 It's a bittersweet moment today because, as you know, today is the last session in the professionalism seminar series that Dr. Humphrey and I structured about a year and a half ago. We've been just absolutely delighted with the quality of the talks. But even more delighted with the level of involvement and participation and attendance on the part of students and residents and attendings and fellows, it's really been extremely rewarding to have you all here. As I've mentioned before, the intention is to have a book of collected essays, not all of these sessions, but perhaps 15 or so of the sessions brought out by Oxford University Press. But these things take time, and it's quite possible that we'll be into the next iteration of professionalism by the time the book comes out in a few years. But keep your eye out for the book. Today, it is an absolute pleasure and delight to introduce to you Professor Charles Bosk. Charles and I go back to early days in the 1970s here at the University of Chicago. When I finished my residency and joined the faculty in 1972, and Charles came as a graduate student in 1971. So the times that we remember from the 70s were really quite remarkable times in Hyde Park and at the University. I'll tell you a little bit about Professor Bosk's recent accomplishments, Professor of Sociology and Medical Ethics, Chair of the Graduate Group in Sociology at the University of Pennsylvania, served as the Chair of the Medical Sociology Section of the American Sociological Association. Recent books include What Would You Do, The Collision of Ethics and Ethnography, a book that actually Charles and I had a little discussion about, not a debate, but a discussion at a McLean conference a few years ago, the year the book came out. Another book called All God's Mistakes, Genetic Counseling in a Pediatric Hospital, published by the University of Chicago. I could go on and on and tell you about his law career and election to the law review at the University of Pennsylvania. I won't do that. Instead, I will tell you about this extraordinary book called Forgiven Remember, also published by the University of Chicago Press. The first edition of it came out in 1979. It was based on 18 months of field work, combining ethnography and sociology at the so-called Pacific Hospital. And many people in the old days, including people here at the university, would speculate on where Pacific Hospital was, and whether it was Stanford or Moffat, or one of the other West Coast hospitals. Can I say? You're on the floor. It has emerged, at least in the last 10 years, that Pacific Hospital, of course, is the University of Chicago. And we were the subject of study. And it was our Department of Surgery, our residents, our students, who are very much the subject of this book. This book, while it's primarily about surgical training, has always struck me as the best book ever written about the clinical process of training in medicine for medical people, Peds people, surgeons. Even though the cases and the issues are surgical issues, there's remarkable resonance about the clinical process of training in this book. It's now available. This first edition is a little tough to find. Although, did I see Alex come in carrying a first edition? Yeah, there it is. But the blue copy is the second edition. Does anybody have a blue one here? And there's a blue one. Todd has it. And it is available at the University of Chicago bookstore through the press. And it's still in print. So with that background, Professor Bask is going to conclude our professionalism seminar series by changing his title. Changing his title. Thank goodness he gave it to me at the very last moment. I was about to announce the old title. But the new title is, he'll explain it, waltzing Matilda, professionalism and humanism intention. Charles, welcome. Thanks, Mark, for the introduction. I'm sorry that my dean and provost weren't here today. And if you could take the clip and mail it to the mic. I'd appreciate that. I'm a mumbler. And so if those of you in the back begin to have trouble hearing me, if you could let me know, that would be helpful. Because I hear the room doesn't necessarily project well. I'm also a monotone. And I'm going to do something I haven't done in about 20 years, which is read a paper without PowerPoint. I'm partly going to read, because I've been at the University of Chicago and I know that if I put my head down, I can ignore the objections that you have even before I start. I know that there are many people that are already, before I start, know that what I'm about to say is wrong and want to correct me. But I want to see how far I can get before that happens. So here goes. I think the title will become clear, but Matilda is the young girl in William Carlos, William's story, The Use of Force, which is a text I'm going to refer to at some point, healthcare providers, patients and their families, licensors and licensees all agree that professionalism and humanism are indispensable elements for developing a healthcare system that's both accountable and committed to quality improvement. The ideal workplace for both those providing and those receiving care is one in which workers display a happy combination of professionalism and humanism in all their undertakings. This healthcare system exists everywhere as a utopian vision and nowhere as an everyday reality. Systematic dissatisfaction reported by patients and family repeatedly directed at their treatment in the healthcare system are a sign and symptom of a want of something essential in the provision of care. A set of unexamined pair terms, professionalism and humanism often identifies the something essential that is typically absent. Enough reform minded educators agree with this global diagnosis of the presenting complaint of those that receive healthcare, that they place the need for better indoctrination of new recruits and the values of professionalism and humanism at the head of their agenda for change. Improving and professionalism are laudable goals. The problem is that professionalism and humanism are not equivalent. In fact, they are often in opposition to one another. One improves professionalism in a market driven healthcare delivery system by creating behavioral benchmarks for care and measuring compliance with them. Behavior associated with humanism get squeezed out of measures of professionalism. Measures of professionalism are often then conflated with measures of efficiency and quality. For example, acting professionally often means following an evidence based guideline. When an apartment chair sits down with a colleague to tell them that their clinical productivity is as reflected in their billings were disappointing and fell short of expectations, the implication is that to be more professional, the offending doctor needs to spend less time in each patient encounter. Professionalism here means managing patients to provide profits to the department. Humanism shrinks as professionalism gains acceptance as a measure of provider accountability. The elimination of humanism as a measure of and for accountability is an organizational necessity. If masses of patients are to be treated in a high volume healthcare delivery system, the inability to incorporate an operationally meaningful, pragmatically