 The lady is the tower of the Matthew Busbound Professor of Pediatrics, Medicine, Surgery, and in the College. She's also the Associate Director of the McClain Center, and she co-directs the Ethics Council of Children. Many of us have published two books on pediatric ethics, one on children's families and healthcare decisions, the other on children in medical research, both published by Oxford, just working on a third book on the genetic testing and screaming of infants and children. Lady is a creative philosopher as well as a practicing pediatrician, and she reminds the philosophical and clinical skills in her research work, often integrating a theory with a theoretical view. Her theoretical work often focuses on policy matters and she works to develop real-world solutions to this problem. She serves on the Committee of Biorepics of the American Academy of Pediatrics, and the book today is called Challenging the Professionalism Movement in New York. So the first caveat is that these thoughts are preliminary, marked in my presentation up by four months. I'm not arguing against professionalism, understood to be clinically competent positions to practice ethical medicine, nor am I objecting to teaching, clinical competency, and ethics. I am objecting to the professionalism movement in which we are one, proclaiming lofty ideals as professionalism. Teaching ethics is etiquette without a framework. And so that's what the focus of this talk is going to be. It's going to be talking about what professionalism really is or ought to be and where we've gone wrong. I do have to mention one conflict of interest, so we're after that. My conflict is I'm asking an author, not the lead author, on the American Academy of Pediatrics professionalism Station of the American Academy of Pediatrics. Despite my role, which I'll discuss, I'll actually criticize the document. So, I have three objectives for today's talk. The first is to analyze, So it was like that sounds like, you know, something like that. Good, so I'm representing myself. I'll make a long video today. So I'm going to analyze the professionalism document of the American Board of Internal Medicine and the American Academy of Pediatrics. I'm going to evaluate current pediatric residency educational curriculum regarding professionalism and ethics. And then I'm going to consider how current trends like social media challenge our understanding of that example, professionalism. So the Physician Charter in 2002 was actually a collaboration by the American Board of Internal Medicine Foundation, the American College of Physicians, the American Society of Internal Medicine Foundation, and the European Federation of Internal Medicine. And their goal was to write a document about medical professionalism in the new millennium of Physician Charter. And this Physician Charter set out three fundamental principles. The principle of primacy of patient's welfare, the principle of patient's autonomy, and the principle of social justice. I want to compare those three principles to the underlying principles of the Belmont Court, which are respect for person, beneficence, and justice. And so there are two changes from Belmont to the Physician Charter. Anybody notice them? I'll give you a hint. I'll put it back up there. What do you think has changed? Right. So we move from respect for persons to respect for economies, and we change the electrical order, both of which are a big mistake. So let me explain why. Let's see. What's the story about Belmont Court? Belmont Court in 1979 was written by the National Commission for Protection of Human Subjects and Biomedical and Biomedical Research, and is one of the best biomedical epic documents of the 20th century. And so I actually criticized this in a paper that I've already published. Why am I so upset about this shift from respect for persons to respect for economies? The first is, what do we mean when we use the phrase, or when Belmont used the phrase, respect for person? It actually had two components. The first is respect for the person's autonomy. But there was a second component integral to that, which is respect for the person's welfare, particularly for those who lack decisional capacity. So this notion of just having primacy of autonomy in a sense ignores all of those who lack decisional capacity. So those who are vulnerable because they're children or because they have development and disabilities of one sort or another. And language matters. The shift from respect for persons to respect for autonomy, I would argue, was actually a poverty-highly precation. I was at a conference this morning where I heard, the patient was found at a decisional capacity and refused treatment. And so we let her talk. I mean, that was how it was described this morning. That's the problem because it failed to acknowledge that there has to be also concern for his patients' welfare. So I'm going to actually argue that here's one mistake that the professional is removing, right? Sometimes we do them our professional responsibility and reinstate our obligations to respect our patients' persons and not just to respect their autonomy. So why the lexical shift? Notice that in Belmont it's respect for persons and then beneficence. And here we're putting welfare or beneficence above autonomy. And the reason for this shift is in part because of this shift in language. But it assumes then that patient welfare is some objective fact. And what we know is in an adoptive patient relationship, returning what is in a patient's welfare is actually a negotiation between the doctor and the patient. And so this professionalism chart, though, because it uses autonomy, has to put welfare first. But if you still had this notion of respect for persons, it