 Welcome to today's seminar, seminar in the professionalism series. We are delighted and honored to have with us Professor Rosemary Stevens. Professor Stevens is the DeWitt Wallace Distinguished Scholar in the Department of Psychiatry at the Weill Cornell Medical College. For many years, as many of you know, Professor Stevens was at the University of Pennsylvania as the Stanley Sher Professor in Arts and Sciences in that great department of history and sociology of science at Penn. In fact, Dr. Stevens, Professor Stevens, chaired that department during her stay at Penn. Also during her stay at Penn, Professor Stevens served as the Dean of the School of Arts and Sciences. Professor Stevens is a distinguished scholar in the history of healthcare and health policy. She's published seven or eight books. Some that you may know or remember include American Medicine and the Public Interest, the book on Welfare Medicine in America, a case study of Medicaid, a book that I was coming through yesterday in sickness and in wealth, American Hospitals in the 20th Century, and more recently a book entitled The Public Private Healthcare State, essays on the history of American health policy. Professor Stevens, I know, is currently working on a new book and in fact I appreciate very much that she was able to take the time out from that project to come join us today. The talk today will be on the limits of professionalism, historical perspectives. Welcome to Chicago. Thank you. You don't say no to Dr. Siegle. I am going to give this presentation sitting down, so some of you may not be able to see me. I'm going to try to project so you can all hear me, but please tell me if you can't, right? Feel free to stand up and make sure I'm still here if you can't see me. And I'm going to run through some slides fairly fast. Liz, you have a copy of the slides and anybody who would like a copy is very welcome to ask for one afterwards. So here I am, now I sit. So I started thinking about this talk with a question, what will future historians say about 2012 when professionalism is included as an item for instruction and evaluation in medical school and residency programs? Shouldn't it be the overarching value for everything else? Well, of course it should. So we immediately start by two meanings of the word professionalism. And here, for example, this is the American Board of Medical Specialties, the maintenance of certification, meaning everybody who gets the board certificate has to maintain it. The ACGME teaches and evaluates in these areas. Here's professionalism, one of six competences. That is weird, isn't it? And here is systems-based practice. You're probably familiar, many of you are familiar with all of this. It's an oddity in history that we've divided out professionalism and sometimes as a subject to be taught and evaluated separate from other things. And sometimes this goes a little far. This is a little bit unfair to hospitalists. I'm a fan of hospitalists, but this is just to show you the title, Core Competences in Hospital Medicine from 2006. Can you find professionalism and medical ethics? Well, obviously, sitting in the back, you can't read this, but the point is, it's right down here. That little line says professionalism and medical ethics. You see? Under clinical conditions, procedures, healthcare systems. These are all chapters of the core competences in hospital medicine as there were struggles to try and define what these were in 2006. They may not be the same now, but the point I'm making is why do we take, why has professionalism become a topic? I mean a narrowly based topic with its own rules. So if professionalism is so important, it has to be taught. Why has it simultaneously first become more visible as in this seminar series and at the same time it's shrunk. Now I've been working as a professional historian now for many, many years, but I've also done inadvertent field work in that I have, since the early 1970s, I've served as a public member on a range of different medical professional organizations. These include the National Board of Medical Salmoners, the American Board of Pediatrics, the ECFMG and most recently the American Board of Medical Specialties. So I've lived through some of these debates about professionalism as something to be considered within the profession. Being a public member is another subject which is well worth a talk by somebody, but I'll just make one brief comment about this. When somebody asks you what does the public think, you don't look surprised and amazed and wondering whether this is a philosophical question or a question of pole taking. You say whatever you like. I want to muse here about medical professionalism with reference to some historical examples, idiosyncratically selected historical examples which as you will see focus mostly on the 1920s and 30s for a reason and working on the 1920s now in my current research. I also want to remind us right here as we get going on some underlying assumptions or themes. In parallel to the moaning and groaning that seems to be going on as to what a hard time the medical profession is having in terms of current pressures today, I want us to start by taking an open mind and accepting that things are actually no better or worse than they've ever been. In fact, in many ways they're much better. Think what doctors can now do which they couldn't do 50 years ago, 10 years ago even. The thinking about context dependent professionalism, obviously there isn't something called professionalism which is the same wherever you are although I'm sure that's debatable. There are a number of different meanings of what it is that you've been through I'm sure in these sessions. It is impossible to fulfill all the expectations that have been of professionalism that have been raised over time and that it follows that professionalism as a concept has both multiple definitions but also multiple limits. So my topic is about limits. All right, so much for the mindset. So I wanted to select these, what I've called, select sections. Oh, this is nice, somebody else did these slides for me. So we'll begin by taking an older assumptions about professionalism that if you belong to a professional class you