consequential measure of humanism into physician report cards distorts the experience of providing and receiving treatment in ways that create multiple dissatisfactions for both the providers and the recipients of healthcare. In a world where professionalism frames a discourse of individual and organizational accountability and where accountability is linked to economic performance, humanism is a residual consideration or preoccupation. The burdens of a genuine humanism are demanding and interfere with most measures of efficiency. A genuine humanism requires paying sufficient attention to such tasks as listening sympathetically to a patient or a family's fears, making certain that basic needs are met and having the person in the provider meet the person in the patient. For professionals in healthcare, everyday dealing with patients are an unending series of tensions in drawing proper boundaries that separate the role of provider from the person of provider and the illness of the patient from the person of the patient. Moreover, humanism as a component of professional behavior is hard to bound. Humanism transcends organizational roles, professional boundaries, and personal identifications. Of all our civil ties to one another, humanism demands a primal acknowledgement of a shared humanity. Although both providers and patients find moments of shared humanism extraordinarily gratifying, such moments often interfere with the efficiency required of professionals who provide technologically and cognitively complex procedures to a high volume of acutely ill patients. Licensed healthcare providers routinely complain that the delivery system and their role of professionals within it interferes with their ability to act as humanely as they desire. Individual providers as well as systems managers perceive the transaction costs of humanism to be ruinous economically and emotionally. As a result, when medical educators and foundation leaders talk about professionalism and humanism being linked and then go on to detail how teaching students to act so that these linked values become a revolutionary force for the delivery of reliable, high-quality care, I wonder if the simplicity and buoyant optimism that fuels this approach. Nothing in my experience justifies this vision of reform. A collective rededication to professionalism and humanism appears to me to be insufficient to combat the forces that make healthcare so difficult to deliver in a way that is satisfying for either or both providers and recipients where educators see professionalism and humanism as energizing providers in synergistic ways. I see the friction created when forces pull in opposite directions and inertia needs to be overcome. To act professionally occasionally requires acting inhumanely. To act humanely occasionally requires acting unprofessionally. A discussion of reform that depend upon rededicating the next generation of practitioners to core values of professionalism and humanism become senseless to me because they deny the complexity of objurate embedded conflicts in everyday experience. Such discussions provide fully elaborated vision of an alternative universe to which I cannot gain entry. A world where one set of values does not ever conflict with another. A world of blinding clarity where neither uncertainty nor ambiguity are ever encountered. As a strategy for reform, enhancing professionalism and humanism without recognizing the inherent conflicts between them makes as much sense to me as hoping that a wise cricket is always perched on the shoulder, whispering to us, let your conscious be your guide into our ears and then believing that what we hear from our cricket friend is always good and never self-serving advice. There are problems of plenty created by a witless approach to furthering professionalism and humanism in the delivery of healthcare. Of these problems, none loom larger than exploring how professionalism and humanism are separable and how that separation creates incomplete evaluative categories for specific performances. Values are slippery as an empirical matter. Values need to be interpreted in situations. Multiple inconsistent behaviors can be justified by the same value. Nonetheless, actual public expressions that talk about the incompatibility of professionalism and humanism are rare. After all, how can one argue against enhancing professionalism and humanism in the delivery of care? Do we not all want care that meets the highest evidence-based standards delivered with more than a dollop of kindness and empathy? In a recent paper on the white coat ceremony, a ritual recently introduced into U.S. medical schools. I think of it as your second bar mitzvah. But only for Jews. I mean, must have some ritual significance for other folks. But to symbolize beginning medical students' commitment to professionalism and humanistic values, Judah Goldberg, a former student of mine, questions the assumption underlying the ceremony, namely that professional and humanistic values are equivalent. Goldberg argues instead that humanism and professionalism are value systems frequently in conflict. Professionalism is an occupation-based code of conduct grounded in a body of expert knowledge for those with a specialized role in a division of labor for providing health care. That's the sociologist in me speaking. Professionalism varies not only among members of the same group, say, for example, in the difference between surgeons and specialists in internal medicine over managing patients, but also between groups of providers who each have their own professional code of conduct. Humanism is a more universalistic code of conduct that refers to the existential obligations we owe one another as fellow human beings sharing a crowded planet with ever-depleting scarce resources. The demands of humanism, at least in theory, do not vary within or between roles in the delivery system. Nor do they vary across culture. They are merely expressed in different behavioral terms. Humanistic obligations are easier to define abstractly than specify concretely. Think here about the strong feelings, questions about hydration and feeding at the end of life evoke. The evidence-based standards that convinces clinicians that the withdrawal of food and water shortens rather than prolonging suffering bumps against the primitive instinct that somehow this denial is humane, somehow in a world of human relations, being the person who denies food and water to the dying person feels like somehow not meeting a human obligation. The question of what is a humanistic response to complex medical problems is a vexed question that requires deliberating all the imponderables that are part of the human condition. One jagged edge of practice among and between professional experts in health care, as well as among and between patients and their families, is different expectations about how much professionalism and how much humanism is required in the everyday delivery of care. For example, professional standards that demand honesty about diagnosis, treatment options, and prognosis so patients and families can exercise autonomy choosing among options is often experienced as an overly blunt, occasionally cruel style that abandons patients to their own resources. Professionals delivering health care and