Professionalism is a dirty word… and why are medicine docs called fleas?

7 06 2010

At the recent AAMC meeting on how to integrate quality into teaching hospitals, the question that kept popping up from speaker after speaker was how to address the fact that doctors in teaching hospitals don’t get along.  Unfortunately, all the specialty bashing that takes place prevents the adoption of a team based culture necessary to advance quality and safety.  As one speaker highlighted, how can we really start to address this topic when specialty services are busy blocking the consult or disparaging the internal medicine doctor by calling them a ‘flea.’  I hadn’t heard the term ‘flea’ in a while but many onlookers were nodding in agreement, possibly thinking about the last time they heard someone disparaging the ER for an incomplete workup or a specialist blocking the consult as ‘inappropriate.’  The discussion about quality and safety morphed into every medical educator’s favorite topic, ‘professionalism.’ 

Ironically, while medical educators love discussing professionalism, this word has become despised by medical students.  It has been the subject of the last 2 years of senior class shows at Pritzker.  Why?  Because in response to numerous calls by the AAMC and other groups including the public, Pritzker, like many other schools, have launched a professionalism initiative designed to promote professionalism.  As you can guess, any efforts to ‘teach professionalism’ to students seem preachy and insincere.  So, what’s a medical educator to do?  After years of contemplating this problem with colleagues and experts, we concluded that we first need to identify and reward faculty role models and ensure that our faculty and residents emulate the behaviors that we wish to see in our students.  Apparently, we aren’t alone.  The American Board of Internal Medicine Foundation has awarded 6 grants to variety of organizations to promote professionalism among physicians in practice.  We are fortunate to have received funding through this mechanism to actually address the topic at hand – specialty bashing in teaching hospitals– particularly between hospitalists, primary care physicians, and emergency medicine doctors.  Interestingly, this problem is more prevalent in teaching hospitals.  When our residents rotate at a nearby community hospital, they often comment on how nice the doctors are to each other, even thanking them for consultations!  Of course, unlike the attendings in teaching hospitals on fixed salary, physicians in the community hospital actually make more money for each consultation.  So, aligning financial incentives can actually promote professionalism.

I was at this meeting with one of our 2nd year medical students Marcus Dahlstrom who earned rave reviews for his presentation on student efforts in teaching quality and safety at Pritzker (while I may be biased, you can see his presentation for yourself.)  On the way home, we noted that although professionalism is a dirty word among our students, but that medical educators continue to perseverate on it even at a meeting about quality and safety.  We need a better word and a better way to address these issues.  Because most students are professional, it’s the actions of a few that are remembered by faculty and attributed to all students and their generation. 

On a side note, Marcus also asked me why medicine doctors are called ‘fleas’ since he had not heard that term…yet.   I did not know the answer but here are some potential origins I found – the most useful of sources being StudentDoctor.net

  • Internists can be spotted with a stethoscope around their neck, or a “flea” collar
  • Internists, like fleas, are the last things to leave a dying body
  • They travel in packs on rounds
  • Doctors were very devoted to their plague patients, similar to fleas that were responsible for spreading the deadly disease. 

While I don’t know the exact reason, its interesting that while 3 of the reasons are clearly derogatory, one explanation of ‘fleas’ actually highlights ‘professionalism.’ Ironically, maybe all we have to do to get doctors to stop using this term is to say that it’s part of that dirty p word ‘professionalism.’

–Vineet Arora, MD

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8 responses

10 06 2010
Daniel Wolfson

I am not certain professionalism is a dirty word – it certainly isn’t to patients. But it is a word that means different things to different people at different times in history.

In a study the ABIM Foundation is close to completing, we found delivery systems advancing 21st century professional values and behaviors don’t actually use the term professionalism. They use terms such as “professional values” and “desired behaviors.” No matter what you call it, it is ultimately actual behavior that matters.

The Physician Charter is one part of a larger social movement to redefine the changing roles and responsibilities of physicians in modern health care. It broadens their responsibilities beyond the patient-physician relationship to a team of caregivers, the health care organization and the larger community. Physicians’ responsibilities — as defined in the Physician Charter — include working in teams, improving quality of care and being stewards of resources. True health care reform will not happen unless we change how care is delivered and waste is removed from the system. It will happen a lot quicker and better when physicians are engaged in the process.

In Educating Physicians: A Call for Reform of Medical School and Residency, Molly Cooke et al. do an excellent job of describing a new pathways in educating physicians prepared to work 21st-century high-performing systems of care. The authors call for “engaging learners in initiatives focused on population health, quality improvement and patient safety.” Instead of talking about professionalism, they refer to professional formation and call for “collaborative learning environments committed to excellence and continuous improvement.”

