Beginning the Journey

A journey of a thousand miles begins with a single step. – Lao-tzu, Chinese philosopher (640 BC–531 BC) The journey is the reward. – Steve Jobs As I embark upon a new journey as editor in chief of Academic Medicine, I have been thinking about other journeys I have taken. As a college student I traveled to the Philippines as a volunteer teacher, where I learned far more from my students than I taught them. In medical school I went to Tanzania and received the most wonderful gifts of friendship from people who had no material wealth. Most recently, I have been working in Washington, D.C., as a Robert Wood Johnson Health Policy Fellow and as a staff member of the Senate Finance Committee, where I have been privileged to be part of a dedicated team. My daily observations as a Fellow contradict the negative news stories I read, making me wonder why my perceptions and the media’s differ so much. Now, as the new editor of Academic Medicine, I have the opportunity to use these lessons and others to help me work with authors, reviewers, and the editorial staff to guide our journal in the presentation and dissemination of important and novel ideas and programs, especially innovative ones. Academic Medicine will bring together thought leaders to surprise us, entertain us, and provoke us to question conventional wisdom with the utmost integrity and respect for the truth. The journal will engage our communities using the latest technology to keep discussions that begin on our journal pages alive and vibrant on the Web. Over the next year, I hope to introduce themes about challenges we in the health care community face, to stimulate our creative thinking. I will use these themes to organize collections of articles and commentaries. For this editorial I have selected the theme of the development of professional identity. Professional identity grows out of the relationship between the healer and the sick, the most sacred, core responsibility and privilege in medicine, wherein the healer takes responsibility for the patient, the patient cedes trust and responsibility to the healer, and in the process something powerful and magical occurs. Because of the power invested in this process, healers—whether physicians, nurses, physician assistants, pharmacists, or dentists—are granted certain privileges, such as self-regulation. The clinician agrees to behave in a competent and responsible manner, putting the patient’s welfare above all other considerations and trying to imagine being in the patient’s shoes. (I use the terms clinician and healer to mean all members of the health care team working together in the service of the patient.) The professional identity of clinicians—all health care team members—is currently threatened by two forces: the commodification of health care and the deterioration of the health care environment. In the commodification of health care, medical services are viewed as products that can be bought and sold in the marketplace like clothing, food, or other items. The business of health care, with money flowing between insurers and health systems, is replacing the relationships between individuals. Health clinicians are viewed as technical experts who contribute to the product and compete with each other in the marketplace, much like chefs at rival restaurants or singers on American Idol. The other force negatively affecting professional identity is the deterioration of the environment of health care. CT scans and ultrasounds have virtually replaced the traditional physical examination, and computers have invaded the consultation room, interposing themselves between the clinician and the patient, diverting the clinician’s attention from conversations with the patient to the documentation requirements demanded by payers and employers. In busy clinics it is not unusual to see all the providers at their computers entering data and orders and reviewing results while the patients are alone in their rooms. Person-to-person communication between clinicians and frontline staff has almost been supplanted by computer notes, alerts, and flags. The new generation of residents, physician assistants, and nurse practitioners is much more comfortable focusing on the technology in their hands than laying their hands on the patients. They prefer to read the screen, searching for a probable diagnosis, rather than to talk with the patients to determine what brought them to the clinic in the first place. The emergence of business values and pressures, on top of these changes in the health care environment, threaten professional identity.1 How is our journal to create a new sense of commitment to the clinician–patient relationship and the development of professional identity? I suggest three ways in which Academic Medicine can help protect and nurture professional identity. First, the journal can encourage further dialogue about the role of economic pressures in eroding professional identity and can promote strategies to address these issues at the national and local levels. Awareness of the nature of the problem and recognition of the presence of allies make action possible. Fundamental questions, such as whether health care is more of a public good or a business, can lead us to rational options and alternatives. Questions of this magnitude must involve not only the academic medical community but also the larger medical community, the public, and the elected officials who represent them. While insurers and the government consider alternatives to fee-for-service payment such as bundled payments or capitated payments, the journal will encourage dialogue within our communities concerning the impact of these new payment strategies and professional affiliations upon the professional identity development of our students, residents, and faculty. Second, the journal can encourage discussion about how to guide the changes in the environment of care to stimulate the development of positive professional identity. Technology can be used to enhance, rather than detract from, clinical care, when designed by end-users. When technological changes appear to negatively affect the clinician–patient relationship, the journal will encourage introspection, inspiration, and innovation. Just as we would expect researchers to assess the risks and benefits of any new test before introducing it to patients, the architects of technological changes in the clinical environment must be challenged to articulate how their changes will influence the professional relationship with patients. Finally, Academic Medicine will provide a forum to share the stories of our patients and our relationships with them. These stories are powerful because they provide faces, places, and situations that are genuine. Professional identity does not appear suddenly one day; it evolves over time, and there are often sentinel events and experiences that accelerate the attachment of professional identity to our individual DNAs. These events and experiences can be captured in stories that we can share and celebrate. One of the journal’s goals is to influence public policy through scholarly debate, and the stories of students, faculty, and patients can help. They will also be a powerful antidote to the erosion of professional identity. The professional identities of faculty and students at academic health centers encompass not only the mission of clinical care but also the missions of research and education. The spirit of inquiry that characterizes research also characterizes the diagnostic process. Also, the connection between student and teacher is similar to the connection between clinician and patient. Finding the connections in our identities across our missions will allow us to support each other to work as a team. As editor of Academic Medicine, I will advocate integration of and excellence in all our missions. I will continue to encourage high-quality education scholarship, which is vitally important to our community’s identity. I will do my best to make sure that the time you, as members of the academic medicine community, spend reading journal articles will be time well spent, because those articles will continue to be of high quality and relevance. Also, the time that some of you spend writing articles that are accepted for publication will be time well spent, not only because you will be making a contribution to the journal’s readers but also because the journal’s reputation for excellence will continue to resonate with tenure and promotions committees. Professional identity can be a unifying value that helps us to reflect daily on who we are and how we are using our time. Professional identity can even be a legitimate topic for scholarship, integrating humanities, ethics, social sciences, and health services. Academic Medicine can promote the scholarly study of professional identity2 across the health professions just as it already promotes the scholarly study of teaching, learning, and the organization of health services and research. By giving wings to our community’s best ideas in all these areas and propelling them forward, our journal can help our community to enjoy and learn from the journey as well as the destination.