have natural ways of dealing with your life, natural forms of manner learned obviously but you have certain behaviors which the public can take for granted. But that's not enough. So here's another one defining professionalism through education and credentials which is all of these credentialing kind of boards and the third is the more recent emphasis on competence as professionalism. On competence as professionalism with the competencies but also thinking about competence as an absolutely key part of being a doctor. It's not enough to behave like a doctor. It's not enough to be trained like a doctor. You have to be competent as a doctor and all of these are in the wider versions of professionalism or ought to be. So let's first begin with, and then I'm going to have a brief conclusion. So let's first begin with professionalism as an attribute of belonging to a professional class. While this title may sound like a truism obviously you are a professional because you belong to a profession but nevertheless in the early 20th century an array of professions sprang up or emerged or were strengthened including medicine, law, theology, engineering, architecture, journalism, nursing, physical therapy, many, many others. And the profession seemed to offer the prospect of having a stable professional class which would play a very important ethical role and policy role really in society. Collectively the professions might be seen as ordered, educated, trusted communities imbued with progressive idealism and there are institutions too. So this is a quote I really like. This is from the book In Sickness and in Wealth. It's a quote about hospitals as ideal institutions just to give you the flavor of the rhetoric on the idealistic side of the equation. Cities on a hill, cathedrals, shrines, places which exclude bickering. Can you imagine? But the ideal is a place where everybody works quietly together, effectively together. It does not argue. And these kinds of things right at the bottom are good feelings, engendering good feelings. And you might even be willing to die for the ideals of your profession or your institution if necessary. This is the kind of rhetoric we don't have today, obviously, but it was very important as a while and it was part of the idea of a class being imbued by certain moral values. So the sense that the professions were essential to balance out the evils of a capitalist democracy were very much clear in the 1920s. This is what I thought you might like. This is Calvin Coolidge's famous and much used quotation, The business of America is business. He didn't actually say that exactly. He said the chief business of the American people is business. And then he went on to say the chief ideal of America is ideals. It doesn't quite have the public relations and zing, does it, of the business of America is business. But I put this up to show you that there are these two ideas, the moral values of professionalism and not-for-profit institutions and other activities. He doesn't include religion specifically and set against the dirt, the clamor, the business orientation of American capitalism in the 20th century and since. Well, obviously, the idea that professions and all of their members are pure in heart, working selflessly for the good 24 hours a day is comforting. But it defies credulity. People then were no different from people now. And however pure in heart, private practitioners and hospitals of long-been entrepreneurs themselves, sometimes these kinds of myths get in the way. But I don't think it was really believed even in the 1920s that belonging to a professional class was enough. Was something special to be expected of this new class of professionals? And there was a conference in Detroit in 1919 which raised this question of what is the duty of professionals in society? Who did architects, chemists, many, many others and doctors? And talked about the interrelationships of professions. However, it was immediately clear at the conference something that would have been clear to anybody here that each profession fought for itself, wary of encroachment from many others and uninterested in a social agenda, whether you were an architect who was uninterested in cleaning up the slums of the time or whether you were a doctor who theoretically was interested in ensuring that all members of society needed medical care. And here is a nice little cry. What is a profession, said one of the speakers in this conference, same cry we have right now. What is a profession, who knows? No longer the same as it used to be. Or we think it should be. And so these are old ideas but in very different kind of settings. From that time on, from the 20s on there's been an imputed public ethic, ethos of public service by professions but it has been a fuzzy commitment with substantial limits to it. Where a major profession has been involved in public policy, it has been only too easy for its leaders to be put down for pushing an agenda in the profession's self-interest or for its members, the profession's members reject because their professional organizations are taking a position they don't necessarily all adhere to, or both at once. And you think of, well, economists, maybe economists associate themselves as experts on the economy. Physicians are not the same, don't make the same claim as experts on the medical system. And indeed, if we jump from the history of the 20s to the near present, the most interesting example of trying to get these public and private interests into some kind of sync was the physician charter of which you're probably all aware which came out now ten years ago. And it has a blog, it has actually a very interesting blog where the blog is talking about more narrow issues of professionalism rather than how to develop systems and how to commit to the three fundamental principles that are stated here, the primacy of patient welfare, patient autonomy, and social justice. Perhaps the Charter's primary value has been its strong signal of support for redefining professionalism in terms that recognize major environmental shifts such as patient welfare in modern conditions, patient autonomy in the current system and social justice given the economic system