patients receiving it use different metrics for assessing quality. For example, no matter how eager they are to be released from the hospital, patients and their families are baffled that shorter lengths of stays are a measure of a hospital's quality of care. They associate longer lengths of stay with a higher standard of care and caring. So next section is embedded contradictions. The embedded contradictions that Goldberg finds in an unselfreflexive linking of an ill-defined professionalism and humanism are there to be found, have been lurking about for decades, and are worthy of extended discussion. What is surprising given the extensive first-hand accounts of physicians and the second-hand observations of social scientists on the impact of medical education on recruits to the occupation is that anyone believes that training in professionalism and humanism will have a positive impact on caretakers' humanism and its behavioral correlates, whatever they may be. There's an entire literature in the sociology of medicine on the coarsening effects of professional education and experience on medical students and residents and seasoned physicians, original conceptions of humanistic, patient-centered care. The entire record of professional leaders and medical educators attempting to create a more professional and humanistic doctor-patient relationship in an ever more complex disjointed health care system has been summed up by the late Sam Bloom as cycles of reform without change. First-hand narratives and thinned out fictional accounts describing the impact of medical education and residency and sustaining a practice make it clear that empathy and genuine expressions of caring are early casualties steamrolled by the intensity and pace of work in a tertiary care center. Medical work is demanding. In the workplace, there is only room for professional response to tasks. Human responses risk emotionally flooding out. The creation of scenes, staffs and families sobbing together in the hallway. Such responses make it harder for workers to continue working. There's no choice but sometimes to suppress every human response to a situation so that one can keep acting within a role. Leaky social organizations have difficulty managing the difficult task of turning people into objects for treatment. The emotions work is the leaky part. Leaks are dangerous. They create social slips and falls, keep workers off balance and off kilter, and disrupt the machine-like running of an inpatient unit. Inpatient care is organized so that the occasions when the hair-shirt of humanism pricks the calloused skin of professionalism are rare. Inpatient care involves for providers accomplishing complex technical work in which interventions are invasive, managing patients who have multiple comorbidities and are at risk of death and anticipating the needs of a full panel of patients. Efficiency in this environment requires a professional task organization that prevents the disruptive leaks that threatens to spring from an overly expansive humanism. To repeat, the transaction costs of providing an adequate dose of humanism at everyday care are forbidding, especially if one is gonna get all the necessary work done for all the patients on an inpatient service or a busy ambulatory practice. A perceived deficit in professionalism and humanism and the everyday delivery of care by medical educators and leaders of professional associations, once again, is both a sign and a symptom. It's a sign that many physicians fail that they feel that they have failed to develop a rough gestural language for communicating caring to patients and their families. It's an internal symptom, it's a symptom of the internal psyching numbing that providers experience as a consequence of the necessity of moving on to the next technical task without acknowledging a patient or their own's personhood. Despite the embedded tensions and internal conflicts that doing so builds into day-to-day practice, medical educators in the United States equate professionalism and humanism throughout the formal curriculum as well as the self-conscious dimensions of the informal curriculum. An unquestioned natural conjunction of professionalism and humanism creates a self-evident, self-validating, therefore coherent, epistemic and moral authority for practitioners and institutions providing healthcare. This essay asks, and I realize I've gone on for a long time before I got to the question, but that's okay. This essay asks, what happens when that unquestioned, indivisible authority, epistemic and moral, becomes divisible? This is a situation that we find ourselves in today, and in the early years of the 21st century, epistemic authority has been cleaved from moral authority for Western medicine. Because of the objury realities of the medical marketplace, the discourse of professionalism is unable to accommodate only the thinnest conceptions of humanism. The discourse linking professionalism and humanism, a discourse that in effect binds epistemic, tomorrow, authority is stitched with slender and fraying threads, which I will now pick at further. The discourse of healing as a sacred calling and healers as a member of a sacred guild with powers so special that individuals who ignore their healer's advice do so at their life's peril is as ancient as discourse on group life itself. Picking a starting point for providing a narrative of how the practice of healing and the activities of healers on the Isle of Coose in the fifth century BC became reimbursable healthcare activities provided by licensed experts in the 24th century is a task made possible only by enormous oversimplification. In this essay, this oversimplification is accomplished by limiting myself to one implausibly broad timeframe, 1840 to the present and focusing on one licensed group of healers, American allopathic physicians, telling even a time-bounded national history as a disturbing oversimplification since licensing healthcare providers is an activity done in the laboratory of the states rather than by a single federal authority. Reimbursing providers and licensing providers is and always has been both a settled topic and a source of contention. Accepted billing codes are evidence of the settled topics. Current domains of contestation include but are not limited to autonomy of nurse practitioners, prescribing rights for psychologists, supervision of residents for billing purpose and reimbursement for never events. In the period chosen 1840 to present, moral and epistemic authority grew for healers who were also holders of the MD degree. In the first decades of this timeframe, the MD degree provided legitimacy less because of its demonstration of superior therapeutic efficacy and more because of its signaling membership in an elite social strata of society. Much of the 19th century in American medicine is described as a riotous cavalcade of frauds, quacks and charlatans. The narrative of the second half of the 19th and the first half of the 20th century is one of an incomplete but nonetheless compelling dominance of the medical marketplace by holders of the MD degree. AMA physicians first routed the cavalcade of imposters and then standards for licensing as a doctor of medicine. One legacy of the Flexster report and the activities of the AMA was the