would be respect for persons before you got to the issue of your patient's welfare. So again, two mistakes before we even get past the first three principles. And so again, now I want to look at these three principles and see how they're actually defined in the document. So I'm going to actually argue that two of these principles are two-demanded. So first I'm going to look at how they define patient welfare and social justice. And then I'll actually argue that they're two-linear on patient autonomy. So let's look at how they define patient welfare. And this is quoted right from the position charter. This principle is based on the dedication to serving the interests of the patient. Outdoorism is a tribute to the trust and essential to the position-tation relationship. Market forces and vital pressures and administrative emergencies must not compromise this principle. And then they go on to define altruism as putting the interests of others first involving self-sacrifice. So in a paper that I had written actually at around the same time, we asked the question to our doctors out there, and I wrote this to the college of Washington, Wyoming. And we actually argued that one of the most fundamental features of medical professionalism is actually a fiduciary responsibility based on trust to the patient. And it applies a duty or obligation to ask for the patient's best interest. And we use the language then of fiduciary and not of altruism. In fact, we argue very specifically that the problem is that altruism suggests that it's super-arrogatory for going beyond obligations and that you can be altruistic in a relationship in which there is no relationship. But in a doctorate relationship where you have a relationship, you actually have obligations. We don't want to be saying to doctors, be professional by being super-arrogatory. We want to see that professionalism is part of their duty. In fact, in this paper we did a bunch with, we actually argued that it was the patient for some kind of altruism. It's the patient who lets the medical student try the LP, even though the medical student admits it's their first time. It's the patient who agrees to be a living donor for another family member. It's not us for being the altruist. And we argued and concluded in our paper that if it is patients and not the doctors who are altruistic, then the patients are the gift barbers. To that extent, doctors owe them gratitude and respect for their many contributions to medicine. Recognizing this might help us better understand the morals of this kid of the doctorate relationship in modern medicine. So again, I mean basically my conclusion here is that altruism is too demanding and inappropriate in a fiduciary relationship. Now let's look at their second principle that I want to say is too demanding, which is the principles of social justice. And again, I'm quoting, although I've added some of the power. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, social economic status, ethnicity, religion, or any other social category. We're not just supposed to be working actively to get rid of discrimination and social inequities. And then my first question is, does this apply locally, nationally, internationally, and is this a requirement for every physician or just for physicians as a group? And I'm sorry, it seems to have come off of me changing the computer. But basically my argument is going to be that I'm not convinced that each of us individually are actually working for that. But I'm going to talk about that. After they give the three principles, they then actually give another ten professional responsibilities. And one of them is commitment to improving access to care, which I would argue fits the law with the principle of social justice. And as the Charter explains, a commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician and physician without concern for the self-interest of the physician or the profession. So who serves the underserved? The first question I would want to know, because if all of us have an obligation, the answer is we should see 100% on every single one of these, and we're not going to. So here was the study published in 2006, although the survey was done in 2001. And what you see is, I would say commendably, three-quarters of these physicians said, I personally want to be involved in providing care for the medically needed person in my medical career. But only 25 physicians said physicians should volunteer their time working in a free clinic. And then 87% disagreed with this statement, physicians should not be concerned about the problems of the medically needed. So we have about three-quarters of the physicians actually expressing an attitude about taking care of those who have left. In the look at behaviors, they say physicians provide charity care, you had 79.8%, and physicians had participation in national or international aid missions, you had less than 10%. So clearly, another study that was done looked at the percentage of physicians providing charity care. And the one thing that's really noticeable is the percentage of physicians who are providing charity care is decreasing over time. And part of that can be the economy. So if every physician is obligated to social justice and one-third of us who aren't providing any charity care are failing, and if the medical community is obligated to actively, remember it's not just providing, it's actively eliminating social inequities that we all fail. Which again is why I feel that this professionalism doctor is just lost the ideal. So now let's look back at these three principles. And now I want to focus on patient autonomy and say that the physicians are here may not be demanding enough. Because here's what they wrote. