Keywords

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

The observations of these medical luminaries occurred at a time when the science of medicine was relatively embryonic. Drs. Osler and Mayo surely could not have foreseen the rapid march of medical science that occurred in the latter half of the twentieth century. They understood however that if patients were to fully benefit from advancing knowledge, both the art and science must together be applied. The discipline of endocrinology has been in the forefront of advancing scientific knowledge resulting in modern clinical endocrine practice being firmly established on a sound scientific footing. The discipline of thyroidology has progressed in tandem resulting in new insights into the genetic and biological basis of disease and in the widespread availability of highly reliable and precise laboratory tests and imaging procedures. The natural history of many thyroid disorders has been defined, and the development and publication of evidence-based practice guidelines have equipped clinicians everywhere with the tools and knowledge that promote good practice and better clinical outcomes.

The art of medicine is the means by which physicians can leverage and apply scientific insights in a manner that optimally serves the valid needs of individual patients. This in turn requires an understanding of, and a commitment to, the attributes and behaviors of professionalism. These include integrity, excellence, dutifulness, and honesty combined with superior communication skills and patient advocacy. Altruism is a central tenet of the healing mission which places patient interest over self-interest. The consistent expression of these commitments by physicians promotes the contract between society and the medical profession that, in turn, is granted certain rights and privileges through licensure [1].

Concerns over the increasing commercialization of medicine in the early 1980s prompted a call to action that included a recommitment to professionalism values and behaviors [2, 3]. The modern professionalism movement with strong ethical underpinnings arose out of these concerns. A recommitment to professionalism values and behaviors emerged and has been embraced and adopted by learned national and international societies [4, 5]. The American Thyroid Association (ATA) established and has published Clinical and Professional Ethical Guidelines for the Practice of Thyroidology [6]. These guidelines set out membership standards for clinical care, the conduct of research, managing conflict of interest, the equitable use and stewardship of resources, as well as membership responsibility to report conduct and behavior that undermine those standards. They are based upon established ethical principles of respect for persons, beneficence, non-maleficence, and justice. Ethical principles are actualized by professionalism behaviors which together engender trust that is essential for good doctor-patient relationships. The era of paternalistic medicine has passed and has been replaced by a partnership model between physicians and patients. Such a model of care improves clinical outcomes and enhances both patient and physician satisfaction.

The time-tested approach to achieving an accurate and reliable clinical evaluation and subsequent treatment recommendations includes clinical history taking and physical examination supplemented by the selection and insightful interpretation of laboratory tests and imaging procedures. The initial interaction with their physician provides the patient the opportunity to tell their story and can help build and sustain trust essential to good clinical outcome. It is undermined by frequent physician interruptions, displays of impatience, inattentiveness, and lack of eye contact. Increasing productivity expectations has reduced the time that can be spent with patients, making it imperative that whatever time is available is used to optimal effect and patient benefit. It is the mark of the artful physician to provide guidance to patience rather than dominance.

Accuracy of thyroid diagnosis is aided by the availability of highly precise laboratory tests of the pituitary-thyroid axis. Artful patient-centric care requires however that laboratory tests should be used to supplement, rather than replace, time-honored clinical evaluation. Symptoms considered compatible with thyroid dysfunction are many and varied, and several, including fatigue and weight changes, are also very nonspecific and highly prevalent among the general population. Such patients are commonly referred for endocrine consultation. Having access to test results prior to or during the initial evaluation may prompt the endocrinologist, despite his or her best intentions, to prejudge the situation. This may be communicated to patients either verbally or more subtly through body language. Empathetic patient-centric care requires that patients be given the opportunity to tell their story and undergo a focused or, if circumstances warrant, a more detailed physical examination followed by a well-communicated discussion and explanation. Such a process of care builds patient trust and confidence that promotes acceptance and a willingness to consider alternative non-thyroidal explanations for their troubling symptom complex.

Attending physicians have the responsibility to role model and champion such a process especially in the teaching environment. Prompt dismissal of the validity of patient concerns by simply reciting normal test results inevitably leads to patient dissatisfaction and increases the likelihood of further consultations and test duplication that are wasteful of limited resources and inflate healthcare costs. Persistence of such dysfunctional cycles of care leads some patients to become disaffected with the medical profession and drives them to seek help from nontraditional, unqualified individuals with questionable credentials who have achieved a prominent presence on the World Wide Web. The artful practice of medicine guided by behaviors of professionalism and skillful communication can greatly reduce such undesirable outcomes. Medical center leadership must provide support for physicians who aspire to such clinical excellence, and recommended systems approaches to achieving this organizational goal have recently been advocated for and published [7–9].

The international thyroid associations have been proactive in championing and supporting the professionalism of their membership. This is reflected in the international collaboration around clinical practice guidelines that have been published in recent years and are readily available on the American Association website (www.thyroid.org). This represents a good example of patient advocacy in practice. The development of best practice guidelines is demanding of time, requires exhaustive review of available evidence, and is followed by consensus building requiring detailed reviews and in-depth discussions that often occur across multiple time zones. The sharing of evidence-based and expert opinion with the wider medical community translates into improved care and outcomes for patients everywhere. Such a commitment reflects the professionalism of the international thyroid associations and their scholarly and dedicated membership.

The contributions of the European Group on Graves Orbitopathy (EUGOGO) serve as further examples of what can be achieved through professional collaboration [10]. This multidisciplinary, multinational consortium comprises endocrinologists, ophthalmologists, basic scientists, and neuroradiologists. Their mission is to expand the understanding of the pathogenesis of Graves Orbitopathy (GO) through basic and clinical research and to translate new knowledge into improved management of patients. The group also provides initiatives aimed at improving education and training of health professionals involved in the care of GO patients. Progress in the management of this relatively uncommon and multifaceted condition can only occur by establishing agreed-upon diagnostic criteria, measures of both disease activity and severity, combined with well-planned research investigations and knowledge sharing across multiple medical centers. GO may cause not only pain, discomfort, and visual disturbances but may lead to disfigurement with resulting emotional distress and social isolation. Recognition of this led EUGOGO to develop a disease-specific 15-part quality of life (QOL) questionnaire. This is completed by patients prior to their initial physician visit as well as subsequent visits, thereby permitting meaningful assessment of the continuing impact of disease on activities of daily living, social interactions, and other parameters. This is an instructive example of patient-centric care that fosters a trusting partnership between patient and physician translating into greater treatment compliance and improved medical outcomes which is the ultimate goal of medicine.

The advent of illness and disease invariably results in patient vulnerability due to a lessening of control over their destiny. Trust serves as an important foil to vulnerability. Patients, and more broadly society in general, are positively disposed to trust physicians as otherwise they would not seek their help and guidance. A higher level of patient trust is referred to as cognitive based and is formed through observations of the competence, character, and benevolence of physicians and the environment of care. Trustworthiness is nurtured through the consistent expression of professionalism commitments that are foundational of both the art and science of medicine. Patients are benefitted as are physicians who gain a heightened sense of meaning and purpose in their work. This improves morale, engagement, and overall sense of well-being and serves as a counterbalance to burnout that has reached alarming prevalence among the medical community. Hospitals and medical institutions are responsible for providing practice, research, and educational systems and environments that are conducive to professionalism and to the art and science of patient-centric medical care [11]. The provision of such professionalism environments provides rich rewards for the organization through improved teamwork and collaboration, staff recruitment, retention and engagement, improved patient safety and outcomes, enhanced institutional reputation, and brand loyalty [12].