elimination of all other competitors, save holders of the DO degree for the occupational title physician. As Jonathan Imbers recently argued, Protestant clergy connected the physician's role to a divine calling in America and in part underwrote the moral authority of allopathic physicians. In America, the moral legitimacy of physicians was never far removed from either their priestly origins or the more Protestant notion of a sacred calling. The state legislators who gave them great deference when writing practice statues, governing medical practice and the clergy who blessed their endeavors at graduation ceremonies belong to the same elite social networks and serve to reinforce the medical profession's moral authority. The passage of time reinforces established frames of meaning and disrupts others. From the discovery of germ theory to the present, the basis the moral authority of the medical profession has shifted from divine calling to scientific practice. While the shift to science is a ground for epistemic authority, did much to promote efficacy in the treatment and diagnosis of illness, of fact that did much to bolster the social and cultural capital of the medical profession, it undercut the profession's claims to moral authority. For when it comes to moral decision making, the epistemic authority of science requires silence. To paraphrase Weber or Weber for those of you who associate him with a kettle grill, science can teach us how to master life technologically. However, science can only stammer when asked whether and under what conditions we should wish to do so. The lamp of science does not light the path of humanism. Professional behavior is a topic made for scientific management. We can grade and make visible physician scores on measures of professionalism. However, we lack data points for humanism which remains a valley of fog. Moreover, the decline of a humanistic canon in liberal arts education for undergraduates plus the overwhelming preponderance of successful medical school applicants from the basic sciences means that even if the desire exists for a more muscular component of humanism, few credible authorities are able to articulate a compelling case describing why professionalism is not the most efficient way available to achieve humanism or to notice that professionalism and humanism are not synonymous. In the last quarter of the 20th century, tone deafness around humanism and its moral demands has become a disability of epidemic proportions among professional leaders in medical education. The most apparent cause of this epidemic is a shift in the discourse used to discuss healthcare policy. Discussions of healthcare as a public good waned while discussions that emphasized market terms waxed. The search for reliable outcome metrics for measuring efficiency and effectiveness is a matter of great concern to insurance companies, employers, and government agencies. As a commercial good with a public service component, healthcare providers are required to cut costs and improve access and improve outcomes. Which I find to be a contradictory set of goals. At a national level, a variety of strategic initiatives have been developed to create incentives for providers to rein in unnecessary costs. Under current arrangement, organizations providing healthcare have slender profit margin. Profit requires attracting a very specific type of patient. One with health insurance that cannot be canceled if the patient is or becomes sick and who requires invasive diagnostic or therapeutic procedures. Not surprisingly, administrators of integrated healthcare systems are concerned about protecting their brand, establishing their product lines, increasing their market share, complaining about their profit margins, bemoaning the administrative costs of documenting compliance with regulatory agencies, protesting the economic burdens imposed by the care of the elderly and indigent. Since administrators are required to develop operating procedures to document compliance with established benchmarks of quality, all of their concerns are real. So real, in fact, one wonders, does professionalism serve and humanism subvert organizational goals in the delivery of healthcare? Nowhere is the strain of meeting the embedded tension of professionalism and humanism more obvious than in the career paths that the last three editors of the New England Journal of Medicine have chosen upon leaving their editorships. Each left a priestly position within the temple of organized medicine to warn the people about the path we are on. Each has become a voice in the wilderness and each regularly delivers fresh Jeremiah's. To state the point more plainly, one of the most bully pulpits in American medicine, editorship in the New England Journalism transformed its last three incumbents into radical critics of how little professionalism contributes to the delivery of healthcare and how the humanism of physicians is an unreliable defense against the forces that threaten the profession's service ethic. I'm gonna skip the discussion of Roman, Cassira, and Angel, but you get the point. And I'm gonna skip the part that I'm just gonna jump ahead given the time to Carlos Williams, the use of force, and then to the questions it raises about our own professionalism and humanism. I think the use of force is one of the most widely read stories in the medical humanities. It's a tale of an encounter that Williams has with a child resisting his attempts to look at her throat to see if she has diphtheria. The story, as Williams tells it, leaves him feeling ashamed that his fundamental humanity has been coarsened. For Williams, the contradiction between humanism and professionalism is wrenching. It's both inevitable and infameral, and yet somehow necessary element of everyday practice at its most primary level. However, I recognize that Williams was operating in a different system for providing healthcare than the one we have today. So I'll conclude the essay, this talk, by reflecting on what the conflict between Williams' professionalism can tell us about our own, a professionalism that is receiving ever more precise categorical specification. Professionalism is given specific dimensions, scaled, rated, and reliably used to grade physicians, although debate remains on how reliable and for what purpose. Humanism is not so concrete an object and as a result there are dangers that flow from assuming that the yardstick for professionalism includes a meaningful measure of humanism. The conclusion of the paper explores the dangers of too rigid a metric for professionalism and the misplaced concreteness that views professionalism as an item fashioned from very specific recipes rather than a dynamic relational entity that evolves in tandem with a social and political system. The embedded tension behavior determined by professional versus humanistic codes is all the more mysterious because of its ability to hide in plain sight. Williams, Carlos, Williams, the use of force, as I said, one of the most widely circulated stories in the medical humanities discusses one encounter in which, I wanna hear the end. No, no, no, it gives me a chance to take a drink politely. The use is one of the most circulated stories in curricular offerings in medical humanities and discusses one