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients' decisions about their care must be power-mounted and their talents are mine. As long as those decisions are in keeping with ethical practice, they do not lead to demand for inappropriate care. And so why do I have this in a palette? My first is, decisions are in keeping with ethical practice. Does this mean that conscience clauses can or cannot override legitimate patient requests? Because that would be one way that they may have a, quote, legitimate request that's going to be overwritten or at least ignored. And then I have to ask the question, who defines what is inappropriate care? Is inappropriate defined by clinicians or utilization review committees? Or is inappropriate care based on evidence-based medicine? And are these boundaries decided by individual physicians or physicians as a group? And is there any negotiation or in a sense what reports that the patient has if they feel their care is appropriate and the physician deems it inappropriate? So in other words, I've now rejected all three of the principles. So let's move away, maybe just because it was written by the internal medicine people and I'm a pediatrician, so do the pediatricians do better or the answer is no? But here's what happens when the pediatricians decided to promote professionalism. I should say that the real process began with the American Board of Pediatrics. They wrote a book with the Association of Pediatric Program Directors called Teaching and Assessing Professionalism in 2008. And then the AAP came out with their own statement. And I was in transition on the committee. The one thing I did get out, in the one part, I'm only part of one of the two AAP statements, one of the statement and one of the technical reports. There's no use of the word altruism, for example, in the part that I'm involved in. And yet we did maintain the principles, the three principles, as decided by the American Board of Internal Medicine. So what do you have to know about the American Board of Pediatrics project? Basically, it's an interesting thing because it was done through the medical education. They said that since 1982, pediatric residency programs have been asked to evaluate training for ethical behavior. And in fact, in 2007, the ACGMA required document teaching and evaluation of professionalism. So they created this project in 2008, which was about teaching and assessing professionalism. There was a program director's guide who's written by eight highly respected medical educators and adopts most of the physician's charter. There were no ethicists on this project. And here's what the AAPP wrote. There are many definitions of professionalism. For our purpose, we will use Stern's definition as highlighted in his book, Measuring Medical Professionalism. And here's his definition. Professionalism is demonstrated through a foundation of clinical confidence, communication skills, and ethical understanding upon the field, the aspiration to a wide application of the principles of professionalism. Excellence, humanism, accountability, and absolutely. This definition emphasizes the fact that professionalism is a behavior that must be demonstrated. So remember, this was a group of pediatrician medical educators whose goal was how are we going to measure and evaluate professionalism. So they define professionalism as a behavior. So is professionalism a behavior? And the answer is yes. But professionalism can be understood as much more than that. It can be understood as an attitude, an identity. It's about values, norms, attributes, motives, or tendencies. I think it's really important to acknowledge that how we're going to conceptualize it is going to structure how we're going to teach it and how we're going to live it. So to have a more global, quote, identity conception of professionalism in medicine, we should say that teaching professionalism is not so much a particular segment of the medical curriculum as it defines it. Rather, it is a defining dimension of medical education as a whole. But we shouldn't have it sort of, hey, this is our professionalism education and we're now done. It needs to be throughout the curriculum. We have to deal with it because we have this whole hidden curriculum. So here's another problem I have is that once you make it a behavior that has to be taught and evaluated, you entrust it to the medical educators. But such an approach fails to provide the analytical framework with which to examine professionalism, which is in a sense coming from the foundations of philosophy and medical ethics. These case-based approaches, which is what both the ABIM and the American Academy of Pediatrics focus on, often use cases alone without theory. And it allows the students, but that fails to allow the students to then take these ideas and apply them to other cases. And there have only been a few articles that actually try to evaluate and they respond to this problem that because it's studied in a concrete way, it's not able to be abstracted beyond. Of course, we also have to acknowledge that one of the most important behavioral components is going to be this whole list of role modeling and the hidden curriculum and something we really haven't addressed so far. So the behavioral approach to professionalism, I just think again, is just a weak understanding of professionalism. When the A&P committee decided to look at the ethics underneath it, they also enumerated the same three principles and ten responsibilities. And one of the responsibilities they focused on, the social justice and advocacy, they went even further than the American Board of Internal Medicine, so I'm going to quote, pediatricians have a responsibility to use their knowledge, skills and influence to