Professionalism and Cancer Care

It is particularly appropriate that this issue published in tribute to the late Martin Abeloff include an article on professionalism in oncology. This is partly because there was no better example of professional behavior than Marty. Also, many might not realize that he published his thoughts on this topic 14 years ago.[1]

Although oncology has advanced tremendously in the past 14 years, the principles that Marty elucidated continue to apply. He quoted William Osler, who described medicine as “an art not a trade; a calling not a business; a calling in which your heart will be exercised equally with your head.”[2] For the definition of professionalism he looked to Abraham Flexner, who said that professions were those occupations whose work is primarily intellectual, personal, and complex; that the raw material of professional work comes from science and learning; that professional work is practical and must be applied to a clearly defined task; that a professional must possess a technique that may be taught to novices; that within a profession there must be agreement on the essential knowledge and skills of the practitioner; that a profession must exist as a brotherhood with activities and responsibilities that are definite, rich, and absorbing; and, finally, that a profession must exist for defined goals rather than to serve the self-interest of its members.[3]

‘Charter on Professionalism’

Over the ensuing years, the essentials of professionalism in medicine have continued to be debated. Our hope to keep our profession self-regulating and not directed by the government depends in significant part on our answer to what constitutes professional behavior and on our ability to enforce those principles throughout our profession. In 2002, the American Board of Internal Medicine took part in developing a “Charter on Professionalism” to help us all accomplish these goals.[4,5] The American Board of Internal Medicine is moving to incorporate these principles of professionalism into the training and evaluation of internists and to make them essential characteristics of our profession.

The Charter identified the following defining characteristics of medical professionalism:

• competence
• honesty with patients
• patient confidentiality
• appropriate relations with patients
• improving quality of care
• improving access to care
• just distribution of finite resources
• scientific knowledge
• maintaining trust by managing conflicts of interest
• fulfilling professional responsibilities

While it would be difficult to argue with any of these principles, it is interesting to reflect on how they fit into the modern practice of oncology.

Commitment of Oncologists

Several of the principles of medical professionalism from the Physician Charter have been tightly integrated into the practices of most oncologists. As a group, we value professional competence and scientific knowledge highly, as can be illustrated by participation in our societies’ scientific meetings, continuing medical education, and clinical trials. We have embraced the concept of guidelines for quality treatment, as illustrated by the widespread acceptance of the National Comprehensive Cancer Network (NCCN) Guidelines. We have been committed to the principle of improving the quality of care, quickly adopting and applying the results of clinical trials in a way that has improved outcomes for patients with most types of cancer treated in our country. Similarly, one would certainly hope that honesty with patients, patient confidentiality, and appropriate relations with patients are principles to which the overwhelming majority of those in our profession would ascribe.

Critics of the commitment of oncologists to the principles of medical professionalism from the Physician Charter would probably address other points. For example, while I believe that oncologists throughout our country regularly treat patients with minimal or no resources, we have not always been leaders in promoting universal access to health care.

Perhaps a more serious criticism of our profession would come from our application of the principle of “maintaining trust by managing conflicts of interest.” The appropriate relationship between the pharmaceutical industry and the medical profession has been debated in all areas of medicine, with oncology as no exception. The level of presence of pharmaceutical companies at our national meetings and the dependence of our societies on funds from the pharmaceutical industry for programs has sometimes been a source of criticism from both within and outside of our profession. Perhaps more disturbing to some would be the trend in oncology practice where regimens for the treatment of patients with a particular diagnosis might be chosen based on profit margin as well as on efficacy.

Maintaining Trust

I very strongly believe that the overwhelming majority of oncologists in our country put their patients’ interests first and are committed to professionalism in the practice of our specialty. However, it is vitally important that we make this commitment clear through the actions of our national and state societies and in our day-to-day interactions with individual patients. Maintaining the respect and trust of our patients and the general public will determine our ability to influence rational decisions about the practice of oncology at all levels. Ours is a wonderful profession that we can protect by striving for the professional behavior that Marty wrote about years ago.

Disclosures:

Financial Disclosure: The author has no significant financial interest relevant to the subject matter under consideration in this article.

References:

References

1. Abeloff MD, Reynolds PP: Professionalism and cancer care. Bull Am Coll Surg 79(5):12-17, 1994.

2. Osler W: The masterword in medicine, in Acquanimitas: With Other Addresses to Medical Students, Nurses, and Practitioners of Medicine, p 368. Philadelphia, Blakeston’s Son & Co, 1932.

3. Foa RP: Are physicians professionals? Pharos Alpha Omega Alpha Honor Med Soc 49(3):21-23, 1986.

4. Medical professionalism in the new millennium: A physicians’ charter. Lancet 359:520-522, 2002.

5. Medical professionalism in the new millennium: A physician charter. Ann Intern Med 136:243-246, 2002.