of medical care. So then we get the refocus on consumerism, quality measurement, health information technology, cost control, teamwork, ethical dilemmas, legal and payment issues and the need for organizational improvements and more the kinds of questions that are very practical and very acute questions today. A rather different assumption about a profession as a social class has been the equation of that class, an educated upper class with manners and etiquette. I can't resist giving you, I'll come back to this in a minute, this is Emily Post and she wrote in 1922 a book called Etiquette, 22 in Society in Business in Politics and at Home. And you won't be able to read this but anyone who wants to read all the details can get a copy of the slides. But very briefly, she discusses, among other things, that manners are a hallmark of civilization, they kind of wrapped into ethical behavior, they're part of morals, the moral duty people have, that there's a code of honor, she talks about the gentlemen but there were a lot of very spunky working women in the 1920s. And this would include the honor of the gentle woman as well, the inviability, poverty, incorruptibly and so forth. Making a good impression, this is still with us, she's using a business thing, if you enter a man's office and he's got his feet up on the table, you don't think he can be a very competent businessman. Well, that's sort of parallel to if you enter a doctor's office and the doctor is on his cell phone or looking at his computer, you wonder how competent that physician actually is with respect to you. So some of these things, I mean this is a very interesting book actually to read in a current context. And she also makes the point that you have to learn to project under the bottom which says the consciousness of self that you have to project yourself to be unconscious in the moment of yourself not so much because of unselfishness as having the mental ability to extinguish all thoughts of yourself exactly as you turn out the light and then you come back which is what doctors do when turning patients over very quickly concentrating totally and then coming back to oneself after. What I'm trying to tell you of course is that nothing is new that we're looking at today in many of these issues. I looked up Emily Post on Google and you may be interested to know the Emily Post Institute in Vermont still teaches business etiquette a vital piece of a professional success puzzle. Incivility in the workplace is rampant. That's what the website says. I'll just leave it at that. And what's more, incivility in the workplace which comes up to questions of cooperation working with other professions communication, handoffs, all sorts of things incivility in the workplace negatively impacts productivity as well as behavior among those working for you for uncivil superior. The point is that etiquette manners whatever you want to call them professional etiquette affects both quality and costs of the professional services you are given and that is obviously true in healthcare how physicians behave how they behave with their team how far the team is all working as a group how far physicians are willing to listen and so forth clearly affects the health the total amount of healthcare that has been given inside hospitals and outside something which does affect quality and costs and perhaps hasn't been emphasized enough in our current context. Remember the old saw manners maketh money. Right? Here's Emily again. Now, but of course there are limits to manners in etiquette. We all have heard about people who can talk the talk, walk the walk but aren't necessarily very good clinicians or giving appropriate care. So, and this was true also again in the 1920s there's a wonderful book this is a quote, long quote from Babbitt a book by Upton Sinclair Sinclair Lewis, sorry by Sinclair Lewis which came out in 1922 the same year that Emily Post was writing and Babbitt is your middle-class, upwardly mobile guy in a fictional city in the Midwest who's making it and Babbitt is a real tour and Babbitt can talk the talk of professionalism so he's driving upwards in this city of Zenith and he uses words like unselfish unselfish service he uses phrases like a servant of society he uses phrases, there's a thing like ethics he says in a parody of the language of professionalism there's a thing called ethics whose nature was confusing but if you had it you were a high-class real tour and if you hadn't you were a shyster a piker and a fly-by-night these virtues awaken confidence in clients and enabled you to handle bigger propositions but they didn't imply you had to be impractical in other words you could still sell a property which wasn't worth anything so he was talking the talk without walking the walk and so talking and behaving is obviously not enough so then other people were talking about professions in the 20s and 30s and some of these you may also have read but I think these messages are useful because the medical profession has over time been noticeably unwilling to recognize other health professions for example as of equal status to the medical profession not necessarily equal authority but equal status to the medical profession and there is more of an agenda to be worked out there many of us have been in hospitals where you go into a patient's room and there's a board and it says your nurse today is somebody is joy, you are in today's joy your nursing assistant is somebody else first name the doctor says your doctor is doctor somebody or it doesn't tell you who your doctor is at all and that's really not teamwork it's not even Emily post etiquette so let's jump on a minute to another set of writers on professions this is a classic book it's actually an English book by two writers, Car Saunders and Wilson which came out somewhat later in 1933 and it's really a sociological book about professions and the really rapid rise of professions in the 20th century in the first few decades of the 20th century Saunders and Wilson also recognized the professions as what they called anchors of society but they were more realistic in many ways than previous documents had been by acknowledging that fee for service professions were