advocate for children and their interests in all domains of society, not just in healthcare. A child's health is broadly understood through emotional, educational, psychological, and spiritual well-being. I've left the clinic, I'm now responsible for all children in all aspects of their daily lives. So my first question is, if I'm really supposed to be advocating, how good are physicians about advocating? And I quote this article, although physicians seem to endorse the idea of civic engagement as a professional responsibility, there's less evidence that physicians actually engage in these activities. The limited evidence available shows that physicians are more likely to engage policy makers on issues affecting their own economic well-being and that on the most basic measure of civic involvement, that is voting, doctors vote less often than other professions or even the public at large. Others have observed that often discrepancy exists between the professional values physicians endorse and the behaviors they demonstrate. And here is the data that you showed in this article showing how poorly physicians have voted in all elections way below the average general public and even way below their lawyer colleagues. So, and that would be the simplest form of that. So what are pediatrics residencies doing about professionalism? We actually did a survey and Peter worked with me as well as Colleen Lang who's now at WashU. Again, I'll get my conflict with the Carson Funded by the American Academy of Pediatrics section on BioEpic and approved by the Association of Pediatric Program Directors who agreed to distribute the survey on their lists or within a sense their seal of approval probably helping us get the 60% response rate that we've got but neither the AAP nor the APTB have responsibility for content or data analysis. And so what did we find? The first thing is as I said we did get a 60% response rate. Programs were evenly divided on whether ethics was taught as an organized curriculum or integrated throughout. Professionalism was combined with the ethics curriculum in 27% of the program but independently in 38% of the program the 35% had no professional curriculum despite the fact that since 1982 it's been required as a Pediatric Residency Program. In almost half of the programs in which faculty could be identified, we asked them who teaches your ethics? Who teaches your professionalism? There was no overlap between those who taught. So these are really viewed as one is in the realm of mental education and one is viewed in the range of the ethicists and the two are rarely actually communicated. More than one-third of the respondents were not able to answer questions about content and structure. So we were asking the program directors tell us who teaches and what format and they had always the option I don't know and for every single question over one-third was I don't know. So taking a real vested interest in what's being taught in their programs in this area. In fact the two-thirds of those who responded they did that program dedicated 10 hours per year to ethics and professionalism respectively. The only three-quarters of the program identified crowding of the curriculum and one-third of it by lack of faculty expertise as their curriculum strengths. So that is what we were able to show why do you only give that many hours and the main reason was for both ethics and professionalism is crowding of the curriculum. Scarily over one-third saying they lack the expertise in their medical schools. So our conclusion was that despite requirements to train and evaluate residents and ethics and professionalism there's a lack of structured curriculum faculty expertise and evaluation methodology. The effectiveness of training curriculum and evaluation tools need to be assessed if the ACGMA requirements are going to be meaningfully realized. So while we as a community need to do professionalism to behave it to be measured other movements in the last decade are further eroding professionalism and I learned that my notion of professionalism isn't called dinosaurism it's called nostalgic professionalism. And this was complexity theory meets medical professionalism and in nostalgic we have the most important value are patient autonomy again number one rather than respect for person altruism, interpersonal confidence and personal morality is the least important thing between things like lifestyle and communication. What was fascinating was that these authors then told me that there's a concept called an equally badly concept called lifestyle professionalism where autonomy lifestyle and personal morality are on top and the least important are altruism, social contract social justice, professional dominance even better is that we have something called unrelected professionalism where we get autonomy interpersonal confidence personal morality but on the bottom we get to have social justice and social contract and basically this article tells us that all of these are competing notions of professionalism I'll just start with the complexity theories are wrong decision is a privilege, not a right if you're not willing to put social justice and other issues higher up and you're only focused on your own needs we have a problem the matter of the professions is not defined professionalism, society does by delegating powers and responsibilities to the profession so again we have it this wrong way we think we get to define it and in the sense it's really society who's giving us the privilege and we should acknowledge it as such so unrelected professionalism is not professionalism nor is lifestyle professionalism so as I've said, I'm a dinosaur that's not to say that there have always been challenges to ethics and