editor's note: This Curbside Consultation continues the discussion on physicians as role models that was started in the March 1, 2007, issue of AFP.

Case Scenario

Medical professionalism includes the obligation of physicians to live not only an ethical life, but also a healthy one. In a previous Curbside Consultation, a physician asked if obese physicians can be effective in motivating patients to be healthy. How does this modeling apply ethically to the physician's role? The effects of some unhealthy habits, such as overeating, are more visible than others. Does it matter if our habits are visible to our patients, and do we have the right to counsel them when we are not healthy ourselves? To what extent do patients expect us to be role models for them, and to what extent should we expect this of ourselves?

Commentary

The basic questions asked in the scenario are whether physicians should always “practice what they preach,” and whether a physician's personal life should be accessible and relevant to patients. Professional role models are important. For example, a person would be unlikely to seek advice from a financial advisor who has filed for bankruptcy.

Are physicians required to have perfect behavior before they can give advice to patients? Can physicians offer therapies to the best of their ability, irrespective of whether they follow the same recommendations? The research in this area is scant and provides little guidance. One study showed that the patients of overweight physicians are less receptive to the physician's counseling about weight loss.¹ Essays have commented on the importance of physicians as role models when counseling patients on lifestyle modification.^2,3 While serving as president of the American Academy of Family Physicians, Michael Fleming, M.D., (Shreveport, La.) emphasized lifestyle modification and disease prevention and launched a public campaign about his own weight loss as a model for family physicians and their patients.

The lack of objective research and the paucity of personal opinion and essays on this subject may reflect how difficult research in this area can be. However, I believe physicians understand how visible their behaviors are to patients but may be uncomfortable acknowledging and addressing that fact.

Understanding how physicians' personal behaviors relate to their professional responsibilities requires an assessment of the specific type of intervention being made, which is highly contextual and specific to the patient's clinical problem and personal needs. Is the physician intervening at a molecular or pharmacologic level (as an objective scientist whose role is to understand fundamental pathophysiology)? Is the physician intervening surgically (the outcome is determined primarily by the surgeon's cognitive and psychomotor expertise)? In these cases, serving as a role model is less important than ensuring the best possible technical results. For example, if a person fears flying, he or she would expect the pilot to be technically able to fly the plane but not be an expert at providing emotional support.

I have often heard patients say they do not care if the surgeon I am referring them to has a good bedside manner, they just want to know that the surgeon is able to perform the surgery effectively. On the other hand, if the physician is intervening behaviorally, the physician's personal values, attributes, and behaviors are as influential as his or her psychological and educational expertise. In that sense, whether or not the physician's habits are visible, the physician has some obligation to practice what is preached.

Although it is desirable for physicians to espouse behaviors consistent with their moral and personal values, setting a positive example does not mean that physicians have to have experienced everything a patient is experiencing. For example, I have never had a myocardial infarction, but I can offer competent services without that personal experience. I can also provide basic emotional support to a patient with myocardial infarction based on my observation of other patients and my understanding of the research on managing the disease. However, deep personal empathy with the depression often experienced by a patient after a myocardial infarction would be more difficult.

If physicians cannot and should not expect to have the same experiences as their patients, what are the requirements of serving as a role model? I would hope that a physician could effectively counsel the parents of a child with behavioral problems even if the physician does not have a child with similar problems. The same is true for counseling patients who abuse alcohol, even if the physician has never been intoxicated.

An interesting question is whether certain physician behaviors or experiences are counterproductive in providing effective counseling about lifestyle modification. If a physician lost 150 lb through lifestyle modification, the physician might counsel patients more effectively or could be more intolerant of their failure. A female physician's personal experiences with pregnancy might make her more compassionate about the common symptoms of pregnancy or could make her more dismissive of a patient's complaints.

The ethical basis of physician behavior probably has more to do with motives than with the behavior itself. Physicians are as imperfect as patients; therefore, expecting a physician to always follow recommendations he or she gives to patients, while intuitively reasonable, is probably not appropriate. A physician's personal decisions are relevant to patients but in different ways, depending on the circumstances and clinical problem. Ultimately, physicians should use their personal behaviors and experiences for the benefit of their patients in a way that is well intended, with a clear analysis of why they are disclosing their personal behaviors, for what purpose, and to what end.