apathetic about providing for the needs of people with whom they were not personally confronted in other words they didn't have necessarily effective, broader community or social goals and we might say the same today and this book coming out in the 30s so socialization in other words government intervention as the way in which health care would be provided so professional men are not philanthropists again please add women are not philanthropists they are for a decent living in return for the services they perform that is in some respects a more realistic view of what a profession was and to some extent still is but the dialogue again has been a continuing one as to how far beyond these limits does one go I think current concerns about the decline in real income of professions of physicians has added anxiety to concern about professionalism in the last few years by questioning the social standing of the physician in the 21st century so some of these issues of social status and professional as a part of professionalism have lingered you know who am I do I have respect whose respect do I have where do I stand in the social hierarchy and all of the questions of behaving like a professional are still clearly with us but neither of these elements is enough to signify professionalism writ large you can have good side good bedside manner but atrocious skills so now we turn to my second I've got it a section because I wanted to give the illusion that this was very very carefully structured as a talk when it is in fact musings this long piece shows you that in 1901 the AMA became reorganized you go down through the Flexner Report in 1910 followed very rapidly by the American College of Surgeons the National Board of Medical Examiners and then some of the American Specialty Boards in the between 1917 and 1933 which is when I stop this slide so you can see there's a great rise of professional organizations in American medicine in the first third of the 20th century with a very strong message to focus professionalism on standardizing education professional education and providing nationally recognized or state recognized credentials you've been through all of this probably I'm just looking at Dr. Winnier who talked about the origins of the American Medical Association also found it on professional standards and ethical standards what year was that 1847 in the 20th century it got reorganized and actually became an effective credentialing and reforming force but thank you I'd love to talk to you about the 19th century part as well actually in this process two different educational movements overlapped reforming medical schools and organizing specialties they happened at the same time the medical profession rose to prominence in the 20th century because it's procedural technique as well as it's scientific knowledge hence the importance of surgery and surgeons and the slide also shows the importance of a third concurrent movement besides educational reform and specialization and that was licensing as a regulatory factor in professionalism indeed the Federation of State Medical Boards and the National Board of Medical Examiners will be coming up to their 100 year anniversaries before too long so this generated a number of continuing questions with still struggling with what to do about specialty credentials what to do about the relationship between licensing and between education and licensing and all these other things in 1933 the American Board of Medical Specialties was founded to try to coordinate different actions independent actions by different boards and this is the list of the American Board of Medical Specialties approved boards today so you can see in 1933 there were some founder members and by 1991 there are 24 boards and still 24 boards with numerous specialty examinations and now subspecialties it's an interesting structural organization so the message of medicine as a self-regulating profession for much of the 20th century was that the best guarantee of quality and public service to American society is high educational standards for medical students and later for residents later in time for medical time for residents first in the specialties and increasingly in the second half of the 20th century through the present additional training and subspecialties this policy has created well-trained experts in an increasing number of fields until today virtually every American doctor is board certified and that includes family medicine and other reforms as Charles Bryan gave a talk recently in New York and he also pointed out that the reforms made medical education extraordinarily expensive, long and expensive among the virtues of this educational approach have been the the powerhouse academic health centers the focus on science technology innovation and so forth and really for most of the time until the recent present it is assumed that producing better physicians in terms of skills and knowledge would produce better care and the ABMS has a registered trademark higher standards better care but of course we know that's not enough right? you can have wonderful wonderful subspecialties and subspecialties but they have no use if the right patient doesn't get to see the right doctor at the right time and there are some other funny aspects here too you know the organization of healthcare is going to arrive while the organization of specialty production has been like a well-oiled machine so and yet we've known for many many years these are not new issues this is 1933 medical care rate ranks as a major industry over a million people were then employed in hospitals medical personnel are not distributed in terms of need only a very small minority of consumers can make rational and informed choices and the growth of specialization is one of the conspicuous features of practice I thought you might like this SS Goldwater was a very renowned hospital administrator in New York and this is from 1927 I told you I was focused on the 1920s specialists are once the hope and despair of modern medicine and yet it's broken medicine into groups of skirmishing skirmishing competitive groups and it's made everything very very much more complicated and we know that's been known for many