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Maintaining professionalism in a managed care environment
EDITORIAL J Oral Maxillofac Surg 59:971, 2001
Maintaining Professionalism in a Managed Care Environment agree that they are not. Rather, there is consensus that there is also a need for adequate guidance and mentoring. There is probably no better way to shape one’s attitudes and behavior than through the use of proper role models. However, although such mentoring may be a good start, the dental school situation, where students and faculty generally practice separately, does not provide a realistic view of what actually occurs in the managed care world. Thus, our residents are usually unprepared for what happens in the hospital environment, where they treat patients together with the faculty, and they suddenly gain a greater appreciation for the practical problems they will face in the future. At times like this, the manner in which we behave will have a significant influence on how they will ultimately react under similar circumstances. In fact, our role becomes even more important when we realize that a resident’s professional behavior is not only shaped by us, but also by their interaction with other faculty, other residents, the hospital staff, and even the hospital administration. As noted by Ludmerer,2 it is unfortunate that we have to train our residents “in today’s commercial atmosphere in which the good visit is a short visit, patients are ‘consumers,’ and institutional officials speak more often of the financial balance sheet than of the service and the relief of patients’ suffering.” It is also an atmosphere in which financial constraints have resulted in less time for us to teach and less time for residents to learn. These are certainly not circumstances conducive to fostering a professional attitude. To resolve these issues will take significant improvement in the managed care process, as well as in the internal culture of the academic medical center. These are not easy tasks. However, until then, we need to pursue our function as mentors and role models with renewed vigor and enthusiasm if we are to foster true professionalism in our specialty and its prodigy.
Professionalism not only infers the possession of expert knowledge, but it also implies subordination of one’s self-interests, adherence to high ethical and moral standards, response to societal needs, and demonstration of a clearly defined core of humanistic values. However, in recent times, the ability to maintain these characteristics has been severely threatened by the incursion of managed care. Whereas the fee-for-service system formerly allowed us to do what was necessary for patients, and provided the time in which to do it, this is no longer possible today. Managed care organizations now have not only restricted the ability to provide patients with the services that they need, but also they have often provided economic incentives to encourage doctors to limit certain forms of treatment. There have even been attempts to prevent practitioners from informing patients of alternative methods of therapy that might be of greater benefit to them. Such restrictions often place us in a position where our professional and ethical obligation to serve as the patient’s advocate for what we believe is the appropriate treatment puts us at risk of breaching our legal obligation to the third party carrier. These challenges to our proper behavior further emphasize the need to continuously stress professionalism, not only on the part of the members of our specialty, but also on the part of our trainees, because they are the practitioners of the future. Learning the tenets of proper professional behavior should actually begin where professional education and training begin, in the predoctoral program. However, this is not always done effectively. Although there may be formal instruction in some dental schools, this is generally limited, ranging from a “white coat” ceremony and taking a pledge of professionalism to a few lectures as part of 1 or more courses. The situation is certainly no better in undergraduate medical education. A recent study1 indicated that although the majority of medical schools recognize the need to address professionalism as a critical element of the education of their students, 10% have no specific curriculum, the course material often does not cover all of the essential attributes of professionalism, and only half the schools have formal methods of assessing the professional behavior of their students. Even if these deficiencies in predoctoral education were properly addressed, we are still faced with the question of whether formal courses are sufficient to instill the proper sense of professionalism in these students. Most would
DANIEL M. LASKIN
References 1. Swick HM, Szenas P, Donoff D, et al: Teaching professionalism in undergraduate medical education. JAMA 282:830, 1999 2. Ludmerer KM: Instilling professionalism in medical education. JAMA 282:881, 1999
© 2001 American Association of Oral and Maxillofacial Surgeons
doi:10.1053/joms.2001.26799
971
Maintaining Professionalism in a Managed Care Environment agree that they are not. Rather, there is consensus that there is also a need for adequate guidance and mentoring. There is probably no better way to shape one’s attitudes and behavior than through the use of proper role models. However, although such mentoring may be a good start, the dental school situation, where students and faculty generally practice separately, does not provide a realistic view of what actually occurs in the managed care world. Thus, our residents are usually unprepared for what happens in the hospital environment, where they treat patients together with the faculty, and they suddenly gain a greater appreciation for the practical problems they will face in the future. At times like this, the manner in which we behave will have a significant influence on how they will ultimately react under similar circumstances. In fact, our role becomes even more important when we realize that a resident’s professional behavior is not only shaped by us, but also by their interaction with other faculty, other residents, the hospital staff, and even the hospital administration. As noted by Ludmerer,2 it is unfortunate that we have to train our residents “in today’s commercial atmosphere in which the good visit is a short visit, patients are ‘consumers,’ and institutional officials speak more often of the financial balance sheet than of the service and the relief of patients’ suffering.” It is also an atmosphere in which financial constraints have resulted in less time for us to teach and less time for residents to learn. These are certainly not circumstances conducive to fostering a professional attitude. To resolve these issues will take significant improvement in the managed care process, as well as in the internal culture of the academic medical center. These are not easy tasks. However, until then, we need to pursue our function as mentors and role models with renewed vigor and enthusiasm if we are to foster true professionalism in our specialty and its prodigy.
Professionalism not only infers the possession of expert knowledge, but it also implies subordination of one’s self-interests, adherence to high ethical and moral standards, response to societal needs, and demonstration of a clearly defined core of humanistic values. However, in recent times, the ability to maintain these characteristics has been severely threatened by the incursion of managed care. Whereas the fee-for-service system formerly allowed us to do what was necessary for patients, and provided the time in which to do it, this is no longer possible today. Managed care organizations now have not only restricted the ability to provide patients with the services that they need, but also they have often provided economic incentives to encourage doctors to limit certain forms of treatment. There have even been attempts to prevent practitioners from informing patients of alternative methods of therapy that might be of greater benefit to them. Such restrictions often place us in a position where our professional and ethical obligation to serve as the patient’s advocate for what we believe is the appropriate treatment puts us at risk of breaching our legal obligation to the third party carrier. These challenges to our proper behavior further emphasize the need to continuously stress professionalism, not only on the part of the members of our specialty, but also on the part of our trainees, because they are the practitioners of the future. Learning the tenets of proper professional behavior should actually begin where professional education and training begin, in the predoctoral program. However, this is not always done effectively. Although there may be formal instruction in some dental schools, this is generally limited, ranging from a “white coat” ceremony and taking a pledge of professionalism to a few lectures as part of 1 or more courses. The situation is certainly no better in undergraduate medical education. A recent study1 indicated that although the majority of medical schools recognize the need to address professionalism as a critical element of the education of their students, 10% have no specific curriculum, the course material often does not cover all of the essential attributes of professionalism, and only half the schools have formal methods of assessing the professional behavior of their students. Even if these deficiencies in predoctoral education were properly addressed, we are still faced with the question of whether formal courses are sufficient to instill the proper sense of professionalism in these students. Most would
DANIEL M. LASKIN
References 1. Swick HM, Szenas P, Donoff D, et al: Teaching professionalism in undergraduate medical education. JAMA 282:830, 1999 2. Ludmerer KM: Instilling professionalism in medical education. JAMA 282:881, 1999
© 2001 American Association of Oral and Maxillofacial Surgeons
doi:10.1053/joms.2001.26799
971