encounter in which the tension between professionalism and humanism presents itself is brought to a crescendo and then disappears. Discussion of the fit between professionalism and humanism needs to become, on occasion, explorations of acceptable trade-offs rather than discussions of virtue squared. As William tells the story, a battle between him and his role as a doctor and a patient who resists his administrations becomes uncomfortably personal. There are images of wooden tongue depressors splintered into shards, a bloody mouth and a struggle to the end because well, one must. Williams makes clear how traumatic it is for him to deal daily with those who are traumatized by their dread of deadly illness. The use of force is a short story of some 1,550 words, I counted, that I've cut by more than half to 703 words, I counted again. My editing has as its goal placing a spotlight on the generally overlooked tension between professionalism and humanism. The short and short story highlights what Williams felt was demanded of him in his role as a physician and what in his role as a human being. One might say that in this story, Williams is all hokey and no pokey. During an epidemic, Williams puts his whole self in and he never takes his whole self out. The apotheosis of Sartre's cafe waiter as a physician doing this task, examining this throat, Williams is completely there with all the personal answa and professional pourswa possible for doing serious work in a thoughtful manner. In his judgment, Williams could not have acted more professionally and less humanely. His commitment to act professionally overwrote his commitment to act humanely. He did his job masterfully and in doing so, he sees himself issuing a potential death sentence and felt shame for the way he used guile and brute force to overcome his patient will, as expressed in her spirited but futile resistance. I'm gonna use us to see Williams' actions in a more charitable light than he does. Because he looked at the child's throat, he made her death sentence less certain and made possible control of infection to the larger community. Sacrifice for the public good, fulfilling an ethic of service, has short run pains and perhaps less keenly felt long run benefits. So let me present the edited text before moving on to the exegesis. They were new patients. All I had was the name. Please come down as soon as you can. My daughter is very sick. The child was fully dressed and sitting on her father's laps. They weren't telling me more than they had to. The child was eating me up with her eyes. As strong as a heifer in appearance, but her face was flushed. She was breathing rapidly and she had a high fever. She's had a fever for three days began the father. So we thought you'd better look her over and tell us what is the matter. Has she had a sore throat? Both parents answered me together, no. She says her throat doesn't hurt. We had been having a number of cases of diphtheria. We were all thinking of that. Well, I said, suppose we take a look at the throat first. I smiled in my best professional manner and asking for the child's first name. I said, come on Matilda, open your mouth and let's take a look at your throat. Nothing doing. Such a nice man put in the mother, he won't hurt you. I did not allow myself to be hurried or disturbed. Quietly and slowly I approached the child again. Suddenly both her hands clawed instinctively for my eyes and she knocked my glasses flying. Both the mother and father almost turned themselves inside out in embarrassment and apology. Don't call me a nice man to her. I'm here to look at her throat on the chance she might have the theory and possibly die of it. Look here, I said to the child. We're gonna look at your throat. You're old enough to understand. Will you open it now by yourself or shall we have to open it for you? Then the battle began. I had to do it. I had to have a throat culture for her own protection. But first I told the parents. I explained the danger but said that I would not insist on a throat examination. I had already fallen in love with a savage brat. She surely rose to magnificent heights of insane terror, insane fury, bread of her terror of me. The father tried his best. His dread of hurting her made him release her just at the critical time. His dread of diphtheria made him tell me to go on. Mother moved back and forth in an agony of apprehension. Put her in front of you on your lap, I ordered and hold both her wrists. But as soon as he did, the child let out a scream. Don't, you're hurting me. Do you think she can stand it, doctor, said the mother? Come on now, holder, I said. Then I grasped the child's head. I tried to get the wooden tongue depressor between her teeth. She fought but now had grown furious. At a child, I tried to hold myself down but I couldn't. I know how to expose a throat for inspection. When I finally got the wooden spatula into the mouth cavity, she opened for an instant. But before I could see anything, gripping the wooden blade between her molars, she reduced it to splinters. Give me a smooth handled spoon of some sort. We're going through with this. The child's mouth was already bleeding. But I have seen at least two children lying dead in bed and feeling I must get a diagnosis now or never. I too had got beyond reason. It was a pleasure to attack her. The damn little brat must be protected against her own idiocy, one says to oneself. Others must be protected against her. It's a social necessity. All and all of these things are true. But a blind fury, a feeling of adult shame, bread of a longing for muscular release are the operative. One goes on to the end. In a final unreasoning assault, I forced the heavy silver spoon down her throat till she gagged and there it was. Her tonsils covered with membrane. She had fought valiantly to keep me from knowing her secret. She'd been hiding that to her throat to escape just such an outcome. So Hal is an account of his behavior in which William recognizes that he had gone beyond reason. Is it possible to claim that this is exemplary of professionalism? After all, it's not an essential element of professionalism, the use of specialized knowledge to resolve complex problem. Does not going beyond reason vitiate any claims of professionalism. Doesn't the professional leave the person acting as a physician when they are in a grip of a blind fury? Further, isn't a blind fury one way to describe the behavior of beasts not humans? Doesn't William's account give lie to any claim of behaving professionally or humanly? William's story presents a challenge to the reader. Williams describes himself as taking pleasure in what he describes as a brutal attack on a sick and senseless child. Most professional codes of conduct employed by physicians, even those in use when Williams was practicing in Patterson, condemn pleasure from brutal attacks on patients, all the more so if the patients are defenseless children. Most humanistic codes of conduct find such conduct repulsive. Williams confesses to what in a difficult context is an indictable criminal offense. Nonetheless, we must reconcile Williams' brutal pleasure and Williams' professionalism. For surely Williams reason for seeing the child is purely connected, is purely professional, connected to a public service of