An actuary, a doctor and a lawyer walk into a bar. The actuary says, “The financial security of many rests on our shoulders.” The doctor says, “Make sure you are trying each time to care for the patient the way that you would want to be cared for.” The lawyer says, “Ensuring the business understands what we are obligated to do by law is an important part of helping the company best serve our consumers.”
What are all three of these individuals talking about? Professionalism.
I recently had the opportunity to talk with the actuary (Karen Shelton, FSA, MAAA), the doctor (Paula Hall, M.D.) and the lawyer (Jennifer Lundgren Lewis-David, J.D.). These are three professionals at the forefront of the financing and delivery of health care in the United States. We explored the importance of professionalism and how it has evolved as they have progressed in their careers.
Jacobs: What does professionalism mean to your profession?
Shelton: The actuarial community takes professionalism very seriously. We are viewed as experts who utilize data to make informed and unbiased observations and financial recommendations. The financial security of many rests on our shoulders, so we are required to act in the best interest of our clients, employers and the public as a whole.
Lundgren Lewis-David: As an attorney, I am required to adhere to a professional code of ethics. As part of passing the bar examination, we also take an ethics exam prior to the two-day bar exam. Once we have passed the bar and are sworn in as officers of the court, we are bound to adhere to the professional code of conduct in our state. Additionally, the American Bar Association lays out a professional code of conduct that is helpful for attorneys practicing in all states.
Hall: Professionalism means “trust.” The patient needs to be able to trust that the physician is putting the patient’s interest above all else—including profit, hospital allegiance and employment arrangement.
Jacobs: What does professionalism mean to you as an individual?
Lundgren Lewis-David: In addition to practicing within the scope of my professional code, civil discourse with all—colleagues, clients and opponents—at all times is something I strongly view as important to maintaining professionalism. Doing what you say you will do, providing the best possible legal advice you can and also offering the non-legal perspective (as appropriate) is a significant way to add value as in-house counsel. Moreover, it is imperative to build relationships with your business colleagues and deeply understand their business and strategic priorities and the industry at large—not just the specific points of law.
Hall: To me, professionalism is taking care of the patient like they are part of my family. Professionalism is not using big words; it is using words patients understand to explain their condition. Professionalism is respecting the patient as a person, not a disease.
Jacobs: How is professionalism taught?
Shelton: Professionalism is part of the actuarial profession from day one as a student and continues through the actuary’s working lifetime. It is woven throughout our exam process, and it truly underscores our education system:
- Professionalism topics are included in early actuarial modules.
- There is a capstone course for associateship aptly called the Associateship Professionalism Course.
- Many of the fellowship exams include relevant Actuarial Standards of Practice (ASOPs) on their syllabi.
- The Fellowship Admissions Course is very dense with professionalism case studies and topics.
Once qualified, actuaries are subject to continuing education (CE) requirements each year, a specific number of which must relate to professionalism topics. The various actuarial organizations in the United States offer professionalism education through webcasts and in-person meeting sessions.
There are also less formal approaches that foster a better understanding of professionalism, such as reading our Code of Conduct, Qualification Standards and ASOPs. I personally find reading the Qualification Standards and Code of Conduct each year to be a good practice. It’s a good reminder, and I often draw out a deeper application to my work.
Lundgren Lewis-David: I graduated from law school in 1997, so my experience may be a bit dated. We were offered a course on ethics in our last year, and we also were required to take a Multistate Professional Responsibility Exam before taking the bar exam. Most states have required Continuing Legal Education (CLE) for attorneys for a set number of hours. And often, as part of a state-specific requirement, there may be an ethics CLE requirement annually.
Hall: I went to medical school in the mid-1980s. The only discussion I remember on professionalism was the first day of cadaver lab. We were told that we should “appreciate the gift before us and treat our cadavers with respect.” Now I believe most medical schools hold a “white coat” ceremony on the first day of medical school, during which they talk about the sanctity of the medical profession.
Jacobs: Is there a governing body that oversees professionalism in your line of work?
Shelton: The actuarial profession is self-regulated. In 2000, all five U.S.-based actuarial organizations adopted the Code of Professional Conduct (“Code”). The purpose of this Code is to require actuaries to adhere to the high standards of conduct, practice and qualifications of the actuarial profession, thereby supporting the actuarial profession in fulfilling its responsibility to the public. An actuary who commits a material violation of the provisions of the Code is subject to the profession’s counseling and discipline procedures, through the Actuarial Board of Counseling and Discipline (ABCD).
