Professional Evolution: Why Today’s Physicians Must Respond to Public Crises
by Danish Zaidi
In a recent Op-Ed for the Wall Street Journal, Stanley Goldfarb, the former associate dean of curriculum at the University of Pennsylvania’s Perelman School of Medicine, wrote: “At ‘woke’ medical schools, curricula are increasingly focused on social justice rather than treating illness.”1 He goes on to lament that this emphasis on social justice and impacting policy is coming at the cost of “rigorous training in medical science.” The profession, Dean Goldfarb decries, is “under attack” from progressives who are seeking to “politicize” medical education. His perspective is shared by those who fear that social justice—while a worthy goal—is not a part of medical professionalism; that macroscale moral quandaries are not what physicians were made to address.
Dean Goldfarb’s position against population health is untenable. But he is part of an increasingly vocal group of physicians who argue that medicine is losing its traditional purpose as an empirical, scientific practice founded upon an intimate patient-physician relationship.2-3
To others, medicine is finally recognizing the impact of social and economic factors in determining a patient’s—and population’s—wellbeing. Empirical data shows that social factors can indeed become determinants of health, such as the zip code people were born in or the education level of household members.4 Lack of health insurance has been linked to adverse outcomes in hospitals.5 These factors are beyond the scope of the lab or bedside—they are macroscale in nature and have broad impact across the medical practice.
At the core of this ongoing debate are certain questions: What is the role of a physician? More pointedly: does “advocacy” have a purpose in medical practice? These questions underscore a tension within today’s medical community that revolves around a perceived shift in medical professionalism. This tension has long-term implications for trainees, as it has the potential to reimagine the work doctors intend to do and reshape medical curricula at every level.
Professions evolve both in understanding and in practice. The concept of professionalism in medicine has gone through countless changes from antiquity to today. In retrospect, many of these changes are generally considered to have benefited both patients and physicians. Today’s medical community would benefit from not only appreciating this history, but adding to it. Looking ahead, a more robust understanding of social, political, and economic factors could continue to improve medical practice in both an empirical and normative way; but moral and ethical leadership is imperative toward realizing such change.
To understand the evolution of professionalism in general—and medical professionalism, in particular—we must first define the term. In doing so, one can borrow from a popular framework in religious theory that explores the “Three B’s” of religion: behavior, belief, and belonging.6 Using this framework, we can craft a useful working definition of “profession.”
Fundamentally, a profession is an occupation that is based on mastery of a “complex body of knowledge and skills.”7 However, this occupation is not simply unidimensional and technical in nature. Consider the classic saying: medicine is “both a science and an art.”8 There is a particular set of behaviors that drive the application of science in medicine; the manner in which data is communicated between physicians and delivered to patients; the reasoning process behind differential diagnoses and subsequent workups; and the way that harms and benefits are weighed before initiating treatment.
These behaviors are rooted in a particular set of beliefsthat further define the profession. Beliefs can take the form of value statements like “the needs of the patient come first”9 or driving prima facie principles like autonomy, beneficence, nonmaleficence, and justice.10 Ultimately, these standardized behaviors rooted in a particular belief system create a medical community to which physicians belong, illustrated by the creation of guilds and associations dedicated to the betterment of its membership.
With this working definition in mind, we can begin to appreciate how the medical profession has changed over time. These changes continue to fit within the aforementioned framework of the Three B’s.
A wide variety of factors can instigate change in any profession. Technology is arguably one of the greatest drivers in changing behaviors across industries. The “e-learning” revolution, for instance, has allowed people to access educational services, and has also shaped the way teachers share knowledge, whether through online modules or videos.11 Beliefs about career agency changed the way law is practiced: what was once a lifelong commitment to a single firm has shifted in favor of lateral moves to accommodate family life and personal wellbeing.12 Changing perceptions of women’s role in the workplace reshaped demographics across industries.13-14
Medicine itself has dramatically evolved. Healers in ancient Mesopotamia, lacking a distinction between science and magic, prescribed medicinal plants alongside spells.15 Celebrated doctors of the past—Galen, Maimonides— shared an interest in theology, recognizing the spiritual (and sometimes untreatable) aspects of illness. Post-Enlightenment paved the way for a budding biophysical model of medicine, rooted in empiricism and evidence. Sir William Osler (who once considered a career in ministry16) reshaped medical training from an apprenticeship to a residency-based model. Years later, electronic health records (EHR) ushered in the age of Big Data, reshaping the way medical information is disseminated and studied. All of these shifts—and countless others—slowly but surely changed behaviors (seeing more patients for 15 minutes instead of seeing fewer patients through house-calls), beliefs (separating magical thinking from empirical science), and belonging (the age of subspecialization versus general practice).
