits, in the outpatient clinic or the GP surgery – always under expert supervision.

Charlotte Haug, former editor-in-chief of this journal, writes this about professionalism: «It is like the concept of quality: Hard to define but easy to spot when it is lacking» (3). We wish we agreed, but unprofessionalism is not always easy to spot. If the doctor excels at some of her tasks, this may conceal failings in other areas. Suboptimal practices in the clinic may persist with or without the acceptance of the medical community.

Unprofessionalism that is accepted or ignored by others is particularly challenging to detect. We are social animals. Thus, unprofessionalism can be catching. What we define as professional accomplishment has a bearing on how we perform our duties and ultimately what kind of doctor we strive to be. Therefore, it is important to have a carefully considered understanding of professionalism. For only then can we detect unprofessionalism.

Good doctors?

As doctors, we like to do well, and the «logical» approach to good performance is to hold in high esteem things that are easily measured. That is probably why we commend the doctor who can reel off dosages and treatments. Do not misinterpret us – it is beyond doubt that the accomplished doctor must have medical knowledge and technical skills at her fingertips. However, she needs more than that to be an accomplished professional – more specifically, qualities such as empathy, pragmatism, the ability to reassure, decisiveness, dedication and wisdom.

Our impression is that such qualities are often not taken into account when judging professional accomplishment in medical training and medical practice. It is a pity if professional conduct and the humanistic traits of medicine are overlooked when judging overall professionalism because they take longer to detect, are difficult to measure and are poorly suited for ranking.

We have outlined two competing understandings of professional accomplishment. A narrow understanding, which implies extensive academic learning and technical competence, and a broad understanding, which also includes those qualities that allow us to understand and treat patients better. We envision a number of objections to this broad understanding of professionalism and will address some of them here.

First: As doctors, we are required to prioritise, and one may view this in an overly simplistic way as: «When it comes down to it, the role of the doctor is to make the correct diagnosis and give the patient the correct treatment.» But is this enough? It is not always clear what the right diagnosis or treatment might be. The wishes of the patient and how he or she experiences the consultation with the doctor are important too, also for the treatment. It often requires a great deal of ingenuity to work out what is «in the patient’s best interests.» Moreover, if we allow the patient to speak freely, and listen actively, in most cases we will probably arrive at the correct diagnosis more quickly (4).

Second: «We should choose the cold and knowledgeable doctor over the warm and ignorant.» Who would not prefer Dr House over Dr Dolittle? In the real world, this is hardly a necessary choice since there is probably not a negative correlation between intelligence and empathy. The professionally accomplished doctor must exercise and practise all aspects of her work.

Third: Some may argue that professional accomplishment is reserved for the most «experienced» doctors. Is there a causal relationship between the number of hours at work and professional achievement? The results of Hertzberg et al. show that doctors themselves believe that a good doctor is a dedicated physician, and that professional dedication can be measured by how much time the doctor spends at work and how efficient she is (5). If this is true, the oldest will triumph because they have the most experience. But experience without reflection does not necessarily lead to improvement. It can just as easily consolidate bad habits. Experience is not always the best teacher.

We can define our profession in many ways, but reducing it to pure physiology, algorithm cramming, or to diagnostic criteria or procedures is unhelpful. It deprives us of the opportunity to perform our jobs well. It also deprives the patient of accomplished doctors. If we exclusively foster qualities that can to a large extent be automated, we threaten the future role of the medical doctor (6, 7).

Medicine is at the intersection of several disciplines (8). It encompasses elements of natural sciences, social sciences and the humanities – and not least extensive experience and wisdom. To be an accomplished doctor is, therefore, difficult, but not impossible. A step in the right direction is to discuss what we think medical professionalism ought to be. The accomplished doctor has many qualities that should be practised from the first day of study and throughout the entire career, and which must not be overlooked or downgraded because they cannot be measured as well or as simply as other skills.

We thank doctors Esperanza Diaz, Anne Berit Guttormsen, Yngvild Skåtun Hannestad and Jørgen Østensjø for constructive comments on earlier versions of this text.

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