years but it hasn't made any difference so what about competence we've looked at defining professions in terms of status and behavior etiquette we've briefly touched on educational credentials and specialization but what about actual competence this has been a very interesting set of developments because we now have this maintenance of certification program which is very recent and was very slow to develop as tail slow I'll show you very very quickly in 1969 the American Board of Family Medicine made recertification of its diplomats mandatory and actually the family physicians have been really interesting pioneers on measurement of competence and they also came out with some kind of worrying data a few years back that showed even though there was recertification what physicians know tends to tail off over time over their time of their lives so there's not recertification one can expect much more tailing off unless there are enormous effects to keep up to date of course in the old model you're a physician because you're a physician because you're a member of the social class it was just assumed that somebody like that would naturally keep up to date but that was always I think an unreasonable assumption so competence 1972 well let's have some general guidelines for all the boards we'll have fiasco adopts and principles about recertification here they are 1975 the years are going by nine boards by 1982 have begun administering recertification programs it doesn't mean that these are necessarily compulsory but it isn't until 1998 almost 30 years after the family physicians put in required recertification it wasn't until 1998 why? because it was in the middle of the quality movement in the middle of the issuing of the IOM report to ER is human which pointed out the huge numbers of medical errors that could be detected and the need for concentrating on competence it wasn't until there were alternative ways of measuring physician quality that the professional organizations began to jump in and this has been a very very interesting and actually an amazing program to provide for new people with new diplomas not necessarily with the old entrenched whose diplomas are more like degrees than diplomas a requirement that there should be an examination it should be based on these six competences we had at the beginning so it's wider than just knowledge and skills and that's now in place it's usually typically 10 years to be taken each 10 years and generally accepted although of course there was a lot of grumbling those who faced re-examination saw it as an unwelcome incursion in their professional role in autonomy and as an unfair distinction between those with the newer diplomats and those with the older time unlimited diplomas it was assumed I think rightly that there are now so many regulators in the healthcare industry that someone else would require doctors to be re-certified so that would take care of itself okay now we move into the last gasp here hope you're still with me I'm covering an awful lot of ground here alright so now we are in before we get to the general conclusions let's make one more point and that is how do consumers choose doctors how do patients choose doctors when you get more and more and more subspecialties for example there are now 24 approved ABMS boards examine in 37 different general areas more than 120 subspecialties now some of these subspecialties are the same between boards but that raises another question which I don't think anybody's researched yet is a patient who can't sleep better off here's a question for you is a patient who can't sleep better off going to see somebody who's credentialed in sleep medicine whose primary field is psychiatry or neurology or otolaryngology or internal medicine or family medicine or anesthesiology so there you go and what about fields which are not currently credentialed like pain medicine which is now very much again once again to the four only three boards currently have subspecialties in pain medicine I hope that will change alright we're back on conclusions again and then I'll stop my sum up really is that professionalism in medicine has multiple limitations but also multiple ways of multiple definitions and that these definitions have been around for many many years and will continue to be around for many many years and with different elements of it emphasized in different periods and I've just got these I think you'll be able to read these so now when we're all worried about what it means to be a member of the middle class let alone the upper middle class a professional class a social class in this in current American society professionalism then there have to be other ways for professionalism to earn the respect of the professionals in the modern healthcare environment in one way or another and it's very interesting that during this recent period where doctors have been feeling betrayed and anxious the Hippocratic oath has come back the white coat ceremony is different forms of accrediting for status so that's number one I've got six number two primary reliance on education and professional status went by the boards years ago and yet there is still this idea that if you want to distribute doctors better you have to train more of them we should have learned in the 1960s and 70s that you don't necessarily redistribute primary care by training more primary physicians so there's a long way to go on this one too incentives in the healthcare system of long defined working roles and hence the current focus on teamwork which should be welcomed third, the quality movement is a reasonable movement and it's just taken a long time to come with its rules, records, checklists, reporting supervisory requirements and measures may not be an ideal way of doing it but the actual quality movement is something which should be applauded other occupations where an individual's life is at stake have been working in such environments for years my daughter the aircraft mechanic who always signs planes out under her own license and lives by the rules because you have to sign out every single thing it's not new, it's important so professionalism is much more than this the stated competences are though they seem to have