Abstract
‘Our Lives begin to end the day we become silent about things that matter.’
Martin Luther King
The transition from idealism to pragmatism in medical practice is commonly viewed as an inevitable response to the commercial realities of national healthcare systems. In the UK, the final report of the Independent Inquiry into the Mid Staffordshire NHS Trust provides a graphic illustration of the current demise of idealism in healthcare. Patients were routinely neglected and provision of quality and safe care was abandoned in favour of cost-cutting and other politically correct mandates. 1
We should not, however, be surprised at the evolution of this catastrophe, representing, as it does, a total abrogation of the idealism which, for most healthcare workers, characterises the initial contact with their chosen profession. Idealism, as generally perceived, may be defined as ‘the cherishing or pursuit of high or noble principles, purposes or goals’. In 1910, at the opening of Columbia Medical School, Christian Herter noted that ‘without idealism of purpose… the career of the student or practitioner of medicine is almost certain to be pitifully limited and mediocre’. 2 A century later, several studies have reported progressive disaffection and loss of idealism in medical students and young doctors as they progress through their training.3–5
George David Stewart, in his 1927 Presidential address to the American College of Surgeons 6 noted that ‘the medical curriculum, crowded by new discoveries and cramped by the demands of Examining Boards, has become too rigid, leaving little time for the teaching of ideals’. Pressures on time for teaching within the medical curriculum persist to this day and we must inevitably contemplate alternative strategies if we are to reverse the apparent loss of idealism in current medical practice.
An essential component of medical professionalism is the acquisition by the student of appropriate attitudes and values. Does this inevitably require that we should include the teaching of ideals within our undergraduate curricula in pursuit of this necessity? It is, perhaps, too simplistic to entirely ascribe the effective denigration of idealism to the materialism of medical practice and the budgetary constraints of the healthcare environment. In the UK, the National Health Service (NHS) has, until recently, protected the profession from the pressures of commercial reality. This scenario, in an age of financial consolidation and changing demography, is no longer sustainable. Perhaps of greater concern, however, has been a consistent failure, over many years, on the part of some of the medical establishment to recognise the value of idealism in pursuit of the goals of ethical and equitable healthcare for all. The erosion of personal responsibility for individual patient care and the increasing implementation of shift-working patterns have promoted inappropriate deference to collective, and impersonal, decision-making.
What can be done to reverse this trend? Smith and Weaver 5 demonstrated the beneficial effects of a well-structured, mentored experience in international health on pre-clinical students’ attitudes and interest in serving under-served populations – all measures of idealism. More recently, the Academy of UK Medical Royal Colleges has recognised the importance of volunteering for both personal development and engagement in Global Health challenges – this applies to qualified personnel and undergraduates alike. Action is now required in order to facilitate this process in an ethical and equitable context. The shift towards increased collaboration between UK training institutions offers major new opportunities in the pursuit of shared ideals especially when such partnerships are extended to include overseas agencies. Such collaboration values and reinforces concepts of idealism, altruism and personal integrity – all core characteristics in healthcare endeavour. Excellence and quality are achievable when patients and healthcare professionals act together in pursuit of shared ideals and aspirations provided that they are supported by equitable health systems and finance. We should appreciate that the current enthusiasm, demonstrated, in particular, by so many of our students and younger colleagues, for greater engagement in Global Health Challenges reflects an appreciation of the major therapeutic benefits of this approach for the individual, the NHS and overseas partners alike.
Michael Marmot’s studies on the social determinants of health support the role of all healthcare workers as advocates for health as a human right for all. The WHO European review of social determinants of health and the health divide 7 is a compelling endorsement of the rationale for the idealistic approach to health and wellbeing. In addressing new themes, the report notes that ‘Human rights are central in our approach to action on the social determinants of health; human rights embody fundamental freedoms and the societal action necessary to secure those freedoms’. Engagement in advocacy of this type has not, historically, characterised the behaviour of many UK healthcare professionals. As stated in the Francis report, ‘Individual patients and their treatment are what really matters’. This observation remains true wherever in the world patients seek assistance. For our young students, full of ideals and entering our profession at the start of their careers, this assertion is implicitly valid. Engagement with Global Health challenges and appreciation of the fundamental need to redress societal inequity in pursuit of improved population health reinforces their appreciation of this truism. Why then have we so often been tacitly complicit in relegating idealism in favour of politically correct behaviour?
We must foster new cohorts of advocates for altruism and idealism in healthcare. In recruits to our profession these characteristics are to be found in abundance and yet, too often, materialism and ‘pragmatism’ dilute or extinguish compassion and dedication – characteristics to be anticipated of our profession. Patients, recognising the merits of superlative care, are our partners and fellow advocates for these ideals. Medical leaders must now nurture these attributes more effectively, reinforce them in combating negativity and burn-out and recognise why they remain valuable for the health of our nation and as relevant today as they were 100 years ago.