“Every house where I come … only for the good of my patients.” HIPPOCRATES

There is a common understanding that the practice of emergency medicine is a profession. Under ordinary circumstances, this concept could be part of the background of the practice. Emergency physicians would operate under certain assumptions about appropriate behaviors, high educational standards, and self-scrutiny that would define emergency medicine as a profession. They are not in ordinary circumstances, however. Instead, they are in the middle of a healthcare revolution. The United States system of healthcare financing and delivery is being re-created so that costs can be controlled. Although perhaps necessary, this re-creation also threatens the fundamentals of the profession. At this juncture, emergency physicians must reaffirm and even extend important elements of medical professionalism. If they fail to do so, they threaten to lose essential aspects of their identity.

The re-creation of the healthcare system is premised on concepts that have served US businesses well so far. Competitive pressures enhance productivity, quality, and cost-effectiveness. Strong business organizations, with healthy competition, respond to the consumer to survive. Similar concepts applied to healthcare seem logical, especially to the corporations that pay for much of healthcare and must operate under such assumptions themselves. In the past, those delivering medical care never had to be particularly responsive to cost-concerns because hospitals and medical practices were essentially oligopolies, rarely threatened by competitive or cost pressures. In the care systems now being created, larger organizations are forming, financial risk is being given to those delivering the care, and powerful incentives to control costs are moving to center stage. Without debating the risks and merits of the new system, one clear danger must be recognized: the very identity of the medical professional could change. In a delivery system organized for cost-efficiency, physicians become expendable providers, not professionals operating according to self-defined standards. As physicians' personal incentives are aligned with organizational, financial, and service incentives, the new provider naturally must shift attention to corporate goals, perhaps even over patients' interests. More threatening are financial incentives applied directly to the individual physician, because the physician's financial interests might be contrary to the patient's medical interests. This setting causes mistrust and diminution of professionalism.

Medical professionalism is based on society and the individual patient's trust. The patient–physician relationship is grounded in the mutual belief that the actions of the physician are directed at the well-being of the individual patient. With this understanding, society gives physicians the right to select who enters the profession, the right to decide how the training is conducted, and the right to ensure the members' quality. Trust is created when a doctor is predictable and consistent in his or her competence and values. Trust also is necessary for good clinical care, including thorough examination, disclosure of personal information, and acceptance of treatment prescribed.<sup>1 Adams J., Schmidt T., Sanders A. , e al. Professionalism in emergency medicine Acad Emerg Med 1998 ;  5 : 12

Cliccare qui per andare alla sezione Riferimenti</sup> When professionalism is intact and trust is generated, the patient–physician relationship succeeds. Professionalism is a manifestation of values, attitudes, and behaviors that result in serving the patient and society's interest before the physician's own.<sup>15 Reynolds P. Professionalism in residency Ann Intern Med 1991 ;  114 : 1

Cliccare qui per andare alla sezione Riferimenti</sup> To act as a professional, a physician must demonstrate integrity, service, compassion, conscientiousness, commitment to clinical and scientific excellence, and appropriate behavior toward colleagues.<sup>3 American Board of Internal Medicine Project professionalism: Staying ahead of the wave Am J Med 1994 ;  97 : 6

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Furthermore, when professionalism is intact, society grants a profession the ability to regulate itself.<sup>1 Adams J., Schmidt T., Sanders A. , e al. Professionalism in emergency medicine Acad Emerg Med 1998 ;  5 : 12

Cliccare qui per andare alla sezione Riferimenti</sup> In this way, physicians set and enforce their own standards, select who enters, and function autonomously.<sup>8 D Blumenthal, The vital role of professionalism in healthcare reform. Health Aff (Millwood), 1994.

Cliccare qui per andare alla sezione Riferimenti</sup> Conversely, if this power if excessive or if there is lack of explicit attention paid to professionalism, there is consequential erosion of trust, status, and self-regulation.<sup>2 Agich G. Professionalism and ethics in healthcare J Med Philos 1986 ;  5 : 3

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In this time of healthcare financing turmoil, radical changes could occur in the way physicians are perceived and in the way medical practice is understood. Powerful incentives that cause physicians to attend to the financing of care could erode the trust of patients and society.<sup>14 Relman A. What market values are doing to medicine The Atlantic Monthly 1992 ;

Cliccare qui per andare alla sezione Riferimenti</sup> As these changes emerge, it is essential that physicians maintain the highest level of professionalism. While physicians are in the middle of change and receive unanswered questions about the financing of care, it is helpful to understand the roots of the modern practice and historical concepts of professionalism to set a course for the future.