downgraded professionalism into one of six qualities necessary for the good physician rather than a description of the whole that was not the intention of the ABMS and the ACGME in establishing the competences in the late 1990s obviously we need all of these aspects professionalism writ large however I think the categorization of professionalism as one of six competences has had the useful effect of emphasizing that professional behavior can be learned and taught and ethics can be learned and taught that professional demeanor, listening and empathy are essential for communication for teams and others and that ethics lie on a behavioral continuum so maybe professionalism as a competency will get relabelled or not it doesn't matter but I think it's been a very useful thing to do five public roles you can't expect a medical profession to change the entire healthcare system and indeed I think in some ways one can argue that the history of professionalism through medical organizations has been far more effective than the history of medical care through government or through the private marketplace so you can't expect a profession individuals may wish to engage fully in reform movements of different kinds professional organizations to change the system and the most important public role is being an excellent physician across all of these different categories and to respond to a changed environment even though parts of that environment seem unnecessarily constrictive the profession has often been slow in the past in acting as a public conscience for medical care I think that's changed I feel quite optimistic about the current status of the medical profession than being in it but last and perhaps most important was something I began with is the importance of living in the present why do we look back at history we look back at history because a lot of the things that we talked about yesterday are still in our mentality today and we need really to think clearly about what are the pressures today what are the values we would like today not being ruled by beliefs carried over from other times and this was put very nicely by Professor Stanley Fish and this really says the same thing only in more elegant language you may have beliefs an extension of beliefs but they are part of the way you think and yet you hold on to these beliefs and assumptions with an absoluteness that is the necessary consequence of the absoluteness with which they shape us so I come back to the beginning and say this institute all of you all of us who write about the professions and the professionalism are wise to think when the times move it is wise to move with them and that goes for historians too so thank you Professor Stevens talk is open for questions and comments you began I think in a very interesting way noting how competency professionalism is a weird anomalous thing I think that is very interesting we haven't heard that from anybody else but it is very interesting I wonder if that is not intention with the second slide basically everything is the same the problems are there people are no better, no worse but isn't it often the case that a law will appear and that is a clue that there is some sort of problem or something different in the time in which it appears and maybe the appearance of professionalism as a competency would be like that looking at a law that is passed because there is some sort of problem that it is trying to address so that is the case what do you think is the problem that has led to making professionalism a competency or given it all that emphasis is it just that we are anxious because we feel our middle class status is being taken away from us or something else there was this huge anti professionalism movement in the 1970s and 1980s where sociologists discovered to their horror that professions were actually working only in their own interests at least that was, I am obviously oversimplifying this for speed but the professions were actually working for their own interests both individually that professional autonomy was a word which was supposed to give the public great trust along the old idea that you should trust people because they were doctors but that didn't hold in the modern world of the 1970s and on and that as Paul Starr said in the early 1980s the corporation was coming anyway to wipe professionalism out and they needed to wipe doctors out so the AMA had been a I'm sure Paul wouldn't say an evil institution but had been a bad influence that's what my mother would say a bad influence so there was this backlash and there was true demoralization in medicine because the corporations were coming actually insurance companies were coming hospitals were getting together but also the insurance companies were coming and then we had managed care in the 1990s which threatened to which did try to regulate doctors in ways they weren't willing to be regulated and an enormous amount of demoralization partly because it was not such a preferred profession to be in in the sense that real incomes began to decline I haven't looked at the recent income figures but you probably have and there didn't seem to be the same public trust et cetera et cetera so I think demoralization is a way of looking at that Stanley Fish said because he's talking about antiprofessionalism in the 1980s that now that you have you have professionalism and you have antiprofessionalism and then you need a new professionalism to be able to reestablish in new conditions whatever you can reestablish and I think that's what's happening now I just want to enter into this discussion I'm sorry Dr. Winnier left because I in the mid-80s around the time that Professor Starr was writing his book I heard an executive director of the AMA which of course is headquartered here in Chicago say that during his tenure which was just starting his 10 or 12 years in the role of executive director he intended to make professionalism and ethics his calling card that it was a way to regain the allegiance and support of the public that it would be an argument against narrow economic self-interest it would affirm a set of values that I had not actually seen but that go back a long way and it would recapture a kind of