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“Communication is the central tenet in medical science“

Physician Job Profile: “Communication is the central tenet in medical science“


Photo: Axel Schmidt

Professor Schmidt; © private

Just like in modern society, the image of physicians is also subject to different developments. The physician’s profession has to constantly meet new challenges. It is particularly difficult to reconcile role perceptions, which have increasingly become more differentiated due to the modern science- and health care system. spoke with Professor Axel Schmidt, Managing Physician of the North Rhine Medical Association and lecturer at the University of Witten/Herdecke about the modern image of doctors and what kind of role basic principles such as ethics and morals play in this context. Professor Schmidt, what is meant by ethics and morals of a physician?

Axel Schmidt: Morals should rank first for a physician. Ethics represent the greater concept of moral philosophy. This is why the term ethics as such is very abstract. When we talk about morals, this term is also linked with ethos and convention. The physician’s attitude is especially important here, with principles such as personality and inner values being part of the mix.

Secondly, practical action and judgment have to also be mentioned. The doctor should consciously deliberate his/her actions, because his/her principles should be in agreement with the respective social expectations, insofar as they can be considered virtuous. It would be desirable in this context that somebody is concerned about the fundamentals of humanism and spirituality. This also makes it a commitment to medical and clinical competence and a commitment to the ability to communicate and a reflected understanding of the law – thus meaning to have knowledge about the regulatory framework.

Another virtue a physician should have is humanity, which besides excellence and professionalism is very important. The role model function of a physician, the responsibility and sustainability, particularly in a volatile and changing society, should not be forgotten – but also stability and self-discipline belong on this list. It is a challenge for the physician to implement these ideals pragmatically into his/her daily routine. This means: The physician should make these moral duties his/her guiding theme in everyday dealings. One of the most important keystones of a physician’s identity is to keep the Hippocratic Oath. It is an oath to have a respectful, social and sincere mental attitude. Is this pledge actually still relevant?

Schmidt: The Hippocratic Oath originated approximately in the year 400 BC and is considered the first fundamental wording of a physician’s professional ethics. To write the Oath in different languages is interlingually critical. It encompasses a prologue, an epilogue and many professional aspects as well as aspects of patient care.

Today it is historically significant in this form and influences the wording for modern alternatives. One of these is the pledge in the medical professional association. This pledge substitutes the Hippocratic Oath, because it is worded comprehensibly and contemporary. As a central topic it deals with the question of how medical science and medical intervention should be reconciled with each other. Generally speaking, it is a communication about the medical profession pertaining to the patient, and thus represents the medical professional ethics. The pledge particularly mentions nine virtues that are important when being a physician: humanity, conscientiousness, dignity, discretion, reverence, delivering the concepts of this profession, equality aspects like for instance gender, nationality and religion as well as steadfastness and respect.

In addition, it is pledged “to not even under threat use medical skills in conflict with the commandments of humanity“. This is an important point which unfortunately in totalitarian regimes can develop into extreme escalation and has actually already developed in this way. Today this is more important than ever. This aspect reflects the idea of steadfastness and humility. These virtues and the thus deducing mental attitude of a physician help serve the preservation and recovery of all patients. The pledge and the Medical Association have been updated time and again until a good and modern substitute for the Hippocratic Oath had been worded. The moral concepts, which were put down during the wording of the Hippocratic Oath in the ancient world, are incorporated into the pledge and more precisely stated. The Oath was also a code of ethics that pertained to the doctor-patient relationship. Now the doctor is some kind of service provider and entrepreneur. Is this a contradiction?

Schmidt: The physician needs to work freelance, and the notion of entrepreneurship and service provision in the sense of service that provides a monetary profit, should not be part of this profession. No doubt something like this exists, but it stands in contrast to the professional ethics of a physician. When it comes to the topics of “reducing suffering“ and “prolonging suffering“ there is often a conflict between the patient’s wish and patient welfare, meaning friction between what is necessary and what is feasible. This becomes specifically relevant for instance during abortion of a pregnancy, reproduction and euthanasia. How can this be reconciled with the Oath?

Schmidt: The wish of the patient is the first commandment for medical intervention. This is also constituted in this way in our professional Medical Association. To find out what the patient wants -assuming mental capacity- is a central aspect of medical intervention, but must be accepted as such by the physician. If the patient is incapable to express his wishes, responsible intervention based on the best medical knowledge and conscience, while involving the entire social environment of the patient, is recommended. In this case, the patient should be treated and action taken as conscientiously as possible. Information needs to be obtained, close family members should be included and then of course a thorough deliberation should occur. In a difficult situation, the physician must also consider whether base motives might come into play in some instances. After an in-depth consideration, an open medical decision then must be made.