infection control. The key to understanding the conflict between Williams' professionalism and his humanity lies in expanding silences in the story. By expanding those, we can see how Williams is being excessively harsh in his self-condemnation. We can see how the instinctual existential elements of Williams' fury aligned with his humanity to permit the values of his professionalism to flourish. In most other situations, pleasure and brutal attacks and professionalism are difficult to align. But in this story, a mark of Williams' humanity is that he came to love the savage Brett because of her spirited resistance to him. Williams recognized the terrified person in his patient and the savage determination of his desire to inspect her throat as her physician. Williams is able to see, respond to, and acknowledge the person in both the physician and the patient. An indicator of his professionalism is that his love ends when the professional task is accomplished. Her will is overcome and her illness diagnosed. His love of her is task-centered as is his entire relationship with her. Before the task is accomplished, there are two persons engaged in a battle, a terrified patient and a determined provider. Once the throat has been seen, two people remain. The still terrified patient and the provider who's fulfilled his obligation to the community and the patient's welfare. So how else might we describe what's going on here? We might use what Mills called the sociological imagination, defined operationally as finding in private troubles public issues. Mills located the sociological imagination at the intersection of biography, social structure, and history. How might we provide a more generous account of and charitable view of Williams' behavior? Generosity and charity require that we pay less attention to the so-called pleasure that Williams claims to take in his blind fury and rather more attention to the public service her throat, exposing her throat for inspection was for the citizens of Patterson and for Matilda herself. We need to see how the shared private trouble of Williams, his patient with Diphtheria and her parents represented a public issue. Williams is making a house call to patients that are so new to him that he knows only their address. There is a current high but officially unreported incidents of Diphtheria in the Patterson public school system. Everyone in the room knows this, but the word Diphtheria is initially unspoken. Williams knows the child's condition must be serious. Why else would the patient summon a doctor whose fee is $3? Williams knows the visit is likely to be difficult. He has recently been called to the bedside of two children who were already dead. Williams presses on knowing how unpleasant the scene that is likely to greet him will be because of what is required of him as a doctor. A good person required to do dirty work, to paraphrase every use. To do anything less would be to betray his service ethic. He cannot put off going and still claim to serve the public good without carrying out the duty that his professional calling imposes. Williams breaks the initial silence around Diphtheria. He expresses irritation at the mother calling him a nice man by being the first to speak the word Diphtheria. He's not there because he's a nice man. He's there because he's a physician who needs to look at a throat to see if she has Diphtheria and might possibly die from it. She's old enough, he tells her, that she knows why he's there and what he and she must do together, relationally as it were. She can choose to play her part the easy way or the hard way, but because her parents summoned him, she must play her part. Williams has already told the father, he will not insist on that throat culture if the parents are willing to accept responsibility for that choice. He permits the family autonomy in the decision making process well before such autonomy was established as the standard of care. The father dreads the result of an examination but recognizes its necessity and becomes an accessory to Williams' attack on his daughter. Williams does briefly consider going away and coming back later, but because of the two dead children whose bedside he had already futilely visited, he sees the situation as now or never. Now beats never because the little brat and the larger community need to be protected from her idiocy. Williams sends a professional obligation demands that he not leave before having a look at the child's throat. Like any good butcher, Williams knows how to expose a throat for inspection. The skill is part of his professional toolkit. Even in trying situations, one goes on to the end. It's what one does, it's a social necessity. William overpowers the child because he has to. It's what his professionalism demands of him. On each rereading of the use of force, since it's 1,550 words, each rereading doesn't take much time. I'm always impressed by how certain William is of what his professionalism requires. How readers today judge Williams' behavior in the use of force is somewhat beside the point. Beastly or not, Williams is certain that his behavior was professional. Today, although we were required to have a curriculum in place to teach professionalism and humanism as well as tools that document that graduates of medical training programs have acquired competence in professionalism and humanism, we are somewhat less certain of what duties professionalism and humanism require of physicians today. For example, we have elaborate checklists to measure whether a physician is behaving professionally or not. The measurable characteristic of professionalism include dress, demeanor, expression of concern, the ability to work on teams and so on. We have rules that limit the hours of work and intern or resident can work without a break. We have 360 degree evaluations of students and residents' professionalism, but there's something peculiar about the measurements and the metrics we use to assess professionalism. Unlike cognitive knowledge, manual skill, and most other competencies that we attempt to measure, professionalism lacks any objective correlate. If a resident is told that their behavior is unprofessional, any response saved, how can I improve, is defensive. When accused of being unprofessional, a physician's first response is, no, I was not, has responded unprofessionally. Professionalism requires an ability to hear criticism, weigh its validity, and make the necessary adjustments. Once professionalism is a set of behaviors that can be assessed, and once those assessments, because they're derived that by scaled metrics that have been validated and normed, those assessments become immune to judgment. Serious discussions of what professionalism is cease once we think we know what it is and measure it. What was once alive and dynamic, the nature of duties and obligations is reduced to formulas expressed as behavioral characteristics on a likered scale in which, like the citizens of Lake Wobagon, all people are above average. Moreover, despite the confidence of curricular specialists that we accurately know how to measure and assess professionalism, I remain skeptical, because I don't think of professionalism as a static entity. Professionalism is mercurial. What is required varies by context. Professionalism's