idealism for medicine that he thought had pretty much gone out of it that depends on how you say what I just said it can sound really nasty and narrowly self-serving and I actually didn't take it to be like that as he was I mean this was his platform and he was trying out what he intended to accomplish in his next 10 years and I don't think he did that individually but I think those were the years that saw this re-emergence of this new lofty claims of professionalism that led to our seminar Well, the marketing strategy there's nothing wrong with the marketing strategy and you're saying he believed I think he thought of it as more than just marketing but there was an element of marketing, even marketing the reputation and status of the physician based on a commitment to ethical and professional ideals not unlike that original code of the AMA or the early years of the 20th century I liked how you brought in the dimension of etiquette and manners that was quite interesting to reflect on and it seems to me that it raises this question of the role of trust because I think it's sort of this etiquette and manners that can create trust in the profession to do the right thing because there's a scientific authority and I think that's always been as you traced out in the early part of the 20th century that's been the modus operandi of the AMA and the medical profession from the very beginning that we have scientific authority and you can trust us because we have the scientific authority but at some point that scientific authority only goes so far there is the mannerisms and etiquette and kind of the bedside manner and also I think the moral and the ethics the sense that if a poor impoverished person comes into our doors we will take care of them and that seems to me on those dimensions there's sort of much less agreement so you've mentioned the specialists and subspecialists and potentially fragmentation there I think definitely fragmentation but also the sort of running history of academic physicians physicians in public health and then private practice physicians which also seems to be important fragmentation that happens around this sort of trying to create professionalism with large and so I just wonder if you do you also see that as an area of fragmentation area that kind of breaks down this notion of a professionalism with large I hope things are moving beyond that because it's very almost everybody needs other people at this point in professions whether you need people in other professions other health professions to work with or you need to have good referral networks preferably you're actually working in an organization with people in different fields so it's fun and you're always learning from other people and as well as giving very good patient care you left out one thing which I think has become extraordinarily important and central and that's judgment because patients can go to the internet and they can look up all sorts of stuff these days so you need to have a judge a doctor, a patient with trust who can say alright you've got these three alternatives these are the advantages this and this and this and the patient says which would you do when this is prepared to argue for one I think judgment has become a core issue of professionalism in medicine today at all levels and that can cope with information technologies, it can cope with patients coming in uncertain and all coming in with Google references and so forth I wanted to call on Jack Jack please When I walked in this building today I had a rather striking realization because I hadn't actually thought about the fact for exactly 50 years since I was an intern in this place and I think maybe I was trying to think back as to what was professionalization 50 years ago and it was two things it was a total responsibility for the patient the intern had a fiduciary responsibility for the patient and there was no time limit I personally feel people do get tired but in 50 years ago the system here was that you were on one out of four nights but on the other three nights and I didn't know that until I came because I was quite poor and I actually couldn't make the trip from Yale to here to find this out until I arrived on the other three nights you were expected to be here until 11 and then just one other thing about this fiduciary thing one point I had a patient who came in late in the day nobody knew what was wrong with the patient and in the middle of the night I suddenly woke up and realized what the problem was a couple of blocks away and ran to the hospital and I started treating the patient for Addison's disease which nobody had thought about just started the treatment immediately in those days patients stayed in the hospital until they were better actually well sort of an amazing concept actually and this man said very little he was a man of few words but as he left this hospital Doc, if you ever want somebody rubbed out let me know I should just comment with a major win for me in a particular bureaucratic argument but this is a great great institution and I have to say I truly love the University of Chicago and this entire enterprise is I think I think characterized by the fact that more than almost any institution I know Chicago is a place where you can ask a question without actually knowing the answer it's a wonderful, wonderful place congratulations with that wonderful statement I did want the you know we have a new program with the Veterans Administration does a national search each year and identifies three candidates of extraordinary merit and then they come and do our ethics fellowship for the year I see two of them here, Thiel Kiltner and John John Wake but your new book is on the Veterans Administration Yes, I'm looking at the I started by why do we have a Veterans Administration which was founded in 1921 then called the Veterans Bureau then there was a big scandal associated with setting it up in the early years so I'm writing about the beginning of the Veterans the Veterans Administration in the 1920s and what happened, it's a really interesting story to me, I hope it's going to be interesting for you too I agree with what you said well I can't thank you enough for coming and John thank you