professionalism but here's a famous quote the most common criticism made at present by older practitioners is that young graduates have been taught a great deal about the methodism of disease but very little about the practice of medicine if you put it more bluntly they are too scientific and do not know how to take care of patients who said it and when that could keep out of you 19.7 you're in the right century in the last half of the century of course the most famous part of that paper being the last line 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 for professionalism but there are some interesting real challenges to professionalism today and I want to talk about two of them one of them being duty hours I figure if I'm going to give this box I'm going to make sure that I insult every single person so now we'll look at duty hours and social media here is a study which looked at the faculty views of the implication of the new duty hours and the one thing you'll see is this one is professionalism and what they felt was so how does it affect a little over 40% felt that it had no decreased patient care 40% thought no change they thought over 70% thought it decreased medical knowledge but here is what they thought about professionalism 60% really felt that it was going to decrease what I would assume they meant nostalgic professionalism the real issue is social media and we're going to have lots of issues with this for example the question of behavior by healthcare professionals there's resident blogging about a physical patient which the patients and the family may access there have been cases where the Mayo Clinic surgical house officer who photographed a patient's tattoo and texted it to friends from the OR anybody know what body part and what it said what? yes it was it was a bar owner who had chewed on his penis the word red top he actually was thrown out of the residency program there have been unprofessional behavior by medical students engaging in drug use documented on a social media site but the social media concerns is actually bi-directional right because the privacy concerns go both ways and by that I mean that patients learn lots of personal facts about their positions unless you don't have people here who don't have a Facebook account okay it's a minority right and LinkedIn and when I say Facebook I mean all of those accounts so can physicians one of the issues that has come up in the medical literature is whether physicians can reach patients blogs so imagine a patient has a blog and then as you may even talk about compliance or alternative therapy secondary goals can you go and try to find out about it now if it's the transplant team it could actually exclude the person from getting a transplant of course it can get even more complicated if the person is reviewing the psychiatrist right we reveal what we want to reveal but now in the sense the whole web is there so physicians can actually have to ask permission and say hey by the way you know I'm just going to scan the web and see if anything you're writing is of relevance to our doctorate relationship so we're going to have issues like this that I think that really haven't been understood by many of us I quote the nostalgic professionalism and Parkinson's don't really take part in this in this era of social media so but how big is the problem they did a couple of surveys recently confident out of the university of bars study Facebook found that only about half of the medical students had about 12.8 percent of their residents and they said a majority of the accounts were not private in some cases that were inappropriately run professional content posted right in 2010 they did focus on medical students from Washington University School of Medicine the vast majority used Facebook the majority were identified online by name and institution and it was disreviewed of what is inappropriate to post online all of these type of violations were wrong and illegal activities were inappropriate but there was disagreement for example about commenting on attending and classmates either professional skills or attitudes so the AMA actually did come out with a very interesting report looking at professionalism in the use of social media it was published in 2011 in the Journal of Clinical Ethics the boundary that exists in the patient's additional relationship is something that we consider when physicians take part in social networks and post online these boundaries is defining characteristic of the professional relationship and respect, trust in the patient's well-being or power amount at least the word respect has finally gotten back in and here were their recommendations physicians should be consistent of standards of patient privacy and confidentiality that must be maintained in all environments including online when using the internet for social networking physicians should use privacy settings to save personal information and content to extend possible which it realized that privacy settings are not absolute and that once on the internet content is likely to be there permanently if physicians enter applications on the internet physicians must maintain appropriate boundaries maybe you should have a recommended separate personal and professional online persona professional responsibility to address unprofessional behavior of colleagues seen online their recommendations first contact your colleagues say hey you're not supposed to post things about your peers if no response then actually they are going to be an issue that should actually go to higher authority the decision must recognize that actions online and content posted may negatively affect their reputation on patients and colleagues and may have consequences for their careers