During the course of rapid medical developments and the resulting ethical challenges, the German Medical Association has formulated specific issues with guidelines and recommendations in addition to the Medical Association’s professional code of conduct. This applies to for instance the "Guidelines for in vitro fertilization procedures and embryo transfer as a method of treatment for human sterility", the "Guidelines for gene therapy in human beings" or the recommendations for approaching death. Ultimately, in 1994 an independent and multi disciplinary panel was established to deliberate ethical questions of principle. The "German Medical Association’s Central Commission on the Protection of Basic Ethical Principles in Medicine" examines current ethical questions that result from these new developments. In light of social and ethical changes and the faster- more efficient-cost-effective principle: How much has the job profile of a physician changed in the past few years? How altruistic can you remain as a physician?

Schmidt: Unfortunately, it seems that our society deliberates less and less morally, and amusement and consumption replace important inner values. I doubt however, that this faster-more efficient- cost-effective principle truly reflects the central social changes. I see these changes more in a moral decline and multinationality, with which we have not sufficiently dealt with yet. The change in the faster-more efficient- cost-effective principle affects primarily the production sector, for example manufacturing. If you look at the whole issue from a moral point-of-view, it is soft factors like morals and sense of value that account for social changes.

What kind of impact does this have on the job profile? I differentiate between three criteria: The first one is about ethos, meaning how doctors themselves understand their profession. If you ask me, these social developments have no impact on professional ethics. The second criterion is job practice. There are physicians, who “go“with the times and are infiltrated by new developments, regardless of whether they are beneficial or regressive. The third criterion is the perception of physicians. This issue is a very divided one. At the start of the last century, the job profile of a physician underwent a somewhat unfortunate mystification: he was considered “the demigod dressed in white“. For the medical community it might have been better to critically and humbly challenge this image during its emergence. And thus there are the idealists in this profession, then the mainstream and then there are certainly also physicians, who would rather earn a salary that’s commensurate with salaries in the free market. Of course this is an extreme case. The materialistic seduction is so intense for a select few to where their comprehension of professional ethics is severely distorted. Such extreme excrescent cannot be disclaimed, but it is not accepted in the general medical profession. Essentially it is a question of personality. If the physician has a strong character, he will act according to his professional ethics and be adequately stable, which can be described as altruistic.

Generally speaking, you have to distinguish between “true“altruism and prudent altruism, which is the altruistic camouflage of selfishness. A guideline for doctor and patient could be the humanistic utilitarianism, which creates the largest amount of satisfaction possible for patients and physicians on a humanistic basis. What does this mean? When you combine utilitarianism with modern humanism, it becomes a sought after direction, the ethos of the medical community could move towards.

Photo: "ethics" in Scrabble letters

Morals should rank first for a physician. Ethics represent the greater concept of moral philosophy; © Andreas Gradin/ After the parliamentary debate is completed, the health care reform will most likely go into effect on January 1, 2011 in Germany. What is going to change for physicians and to what extent does this impact the modern job profile?

Schmidt: Recently, many health care reforms were adopted in succession. Meanwhile the changing reforms cause numerous uncertainties in the medical community, which are expressed to a certain degree with anger and frustration in patients and physicians. It is probably one of the reasons, why we notice that a number of German physicians are fleeing their country. I think the new health care reform is certainly not going to change that.

If you take a look at the new reform, it is less a fundamental reform of German health care but rather a tiny reform. Among other things, it affects health insurance companies, additional premiums as well as physicians and hospitals. Physicians will see a reduction in medical fees and this also affects hospital physicians. Already most physicians, especially those working in hospitals, are not adequately compensated.

The Drug Savings Act can also only be viewed ambivalently. The fact of the matter is that a certain financial contribution has to be rendered, if qualified and top quality research and development in the pharmaceutical area is meant to continue. In this particular area, two billion Euros are scheduled to be cut per annum.

Unfortunately, the reform does not address several important topics, which occupy the minds of the medical community and patients. Statements on conclusive health care concepts, family doctor care and hospital planning are missing for instance. We need a higher quota of medical specialists in hospitals for example. The care overprovision in urban areas compared to rural areas is also not addressed in the health care reform. Such types of needs assessments and planning need to more and more become the center of attention in the future. Often patients receive unnecessary examinations. This mirrors the area of tension between individualization and standardization of the doctor-patient-relationship, which is often experienced as a conflict by the patient. How could this be changed?

