Code of Professionalism: History

The following pages, authored by Hershel P. "Pat" Wall, M.D. in the early 1990s, recount the process that led to the development of the Code of Professionalism, a document that has withstood the changing times. In the late 1980s, Dr. Wall, at the time Associate Dean of Admissions and Student Affairs, spearheaded the effort. Dr. Wall now serves as Special Assistant to the President of the University of Tennessee.

In 1986 there emerged significant concerns among some students, faculty and administrators over the state of professional conduct on our campus. More specifically, we were concerned about students' behavior on the wards in dealing with patients, which was in many ways, unfortunately, a reflection of housestaff and yes, even faculty attitudes. This behavior was contrary to acceptable norms of professional conduct.

When one went to the student handbook one found only vague references to unacceptable behavior-and these were in terms of "Thy shall not." A small work group was formed to discuss this issue. Our group was unanimous in thinking that there is a perception that medicine is moving away from the noble goal of improving the human condition and from its primary responsibility of healing the sick and helping maintain good health. We agreed that being a professional in medicine was a privilege, not a right and that we had significant power over the lives of our patients; that it was our responsibility as physicians to bring to the profession the qualities of humanist, clinician and scientist. We agreed that basic to the practice of medicine was the respect for our patients regardless of their condition or station in life.

We decided to hold a series of forums to which all students and faculty would be invited. Professionals from the University and medical community would be asked to address important issues dealing with responsibilities of medical professionals. The series would be entitled "On Being a Professional." Early on we agreed that we needed a national figure to "kick-off" this series. We asked Alpha Omega Alpha to financially support a Distinguished Lecturer on Professionalism and they did so enthusiastically. Dr. William Webb, former Chairman of our Department of Psychiatry and currently President and Psychiatrist-in-Chief at the Institute of Living in Hartford, Connecticut was asked to be our first Distinguished Lecturer. In February of 1987, Dr. Webb at a combined Grand Rounds spoke on "The Meaning of Professionalism".

To quote Dr. Webb: "Doctors are afforded privilege and power and the medical profession does set forth ethical codes and standards of clinical practice, but I maintain that we cannot understand the professional status of doctors unless we are sensitive to the main reason why doctors exist, namely, to take care of patients. I have, therefore, said a number of times to students in these hallowed halls that it is very difficult to know how to be a doctor unless you have had the experience of being a patient. For it is my belief that only in the covenant with a patient is the professionalism of medicine given any meaning. Only when you have felt the power and influence of a doctor and only when you have experienced the relief of pain and suffering from a physician can you comprehend the true meaning of professionalism."

As part of that day long activity, a panel discussion was arranged to discuss "The Physician--Professional or Business Man?". This idea originated from our earlier review and discussion of the now famous published dialog between Dr. Arnold Relman, Editor of the New England Journal of Medicine, and Dr. Uwe Reinhardt, Professor of Economics and Public Affairs at Princeton. Among many issues addressed by the panel was the question "Does society expect physicians' behavior to be different from that of providers of other goods and services?"

Following that spectacular initiation of our year long series was a forum on "Death and Dying; How Do I Feel." Included were a surgeon, a very senior internist, and former Dean, and was moderated by an Emeritus Professor of Religion at Rhodes College who has for many years taught a course on Pain, Suffering and Death.

Next followed a panel discussion and forum by four physicians from the community entitled "Do I want My Child To Be A Doctor?" or "No Regrets". In other words, could we reassure our children of the continuing nobility and worthiness of our calling?

By this point, the work group was ready to begin drafting the document on professionalism. We had attracted a large group of students extraordinarily enthusiastic about the project!

We agreed that the document should address those responsibilities to our patients, colleagues, family, ourselves and our community. Small sub-groups were chosen to speak to these important responsibilities. It cannot be emphasized enough the time and commitment those groups devoted to the task. After many rewrites we had proposed a document by late 1987 and the Committee made the presentation in early 1988 to our constituent groups including students and faculty via Departmental Meetings. The Dean presented the proposed Code to the Administrative Council. It was adopted in 1988. Later, the County Medical Society adopted the Code for its organization as well.

The AOA Distinguished Lectures continued. One such lecturer, a Regent of the American College of Physicians spoke on "Changing Rules at Half-Time; Some Reflections on Social and Economic Issues on Health Care". He later participated in a "fireside chat" reviewing Tolstoy's, The Death of Ivan Illyich.

It is important to note that the document is designed to be a statement of the purpose of medicine in the face of a changing world. It is an attempt to refocus attention on the true soul of medicine, service, an aspect that many feel has been undermined by intrusion of new economic models in health care.

In writing the Code, we felt that it should be a very positive statement to which we as professionals could all subscribe.

Our College of Medicine has a thirty year old Honor Code to which all students are required to subscribe at the time of they enter medical school. The Honor Code deals specifically with academic misconduct therefore, we felt no need to construct our Code in such a way as to be punitive. Furthermore, as many of you know, we have an active program for dealing with substance abuse on our campus and felt that issues of drug use and abuse should be treated as an illness not necessarily as a breach of professional conduct.

This Code is presented and discussed at some length with every entering class to our school by the student members of the Committee on Professionalism. Recently, the Dean supported our request that the Code be reintroduced and discussed as part of each third year clinical orientation, and furthermore, that the orientation include new residents and interns as well. Departmental Chairmen were encouraged to reemphasize the Code at their departmental meetings.

Although we have no objective evidence that the institution of the Code has changed the behavior of professionals on our campus, it is my "gut feeling" that the presence of the Code has modified behavior among the professional staff. It is one which supports our feeling that professionalism means relationships and emphasizes responsibilities-including relationships and responsibilities first of all to our patients, but also very importantly to our colleagues, our families, our community and to ourselves.

As mentioned, the work group, now the Committee, agreed to work in small groups to address the major components of our concerns. There were many meetings, discussion over outline, debates over wording and much rewriting.

It should be noted that it was the students in our group who most often led the way-it is to them that the major credit is due.

In the final analysis, this statement can be distilled to two terms-buzz words if you will-BEHAVIOR AND RESPONSIBILITY or RESPONSIBLE BEHAVIOR.

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Hershel P. Wall, M.D.
Associate Dean, Admissions & Student Affairs
University of Tennessee College of Medicine

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