The essence of professionalism is to be constantly striving to take better care of our patients. “The aspiration to do better, coupled with commitment and a sense of personal responsibility will drive knowledge seeking” and empathy and compassion for those who are our patients.
And yet we know that during medical school students become less compassionate and less altruistic; the largest drops in empathy have been documented between the beginning and the end of the first year and between the beginning and end of the third year of education.
And we also know that there have been recent revelations of numerous occasions where practicing physicians have failed to live up to the ideal. The Wall Street Journal documented spine surgeons who did large numbers of spine surgery and received large payments from a medical device manufacturer. Pro Publica has shown that faculty at prestigious medical schools have failed to comply with university conflict of interest policies. A Maryland cardiologist has had his medical license revoked and his hospital had to pay back Medicare millions of dollars because of allegedly inserting stents in patients who did not need them.
How can we support our fellow physicians and medical students so that we all strive to become the best caregivers we can possibly be? Is the problem with living up to the ideal a specific problem within medicine or is it a more general problem of human nature and the current cultural environment?
I am worried that the difficulty of becoming and continuing to be a compassionate, master physician is complicated by the mixed messages that we send and receive as we practice in an environment where there is conflict between the ideal culture and the real culture. In medical school this concept has been identified as the informal or hidden curriculum where medical students sadly emulate the unprofessional behavior of physicians and staff, instead of the lofty ideals listed in the catalogue. Everywhere I look in modern society I find a similar tension between what we say our ideals are in pamphlets and guidelines and how we actually get work done and manage our careers.
Billionaire Raj Rajaratnam is a very successful investor who is a graduate of the Wharton Business School at the University of Pennsylvania, one of our best and most prestigious MBA programs. He has also been convicted on several counts of insider trading.According to a profile in The New Yorker, Rajaratnam liked to call himself a “rogue” and encouraged his employees at Galleon to “get an edge” when making investments. The article states that Rajaratnam’s view of human nature was similar to Willie Stark’s in All The King’s Men: “Man is conceived in sin and born in corruption and he passeth from the stink of the didie to the stench of the shroud.” His younger brother Rengan, who graduated from the Stanford University School of Business is quoted as believing, “Everybody is a scumbag.” My impression is that insider trading is rampant among investors on Wall Street.
The culture that Rebekah Brooks encouraged as editor of The News of the World featured cynicism, cut throat internal competition, and gallows humor. Phone hacking and using criminals as sources for exclusive scoops were standard operating procedures. “We used to talk to career criminals all the time. They were our sources,” says another former reporter from the paper who also worked for Murdoch’s daily tabloid, The Sun. “It was a macho thing: ‘My contact is scummier than your contact.’ It was a case of: ‘Mine’s a murderer!’”
“It was a don’t-get-caught culture,’ said the reporter of seven years’ standing. New staff would be given the cold shoulder until they’d proved themselves to be ‘thoroughly disreputable’ so their colleagues could trust them.
It was no place for anyone to pipe up and say: ‘This doesn’t seem ethical to me.’ That would have made you a laughing stock.” The News of the World, which was Britain’s most popular Sunday tabloid has been shut down, and at the time of the writing of this blog, the entire Murdoch media empire seems threatened by the phone hacking scandal.
At first the Murdoch executives contended that the phone hacking and questionable reporting practices were limited to a single bad apple. Now it is clear that is not the case. We are now being told that the problems are the ethics of the British tabloid press, and that the Murdoch American companies are ethically run. However, David Carr of the New York Times has discovered what appears to be a similar culture at an American Murdoch company. Paul V. Carlucci the executive in charge of News America used to show the sales staff the scene in “The Untouchables” in which Al Capone beats a man to death with a baseball bat. Robert Emmel, a former News America executive who became a whistle-blower, testified in a civil suit with a competitor that Mr. Carlucci was clear about the guiding corporate philosophy.
A disturbing and thought-provoking Christian Science Monitor article asks the question is the US a nation of liars? It summarizes the recent court cases of Barry Bonds who was found guilty of giving evasive answers to a grand jury, Casey Anthony who lied to police officers investigating the death of her child, Roger Clemens who was tried for allegedly lying to Congress about his steroid use, Anthony Weiner who resigned from Congress after admitting that he lied about his Twitter photos, and the Atlanta public school teachers who lied about tampering with student tests to make their schools look good.
David Callahan, author of The Cheating Culture, states, “Every day there’s new evidence of successful people who have cheated to get ahead, and it creates cynicism.” Douglas Porpora of Drexel University in Philadelphia, comments, “At a certain point, you’re watching all these jerks and you say, ‘What am I, a schmuck?’ A lot of people want to do the right thing, and after a while they say, ‘You know what? I’m going to follow the jerks.’”
The problem of unethical behavior in medicine appears to be part of a much larger societal cultural problem. We need to hold each other accountable; we need to speak out when we see wrongdoing; we need to accept constructive criticism from our peers; we need to provide better role models for our medical students and colleagues. We need to be professionals who really do care more about our patients’ well-being than our income or status in society.
Kent Bottles, MD, is past-Vice President and Chief Medical Officer of Iowa Health System (a $2 billionhealth care organization with 23 hospitals). He was responsible for the day-to-day operations of a large education and research organization in Michigan prior to his work with in Iowa with IHS. Kent posts frequently at his blog, Kent Bottles Private Views.