Starting With Curious

When I first get out of bed the word unkempt comes to mind, mainly because my hair is unruly. But after I clean up you wouldn’t call me “kempt,” or my hair “ruly.”  These adjectives don’t, at least in modern use, yield words with opposite meaning by dropping the prefix “un-.”  The same appears to be the case with “unprofessional.”  When applied to a doctor, for example, it most often signifies behavior that is unethical, unbecoming, and unacceptable for a member of the medical profession.  But when someone does live up to those standards, we rarely use the term “professional” to describe them.  Professional in the affirmative more often is used in distinction to “amateur.”  As with the concepts of kemptness and ruliness (neither of which exists according to my spell checker), the concept of professionalism is most often acknowledged in the breach.  It is easier to note its absence than its presence, which makes it difficult to reinforce a positive notion of professionalism, one of six core competencies recognized as essential to becoming a successful physician.

It’s also difficult because professionalism in medicine is a complex and slippery concept.  It includes commitment to ethical principles such as integrity, respect, and compassion; service to patients and society that supersedes self-interest; responsiveness to the needs to diverse patients; and accountability to the profession.  Some of these, like integrity and compassion, have changed little since the time of Hippocrates.  But others evolve with time.  For example, there was a time when doctors were expected put patients first to the degree that they could even endanger themselves.  While some degree of self-sacrifice remains laudatory, few at present would condone such dangerous self-experimental practices like Dr. William Harrington’s exchange transfusion between himself and a thrombocytopenic patient, or Walter Reed and colleagues intentionally infecting themselves with yellow fever in search of a cure. (Not to mention 100 hour work weeks and 36 hour days.)

Yet the degree to which we are expected to put our patient’s needs ahead of our own continues to be something on which there is disagreement.  In part, at least, this appears to reflect generational differences.  Now unlike some of my Baby Boomer compatriots, I do not subscribe to the notion that Millennials are inherently less altruistic.  If anything, my experience with my own children and their peers suggests exactly the opposite.  But I do believe there are differences in how they show it.  My generation was more willing to sacrifice time, while Gen Y foregoes money (though both only to an extent).  And as medicine has become corporatized and more transactional, those who have only experienced that will see it as the norm.  Physicians who have always practiced in an environment where their contribution to patients is measured in relative value units (RVUs) are naturally going to be influenced by RVU considerations.  Those of us who trained 30 years ago should be neither surprised by this, nor feel superior.  (Only a couple of my medical school classmates work for free, after all.)

There are also differences in how we view “accountability to the profession.” Consistent with their overall greater attachment to organizations and institutions, earlier generations were raised with the notion that medicine was a sort of fraternity, and that as members we had an inherent responsibility to it.  If declining membership in medical societies is any indicator, I doubt most Millennials feel that same sort of attachment to the institutions of medicine.  And this isn’t necessarily bad.  Medicine, like many professions, is largely self-regulatory.  The traditional unwillingness to speak ill of a colleague has, fortunately, given way to a greater openness to mutually recognizing, acknowledging, and learning from errors.

Since the more seasoned (i.e., older) of us are the ones in a position to both teach the precepts of professionalism and judge adherence to them, we need to be aware of how the concept evolves. Otherwise we may fall into the trap – described by George Thorogood in the song “Get A Haircut And Get A Real Job” – of believing our younger colleagues are inherently unkempt, unruly, and unprofessional.