While change is never perfectly linear or without flaw, most would agree that these shifts in medicine have vastly improved the profession. Medicine is more efficient, more accessible, and safer today than it has ever been in history—we would not want to go back to the time of the shaman. Today’s rapid pace of technological advancement can sometimes elicit an understandable impulse to decelerate; nevertheless, the evolution of the medical profession continues to improve life in measurable ways for both patient and physician.
Today, most would still agree with the traditional, post-Osler view that places the moral center of medicine at the patient’s bedside. The late Edmund Pellegrino, famed physician and bioethicist, wrote that the patient-physician relationship was a “covenant of trust, a special kind of promise to serve those who require her (the physician's) expertise.”17 This notion of medical professionalism centers, as a core responsibility, the physician’s obligation to serve the immediate patient. Such an understanding also emphasizes the tension between said duty and potential conflicts of interest (and implies that these “dual loyalties” may be unfeasible to balance).
Unfortunately, the lines of said responsibility have never been properly demarcated. If physicians regularly encounter patients who cannot afford the medicines they need, for example, do they then have a professional and ethical obligation to advocate for affordable drug pricing? And, if one accepts that a physician’s role is to serve the immediate patient above all else, what happens when systemic problems—such as poverty, racism, or limited health literacy—prevent the physician from providing the patient with proper care?
It is often obvious how “macroscale” problems like drug pricing harm patients, but these sorts of issues can also impact physicians. Recent studies have found that physician burnout is related to factors that are generally unrelated to direct patient care.18-20 The desktop duties of EHR, obligations to “upcode” for insurance, and ever-diminishing face-to-face time with patients are only a handful of suboptimal “system-based” conditions causing cognitive decline and mental fatigue among physicians nationwide.21-22 Physicians could arguably benefit from addressing these issues publicly—and perhaps owe it to themselves to do so. Regardless, it is clear that social, political, and economic factors affect not only patients, but also physicians.
The natural response would be to mitigate the harm from these systemic issues in order to—as professional evolution has done in the past—make medicine more efficient, more accessible, and safer. One would be hard pressed to find solutions to macroscale issues at the bench or bedside. No amount of work in the lab itself will reduce the pricing of orphan drugs bought out by predatory capitalists. And while advancements in post-operative management may improve the treatment of a gunshot wound, they can do little to reduce the epidemic of gun violence. The most immediate and powerful way to mitigate the harm of these system-based problems is therefore through system-based solutions: through advocacy and policy.
Experts in public health have underscored the importance of policy in impacting macroscale problems for decades.23 Looking ahead, medical schools must clarify what medical professionalism entails—including if and how the responsibilities of doctors extend from the bedside to the “outside.” If educators feel that macroscale issues impacting patient and physician well-being are within the purview of medical professionalism—and if we agree that policy and legislation can positively impact such issues— then medical schools must consider incorporating advocacy when innovating their curricula.24
While not all physicians may be comfortable advocating, few of them can deny the immense impact of organized medicine. History has shown how groups of physicians have commanded influence—and not always for the best. Physicians in Nazi Germany appealed to population health when reasoning that Jewish people were “infecting the Volk,” veiling genocide with scientific language.25 Involuntary sterilization in the United States was done in the name of public health, where arguments were made for saving money and resources, and for reducing the perpetuity of disease.26 These atrocities teach us that medical professionals, working as a collective, have immense advocating power to shape public perception and policy.
The medical community cannot disown this power, and must therefore have safeguards in place to ensure that it is used ethically. The commitment toward benefitting some should not inadvertently harm or violate the rights of others, namely minorities or the disenfranchised. To that end, another aspect of social justice comes into play: ensuring that the physician and medical workforce is representative of the diverse population that it serves. In doing so, diversity can “keep in check” the advocating power of the medical profession as a collective.
Ultimately, within the framework of the Three B’s, a focus on advocacy (1) changes behaviors by promoting civic engagement; (2) affects beliefs by reinforcing an appreciation for social, political, and economic determinants of health; and (3) expands a sense of belonging by widening the community of medicine to be more inclusive and representative of the population it serves. Instead of being afraid of how medicine is changing, we should be excited about how this next step in the profession’s evolution will benefit the providers and beneficiaries of medical care. Physicians should embrace advocacy and its power to improve the wellbeing of both patients and doctors. The evolution toward social justice is one of many shifts that has occurred in medicine over centuries; similar to prior shifts, this change will reshape professionalism in medicine for the better.
Danish Zaidi was a 2019 Medical Fellow. He is a medical student at Wake Forest University, pursuing a career in internal medicine.
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