behavioral constants are few, and when spoken aloud, sounds suspiciously like platitudes. Be honest in all your dealings. Treat everyone with the same respect that you would expect from them. Do not overstep the boundaries of your role. Professionalism, however, varies over time. The standards of professional conduct that govern the relationship of medical men in George Eliot's middle march are a subject of satire, and if one reads the extensive footnotes, presented as an argument for reform. St. Clair Lewis's Aerosmith is a concise history of changing standards among medical professionals, a history that chronicles the triumph of scientific medicine. Shem satire, and it is a satire, though you would think the entire medical profession lacked a sense of humor if you read the reviews of House of God in medical journals. You would, it's really quite extraordinary. Yeah, I'm gonna wrap right up. Shem's satire, House of God, makes much of the gap that's created when adhering rigorously to standards of professional care while failing to deliver treatment that meets even the most basic requirements of humanity. Further, once not so long ago, really, advertising one's services was unprofessional behavior. The Federal Trade Commission and the Supreme Court decided otherwise. Once it was considered unprofessional to testify as an expert witness in a malpractice case, a remnant of the Hippocratic injunction not to speak ill of a brother physician, Massachusetts Supreme Court case that was adopted by the other 49 states changed that. Now as I travel forth between Philadelphia and Baltimore for a research project that I've just become, I'm greeted by large billboards informing me that Johns Hopkins and the University of Pennsylvania are well thought of by U.S. News and World Report. At the same time, there are other billboards that advertise the legal services that I might employ. Should I meet harm at either of these fine institutions? Now there's a section here on how duty hours challenge both professionalism and humanism. In the interest of time, I'm gonna skip that but say that in some ways, what is professional and what is human? Come into conflict again around duty hours and there's a series of papers that I've written with my graduate students if you wanna explore that. So Williams was sure of what is professionalism required of him. He had to see things through to the end. The changing conditions of practice today make us less sure of what professionalism requires. Is it merely compliance with best practice guidelines? If so, what humanism is expected of healthcare professionals? Have empathy and kindness to hallmarks of humanism in the professionalism of physicians somehow become beside the point because unmeasurable. We are clearly in a transitional moment. Healthcare costs need to be reduced. Resources need to be deployed efficiently. Standardization seems to be one route to improving quality. Yet it seems inevitable that when the object of standardization is a unique vulnerable person cast into the role of patients, the highest standards of professionalism may produce the least humanistic care. This is a dilemma, the horns of which we are likely to sit uncomfortably on for some time in the foreseeable future. Thank you. Is there a quantitative measure in the humanism or it's all qualitative? I think that it's all, I think the problem is that it's almost impossible to think of a measure of humanism that you can translate into a quantitative measure. But you also get a lot of, I got, when we were doing the 80 hour work week study, which where we looked at four, the 80 hour work week and four different institutions, when we would ask the residents what professionalism was, because that was one of the research questions, they'd often pull out this little card from the ACGME and read the definition to us, and we said, is that it? And then they would complain that they were being held to standards by attendings that attendings themselves did not honor. And that was really the sticking point, was that the degree to which they felt that there was an obligation placed on them that was not shared by those who were judging them, created large amounts of resentment, and anger and discontent, and bad behavior, truly. Except now the... Now you got to get, you get measured too. I guess my question is, you did the 80 hour work week study, and you probably did it when we were first reverting, no, recently? No, I did it five years into it. 2008 to 2010. That wasn't the beginning of it? No, 2003 is the beginning. I mean, a lot of you are still in the beginning of it, but... It wasn't, okay. Because I just, to me, I would like to hear what your perceptions are, the difference between looking at the words and forgiven remember, and where they really are now in the 2000s, because I think there's been a huge transformation, and I think it has to do with humanity and professionalism. I think there's a yes and no to that. In that, when I did forgiven remember, a hernia was a five day procedure, and an appendix was a seven day procedure, so that when patients were discharged from the hospital, especially older women, they would gather the residents around the bedside. They would say, thank you so much for taking care of me. I feel really good. And then we'd sort of all have to line up and get kissed. And I suspect that does not happen as much anymore, because their shorter length, so the intensity in the acuity has gone up so much. The technologies have changed so much. The amount of coordination because of the elderly brittle comorbid patient requires so much more coordination that it's really hard to compare then and now. And I think if I go, I think I can find complaints about kind of increasing technical proficiency and a want of feeling, if I track the record back to the 1920s, I know we've found complaints about the nine to five resident as early in the literature when we were doing the 80 hour work week stuff as the 1930s. It's an amazing thing that each generation is always less skilled, less dedicated, knows less and works less hard than the one before it. And we continue to make progress. I remember getting, when I started teaching some of my senior colleagues at Penn complain that nobody was well trained anymore. And now sometimes I find myself grumbling that nobody is well trained anymore, except I realized how much more my graduate students know than I knew. And it seems to me that they're actually much better trained. And it wasn't, every generation prior to the one that they're training always had to walk up to school uphill both ways before feet were invented. May I comment? That perhaps the leaders of this hospital attended the meeting in Birmingham as well because I got an email when the electronic record started and they said when you walk into a room the first thing you should do is look the person in the eye and smile because that will be the last time that you're having to look at the person. That's not the way I practice medicine. That's the way apparently our leadership believes it's gonna be. So you talk about a transition, what's the transition? What's gonna happen in the future? Nostradamus, I'm not. So I think we're at one of those kind of liminal moments where the demands being made on the system are so