Wars among specialists and belittling any member of a team need to be replaced by mutual respect and collaboration. If being in longitudinal relationships with chronically ill patients means being a “flea,” I want a “flea” taking care of my 89-year-old mother who recently broke her femur. Maybe those “fleas” can swarm — constantly learning, designing and improving their practices to take care of populations of patients; thereby thinking beyond one patient at a time and considering the effects of the overuse of services on the community. Maybe we need more “fleas.”

Daniel Wolfson
ABIM Foundation

16 07 2010
futuredocs

Thanks Dan for your thoughtful comments and sorry for my long delay in replying!

I think that the issue is that this generation of medical trainees has been hit over the head with the word professionalism since it is the big buzz word in med ed – and is reinforced by major medical groups and initiatives, like the Professionalism Charter.

I think the problem is that teaching about it is not easy and can actually backfire. One of the themes that has come out of our professionalism work is ‘hostility towards professionalim education’. We don’t have good answers, but maybe raising more questions for medical educators to think about how to operationalize this teaching….maybe the video approach can help?

Best,Vinny

22 06 2010
theatreone

I wanted to comment on one part of your post that resonated with my thoughts in particular.

“[W]e first need to identify and reward faculty role models and ensure that our faculty and residents emulate the behaviors that we wish to see in our students.”

I believe this quote implicitly addresses something that is by and large missing in the current generation of medical students: admiration for their preceptors. Rarely do I hear medical students quote pearls of wisdom given to them by preceptors or speak of a physician or surgeon’s skill the way they do of LeBron James or Sidney Crosby. It also seems as though the medical curriculum (at my institution, at least) neglects teaching the History of Medicine. Thus, I think students lack appreciation for humanistic medical achievements.

Your quote provides one concrete solution–reward those physicians whom we would like to become role models for students. I think that providing such incentives for positive behaviour will propagate them. However, there is one implicit problem which I hope that I have identified in sufficient detail above: we need to create an atmosphere where it is “cooler” among peers to hang a picture of Michael DeBakey in one’s locker, instead of Michael Jordan.

Thanks for the great post,

CD

16 07 2010
futuredocs

thanks – couldn’t agree more about history of medicine or recognizing peer role models –

please check out the University of Chicago History of Medicine Project website started by Dr. Mindy Schwartz to promote this teaching http://uchomp.bsd.uchicago.edu

To try to recognize positive role models, we created the peer role model awards at Pritkzer – http://pritzker.uchicago.edu/about/news/cohen.shtml given to preclinical students and to faculty but voted on by their peers.

31 08 2010
edward(MA)

I don`t agree with you that professonalism is a dirty word,because professonalism is meaning of acting in a businesslike manner in the workplace.And in the medical Assistant used this word to remain professional at all times while working.Let me tell you the Key Terminalogy used this words compassion,competence ,respect,responsibility,and professionalism. all these is very important

31 08 2010
futuredocs

Thanks for your comment. I just wanted to clarify that I wholeheartedly support the need to behave in a business like manner and the concept of professionalism. THe story above (and title) are to highlight that our students do not like hearing this word over and over again.

15 11 2010
Is Medical Education Oppressive? Expert Failure, Social Media & Other Lessons from AAMC 2010 « FutureDocs

[…] by the famous “P=MD” promulgated in medical schools today. The increasing emphasis on student unprofessionalism, with little attention on altering the environment or examining the role models – positive or […]

6 04 2014
antirepublicanstupidity

This is exactly why I hated Internal Medicine (and a sizable number of medical students do too) and thus went into a competitive specialty: ROAD specialties. Mainly it was the constant droning on by medical school faculty (usually administrative faculty – the ones who weren’t smart enough in their residency class to specialize, whose interests suddenly became “medical education”) about professionalism which mainly amounted to labeling anything as “unprofessional” just bc they didn’t like hearing it — i.e. real criticisms about the quality of teaching during the basic science years from students, etc.

The lecturing to the modern medical student about professionalism from doctors in the previous generation is quite hilarious if not hypocritical considering the general public knows now, quite well about how med students and residents are treated. It’s any wonder your students poke fun at it in their class shows. I’m quite surprised those students in that show weren’t accused of unprofessionalism for making fun of it. When you perseverate on something, it loses its meaning.

In doing a PubMed search it looks like Maxine Papadakis from UCSF started all this mess (she must have had nothing better to do as she definitely doesn’t actively practice medicine). Somehow tying license actions to comments in dean’s letters, with the methodology quite tenuous at best. Residents and disruptive attendings alike can thank her for being able to use an accusation of “unprofessionalism” as a weapon against medical students they don’t like.

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