Why would a slight, 79-year-old physician-scientist stand up to a volatile, combative President Trump on national television? Here’s a related question: Why do millions of health care workers — doctors, nurses, emergency responders, aides, transport specialists, and more — risk their lives every day to care for those with Covid-19, a potentially deadly infection?
Personal courage is part of the explanation. But there’s more to it than that. What we are seeing is the professionalism of people like Anthony Fauci and thousands of health care workers at work. The essence of their professionalism is that they put the interests of patients and the public before their own.
We take it for granted at our peril.
Professionalism is ingrained during medical training, role-modeled by the senior clinicians who teach, and reinforced by powerful aphorisms inherited from legendary practitioners going back to Hippocrates. One was the eminent Boston physician Francis W. Peabody who, in 1927, famously wrote: “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”
Professionalism also instills a commitment to peers who join together on the frontlines of medicine. In this way, health professionals resemble soldiers who sacrifice for their comrades in the trenches. And like the military, they accept collective responsibility for their behavior.
A core tenet of professionalism is a commitment to professional self-governance. A well-functioning profession supervises itself, setting standards of practice that are based on science and evidence and ethical conduct. That is why society entrusts health care professionals with designing their own licensing exams, training curricula, and disciplinary proceedings. Responsibility to and for peers is another force driving clinicians into the fray.
A third essential dimension of professionalism is commitment to maintaining competence in a specialized area of expertise, in this case, the science that underlies clinical practice. It is not by chance that professional societies publish their own peer-reviewed scientific journals, or that publication in those journals conveys prestige and standing among colleagues. It should come as no surprise, then, that professionals bridle when lay leaders broadcast assertions that fly in the face of existing evidence.
We should not be naïve about professionalism or professionals. Clinicians are human. Some allow profit to distort their judgement or fail to maintain their skills. Some don’t hold themselves or peers accountable for errors or unethical conduct. They fall prey to substance abuse and mental illness. Through long periods in our history, organized medicine fought the extension of insurance coverage, including Medicare and Medicaid, to their patients even though coverage would have huge benefits for their patients.
But we should also recognize that in times of crisis like this, professionalism reinforces the sense of duty, the courage, and even the heroism of millions of clinicians who feel its pull. We would certainly be worse off without it.
That is why it is important to be aware of significant forces that threaten professionalism both in the midst of this crisis and beyond it. One is the sense that the larger society is taking health care practitioners for granted by leaving them needlessly exposed to harm through lack of personal protective equipment. Why hold themselves to the high standards to which they aspire when the country seems to care so little for their personal welfare? The stakes for personal protective equipment go beyond preserving a physically healthy workforce. Protecting health care workers is a sign that society values and respects them for the professionalism they show every day.
Another potential threat to professionalism lies in the market philosophy that increasingly permeates the U.S. health care sector. Markets encourage participants to act in their economic self-interest on the assumption that the net result of self-interested behavior will be an efficient allocation of societal resources. The U.S. is the only country in the world — aside, ironically, from China — that relies largely on market forces to govern health and medicine.
Think about the message this sends to health care providers. At a minimum, the tension between the ethical injunctions of professionalism — put your patients’ interests first — and the economic injunctions of the market economy creates confusion and hesitation. In a purely market-driven health care economy, would doctors and nurses flock to health care facilities during a pandemic? Might they demand a huge financial inducement that generously compensated them for the risk?
Americans deeply admire health care workers, and that admiration has justifiably grown during this crisis. But the public should realize that the professionalism that undergirds the behaviors they so admire is potentially fragile and needs to be supported now and in the future.
The next stimulus bill, if there is one, needs to attend quickly and generously to the needs of health care workers. And as they promote market regimes, policymakers should encourage methods of payment and clinical organization that protect clinicians from the harshest imperatives of competitive market economies. For example, middle and large-size group practices can often compete in markets while rewarding their physicians for meeting their professional responsibilities, like continuing education and peer review. Above all, advocates of competitive markets should take into account their possible effects on the culture and practice of professionalism.
David Blumenthal, M.D., is the president of The Commonwealth Fund.