so let me end where I began challenging the professional movement as currently interpreted ethics and professionalism are integral to medicine the three fundamental principles are respect for persons, beneficence and justice medicine is a social contract between physicians, patients and the public at large it's a fiduciary relationship not an altruistic one and that while changing social, technological and political events impact on how we behave or ought to behave as professionals the fundamental component of the social contract in Georgia so I'll end there and take questions we respect others one level because they are human being we respect a person because a person is human we also respect a person for their character we have owl for certain people respect them because of their accomplishment and sometimes we respect people because we are afraid of them you respect someone with a gun in the hunt so the respect can be vague but we respect patient for their autonomy and for their individuality but we may not even respect a person who for example was in a process of putting a bomb someplace or was going to kill someone and then somebody shot him and now this is our patient so we may not even respect this person but we respect the person's autonomy and being a human being so why would be bad to replace respect with autonomy so with everyone able to hear so Javad's point very fairly is that respect has many different connotations so I was using respect in a technical sense I was using it in the phrase respect for person which is clearly articulated what it's defined as in the Belmont report and the first is about respect for patient autonomy but it's also about respecting the patient's welfare particularly for those who lack autonomy and even for those who have autonomy but may be in a vulnerable situation being sick is a vulnerable time for all of us and so that's why it's not just about autonomy or the person said no I'm done the person said no is the beginning of a conversation and that's the difference so Lanny you mentioned that this talk actually came four months before it was supposed to be given so a work in progress which were pretty definitive for example if the enemy talked about social media you had a very clear statement about boundaries between professional and personal persona but there were other parts social justice part where I think in some ways both what was presented in terms of the societies regarding social justice issues and then your discussion of it was less clear so let me give you an example you mentioned for example that the society talked about well active physician advocacy and a variety of areas for social justice but it really wasn't defined in terms of the professional charters so in some ways some of your critiques I think were potentially unfair in terms of being vague and you started putting words in people's mouths so for example you mentioned for example the uncompensative care slide where you then defined the same well if one fourth of the people weren't giving uncompensative care well maybe they're being hypocrites or the issue about well pediatricians getting involved in schools and poverty and a variety of non health issues if they weren't very strong advocates then you know they were hypocrites in some ways with the implication the last SHIM meeting the theme was advocacy and it was a very impressive speaker who was basically Gandhi in terms of her life career but she had one slide where she had like a ladder of ten different ways to become involved ranging from feeling minimal to being like her in terms of being Gandhi at the point that well you know we don't all have to be Gandhi that we have to figure out given our interests our strengths and talents what do we fit in the continuum but everyone has to do something in terms of social justice so I guess in terms of that particular topic of social justice it's going to spin a little bit more in terms of I guess a little more specific in terms of where you think we should be then because in some ways it took a straw man in terms of the existing I use the voting example as the minimal amount of social advocacy and we don't do a very good job there so you know I'm not asking for Gandhi I was asking for something that minimal but you said I was unfair I'm using their definition which was the decision to work actively to eliminate discrimination in healthcare whether based on race, gender, socio-economic status, ethnicity, religion or other and the other social categories and I think that it's demanding too much to ask that everyone do it actively so I agree with the speaker who said it's all on a continuum and that different people should do different things but my point is if we really require that then we're failing because we can't even get us to vote let alone get us to actively try to change the system try to you know try to work for the Obamacare and trying to get all those people without health insurance meaning more positions are against it than are for it right so I think we're failing and I don't think I'm being too harsh I guess my concern was I know you had this slide I thought you were implying that well we shouldn't be actively whatever actively means be trying to eliminate discrimination along these different lines I think that if we're going I think this is too lofty and ideal for all of us to be at that level of activism I'll settle for having all of us vote and take an active interest right we can't even get more than 40% of us to vote in any election when you talk about then what should be done you know if you were the charter writers what I'm hearing is that you're thinking that everyone should play their part you know some people it's going to be a public policy others it's