Schmidt: Patients sometimes receive unnecessary care, because we have a surplus of care benefits in several congested areas. We have a vast number of laboratories for instance and many other technical innovations that would like to be optimally utilized. Often during exams things are checked that are “nice-to-know“, but have no relevance to the patient’s treatment. If you examine somebody, this needs to form the basis for medical intervention. Some questionable overprovision serves the purpose of medical safeguarding. This is in part also easy to understand, because physicians are under an enormous amount of legal pressure, which is also intensified by patients.

To acknowledge a degree of pluralism in medical care is also important, particularly as it relates to individualization and standardization of patient care. Standardization is a basis, but it should not be set in stone but rather be adapted to the needs of the patient. It depends on the particular competence of the physician and how he implements all this. If this would result in tension, it would be a shame and only solvable through communication.

We have a drastic communication deficit between patient and physician, as expressed in a quote by Wittgenstein: “The limits of my language mark the limits of my world“. If physician and patient are not talking with each other on an equal footing, it results in misunderstandings and almost certainly creates tension. Additionally, it is unfortunate that this deficit is not adequately taking into account in a physician’s salary. Yet it is the conversation, the interaction, listening and responsiveness between patient and doctor that are one of the most important prerequisites for a successful doctor-patient-relationship. For me, communication is the central tenet in medical science as well as life as a whole. The physician profession is becoming more and more feminine. To which extent can women change the picture of medicine?

Schmidt: I think that women generally are somewhat more empathetic than men. You can see this especially in the bond between mother and child, which is often stronger than the bond between father and child. Ultimately, the woman is still more strongly present for the child through her role as a mother. This is also a gain for medical science. However, if you take a look at the congeniality between men and women, women in the same professional environment often interact with each other in a more emotionally charged way than men do. For medical science it definitely provides opportunities, if more women work in this profession.

A second aspect is the fact that female physicians also have babies. Since they drop out for some time in this case, in the future more flexible solutions for the working environment need and should be found. If a woman has high professional ethics, she quickly comes into conflict between her profession and childbearing. That is a pity. For the most part, working women don’t want to become pregnant, because they stand by their high professional responsibility. Women thus eventually put themselves in an ambivalent situation. This has an impact mostly on society in that it will not be as young in the future. TCM, homeopathy and other types of medicine are becoming more popular. Why do many patients not feel at home with traditional medicine anymore?

Schmidt: I have never noticed that people are not comfortable or don’t feel at home with traditional medicine anymore. The thought or the belief in traditional medicine seems undiminished to me. Other types of medicine are used as a form of complementary choice, like for instance homeopathy.

Another aspect is the handling of despair. People, who are terminally or gravely ill, unfortunately in their desperation, often turn to the worst charlatans who make their money with despair.

Generally I believe that if a certain type of medicine helps the patient and does not do any harm, nothing is to be said against continuing this type of treatment. Monetarily this only applies to medically approved therapy approaches, because otherwise you have to bear the cost yourself. When taking drugs, patients should keep in mind that everything that is effective sometimes can also have adverse effects. To achieve impact without adverse effects is to some degree not possible. A good pharmacotherapy needs to adequately balance effects and adverse reactions. At the opening of the 113rd German Medical Assembly 2010 in Dresden your boss, Professor Jörg-Dietrich Hoppe, President of the German Medical Association and the German Medical Assembly, used the phrase “a long-living society“. What does he mean by that, and what can be derived from it?

Schmidt: First of all you need to ask whether the conflict between different generations is not some self-fulfilling prophecy. The “long-living society“ after all gives us the chance to live with each other and to accomplish a penetration of the young and the old with love, respect and tolerance. On the other hand it should make us think about whether we want to continue the current development. We will only be able to continue longevity if we provide the adequate funding for it. We also need children and a supporting younger generation for this. What’s more, it seems sensible to take a closer look at the scale of frequent work overload, the so-called work-life balance.

This is why I think it’s great that our president introduced the term “long-living society“. Contrary to it is the idea of an aging society, which has a certain discriminatory undertone, which is in term topped by the term overaged society. What is the measure to evaluate a demographic aging structure? There is no guideline for it.

This is why the term “long-living society” is exactly the right one. This term highlights the grace, which we should regard with humility. It gives people the realistic hope to be able to live longer in dignity, thanks to better medical care.

The interview was conducted by Diana Posth and translated by Elena O’Meara


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