contradictory that, A, one of the notions of professionalism which is that you alone own your patient rather than the patient is a distributed responsibility among a team that somehow coordinates care is gonna be the first element of change in professionalism. But one of the things that just blew me away when I was doing the 80 hour work week was that there was a conference room with computers in which residents entered orders and then there was a conference room in which nurses sat to get the orders but nobody talked to each other, nobody knew each other's names. And it just, I thought, and then there are certain parts of the system that I just seem to me that technology has made a lot of stuff that was simple, fairly complicated. So at one of the hospitals we looked at, you could only have an electronic, the only valid informed consent was one that was signed off on this little electronic E-writer. But it took hours to find one that worked. Or you had to have paper in the printer for the computer ordered entry to be received. And then the printer had to work and then somebody had to notice that the order got there. So I don't see enormous cost savings and efficiency coming from technology because I think of medicine as a human enterprise. And so it seems to me that it's better human communication not reliance on systems that are opaque to operators that will save costs and improve care. Thank you very much for this paper. I really enjoyed listening to you. I've read your works over many years and have enjoyed those as well but it was a treat. I'd like to say that I was forgiven remember when I was nine in case there were one. It was a treat to hear this paper. I was going to ask the question that you just heard about based on your insightful observations of the present. What advice do you have for the profession, for the future? But since you were a little hesitant to answer that, I'm wondering if you have any advice for those of us in the trenches today. Surrounded by these inherent contradictions that actually lead to a fair amount of hypocrisy let alone an undermining of the profession itself. What's your advice? Let me backtrack. I have a daughter that's second year medical school in an osteopathic school. She doesn't take standardized tests well. As far as I can see, you're selecting on all the wrong criteria that the MCAT score keeps getting higher and higher but has nothing to do with the actual performances that you want is highly correlated with the SAT score. And so your SAT predicts your MCAT score which predicts your US LME score which predicts nothing about your performance. So you need to find ways to brought, you need, essentially you've set up a system where you're picking people that don't play well with others. And then you're asking them to play well with others. So until you fix that, and it's like when I was grad chair, we used to get these students with these extraordinary GRE scores that I used to consider wasted GRE points because it had nothing to do with their creativity. It had nothing to do with their ability to think of a researchable problem. It had nothing to do with the tasks that they were gonna be required to do. So unless you can figure out a way, they're standardized patients and whenever my daughter sees a standardized patient and they say, you did this or that, she says, well, how can I improve? And she's had standardized patients cry because what she says is that she's the first person that doesn't say, no, I did it right, you were wrong. And until that added, until you figure out a way to select people that can work within the system that's evolving, which involves distributed responsibility, better communication skills, and the kind of ability not to produce a multiple choice answer at a context, but to think in context, I don't think you can improve. I think you're picking the wrong. I don't think that, you know, not everybody fits this, but I think you're picking too many people that have worked too hard individually and never really thought about others, never put aside their own self-interest to help a friend, never seen a sick person. And I despair at the way that that's happening. And as she's studying for the complex exam, she's now being required to memorize data that she can look up in a nanosecond. And she keeps saying, what is the point of this? And I keep saying it so that you can suffer. I mean, I can't think of any other reason other than suffering. They say that through suffering wisdom comes and so you're in a Greek tragedy. And that's the only way I can understand it. So I enjoyed your talk also and I thought that the way you set up dichotomization between humanism in terms of the caring aspects of the physician and professionalism in terms of evidence-based standards and cost-and-sistance pressures was a useful construct. But on the other hand, I think in some ways that you created sort of an over-idealized definition of humanism as an ideal in medicine in the sense that, you know, we've got to have the caring physician, but I think at the same point we'd all agree that we've got to have people that know what they're doing, take on expertise, there's some science involved and that, you know, realistically we do work under economic pressures and, you know, we need to have, we need to have sort of a silent vantage point also. And, you know, and I think in some ways, nationally people are trying to put more of the patient-centeredness into some of the system issues you've been talking about. So for example, the National Priorities Partnership, you know, Pitchton's is one of the big six, or today the first RFA came out from PCORI and, you know, the Affordable Care Act, you look at the RFAs, you know, it's embedded throughout all throughout, in terms of patient-centered language. So in some ways, what I would have liked to hear you talk more about was sort of like really the integration of the two that, you know, in some ways. Guilty is charged. I agree with you, but I felt this was more provocative. You know, this is a more challenging talk and that's the next step is to figure out, I mean, for me to figure out where they get integrated, you know, when I was doing Forgiven Remember, I remember being asked over and over again, would you rather have a technically expert boar or a friendly incompetent? And it wasn't a difficult choice for me. But it seems to me that that's a false choice. And we need to figure out, I mean, Dr. Arthur used to say, you don't have to spend a lot of time with a patient, but you have to sit down in the room. You don't have to sit long, but you have to sit down. If you don't sit down, you haven't delivered the right care and you have to put your hands on the patient. And at the same time, you said, but you can never let the family get between you and the door. So you had a deal with that sort of, you know, tension. This has been a wonderful conclusion to the year-long professionalism seminar. I do again want to thank Dr. Humphrey and the medical school and the merits program for their support and involvement in the organization of the series and in carrying it out. Again, I also want to thank all of you for your involvement and participation and our distinguished speaker at this last session, Charles Bosk. Thank you so much. Thank you. Thank you.