going to be how we treat individuals in our institution well the policies we create in our institution or the role modeling we set and all so I think we're on the same page but the message that I heard though was that it's either all or nothing that you know you either sort of you're doing the public policy or else if you're not doing what you interpret it to be what the charter meant then well you know but that's what the charter is demanding not demanding that it's a team effort and that we as the profession move forward it's demanding individuals each one of us have a personal responsibility and it's conflating the person on the professional I just want to follow up on Marshall's question when the WHO defined health as not just the elimination of disease but a positive state of social of physical and economic well-being and I didn't quite get it right it was pretty much understood that that definition did not describe the situation on the ground that was not the way things were but it was a kind of aspirational vision of how things ought to be in some future time and place in a similar way I'm wondering if this discussion between you and Marshall doesn't turn on what the charter means I mean whether it actually lays down a code of expectations and responsibilities to each and every doc today and forever or whether it does have some of this aspirational quality to it that in the right sort of medical world of the future where health is social, economic and physical well-being these would be the kinds of aspirations that doctors ought to have and ought to work towards so it's a real difference so there are two issues about it one is that remember that this is being developed for medical education purposes so lofty ideal we'll get back to but we're supposed to be evaluating and measuring whether they're achieving this and we have it, let's talk about the World Health Organization definition have we gotten any closer to that definition in the 25 years of anything we probably made three steps back so we're not moving towards there so lofty ideals are great but when you have to quote measure it and infuse it into your medical students we're not doing a great job if it's just a behavior and I don't think it is but if it's just a behavior that's one way of responding that they're talking about behaviors so if we ignore it as a behavior and then say well maybe it's lofty ideals I still think that they're demanding too much of individual physicians if it's about lofty ideals it should be about the commitment of the healthcare profession it shouldn't be about each one of us having these responsibilities Laney one of the observations you made that I think was very important was the sort of rupture if you will between ethics and professionalism or the way in which they are often conceived of in parallel and I wonder sometimes I've wondered whether or not the modern professionalism movement as currently conceived came in some ways as a reaction against medical ethics either conceiving it as saying these are rules of people telling me what to do and I don't want that or a bunch of people abstractly reasoning about cases and went off in its own direction so the first question is do you agree that there is anything to that theory of how it happened and secondly regardless of how it happened do you have any suggestions for bringing ethics and professionalism back together so I don't think that's actually how it happened I really think this was sort of a decision was made that we need to incorporate this and the educators who are very clinically competent and ethical people felt they could do this and didn't really think about it in the notion of I mean I think this wasn't a malicious intent I think it was just sort of obliviousness about the fact that in a sense the three principles they are never cited as where they came from they came like mushrooms out of the ground rather than that there's a whole history of medical ethics in which these principles come from so I think that's the issue and I think it's a failure on the ethicist part for not sort of engaging as this movement started to take place and saying we can help with this as well so from what I've heard today it isn't that hard to figure out what is an professional behavior at least once it's been committed but since justice potter but you teased me having four months with a very brief suggestion of the other side of the so called super professional when you said we're going to have to deal with professionalism and conscience clauses what is it that it is professional to ignore orthodox medical treatment because of conscience I don't think it is and I've written that so well you got some argument in this room I know I do I have a theoretic question can you define and contrast ethics and professionalism as terms and concepts you know I actually thought about that a lot the other day trying to do it so in a sense I would actually argue that professionalism is in a sense one component of ethics that ethics is sort of the theory of what is right and what is wrong and what is good and right and things of that sort and professionalism is just looking at it in the particular area of healthcare it's not adequate but I've been thinking about but I do think they're totally overlapping the principles we're using are the same now professionalism also has another component which is about clinical excellence but I would actually argue you could sort of assume that in ethics as well I think that's an important point because from seeing in educating groups ethics is seen as a subset of professionalism not professionalism as a subset of ethics and I think that paradigm shift is part of what I think you're pointing out join me in thanking ladies for wonderful