Lundgren Lewis-David: Yes, and it may vary somewhat by state. In Maryland, for example, all attorneys are sworn in at the Court of Appeals and subject to the court’s authority. There are annual filing requirements and obligations to pay into a Client Protection Trust Fund and respond to any inquiries from the Attorney Grievance Commission.
In Maryland, we also are required to report annually the number of hours spent providing pro bono legal services and the amount of money we have donated to pro bono legal organizations. As previously mentioned, the American Bar Association helps form standards of conduct and provides a helpful ethics perspective on changing legal scenarios.
Hall: The Medical Licensing Board is the body that has legal authority over our professionalism. All of the specialty organizations and state and national medicine organizations have professionalism in their tenets.
Jacobs: Since you became accredited in your profession, has professionalism in the industry changed?
Shelton: Ever since I’ve been a credentialed actuary, the concept of professionalism always has been about operating at the highest level of ethics, with responsibility to the public, our employers and clients, and to the profession as a whole. That said, the application of professionalism has greatly expanded as actuaries work in new domains and our work often overlaps or integrates with other areas. Statements of Actuarial Opinion are now broadly defined, and we have new standards of practice developed for emerging areas.
Lundgren Lewis-David: I don’t believe professionalism has formally changed, but it has adapted and must continually evolve. Standards have gone from typing a formal memo or letter and couriering it or posting it in the mail to the more instantaneous tools of email (and even texting).
These new methods have different pros and cons. The convenience and swift opportunity to exchange information and provide advice via email or text is terrific, but there is a need to monitor tone and the potential that complete understanding may be sacrificed with quick information exchanges. Keeping in mind how your communication comes across in times of stress and how it could be misinterpreted is important.
Of course, those who use social media also may need to have a heightened awareness as to how posts and photos fit with their professional image. Moreover, ensuring appropriate protection of attorney-client privileged information—given the significant cybersecurity concerns with increased hacking, phishing and so on—is something that would not have been a core component of professional ethics 25 years ago, but it is now critical.
Hall: Almost everything in medicine has changed! I would like to think that the one thing that has not changed is our professionalism. Unfortunately, I don’t think that is the case. Physicians seem to spend more time talking—and one also would assume thinking—about their compensation. When I started my practice of medicine in 1987, I was told, “Take care of your patients and they will take care of you.” Unfortunately, you can go broke taking care of your patients.
Medicine has become a big business. Insurance, coding, electronic medical records and so on all require a level of expertise. The average physician who is trying to take care of patients may not have the skill set—and certainly does not have the time—to master all of these entities. Because there are only so many hours in the day, time spent with patients or thinking about patients has been sacrificed for these other components of the business of medicine.
Hopefully, the push toward value-based care will swing the focus away from data entry and back on caring for the patient. According to the National Academy of Medicine, 50 percent of physicians report “burnout.” I believe this is because each day we spend a tremendous amount of time and effort checking boxes and jumping through hoops instead of just caring for patients.
Professionalism may have changed in definition, adherence, importance and how it is taught. I believe medical education recognizes there is a bigger need to lecture about professionalism, because students do not have the strong role models they once did.
Jacobs: From the time you became accredited in your profession, have you personally changed the way you think about and view professionalism?
Shelton: When I first became credentialed, professionalism was mostly about performing my calculations with care and full disclosure. As I have grown in my role, professionalism has become something deeper. I am more aware of the broader implications of our work as actuaries, particularly as data gets bigger and innovation continues to accelerate at unprecedented levels. We are being asked to step into new areas, sometimes with few historical references on how our products will work. Our ASOPs and the ABCD are there to provide guidance as we evolve, which is a comfort.
Hall: No. I still think a physician who displays professionalism is a doctor who takes care of their patients like they would want one of their family members to be cared for.
Jacobs: Do you think the public knows your profession must adhere to professionalism or follow a code of conduct?
Shelton: There’s a large portion of the public that doesn’t know about the actuarial profession at all, let alone that we have a Code of Conduct. We have a small presence in the United States, at around 25,000 professionals, according to the Bureau of Labor and Statistics. (Comparatively, there are more than 800,000 lawyers and 750,000 physicians/surgeons.)
Once I explain generally what I do, the response is often, “Oh, you’re the one who makes my premiums go up!” While premiums in health insurance often outpace inflation, it is due to underlying costs and not the actuary trying to make egregious profits. We are prevented from doing this through our Code of Conduct, but we also are required to ensure the financial security of the products we develop.
Lundgren Lewis-David: There have been so many TV shows and movies (good and bad) that showcase the legal profession, so I think most people are aware that lawyers are subject to professional codes of conduct and can be disciplined or even disbarred for significant violations of that code of conduct. Personally, I am a big fan of all of the Law and Order shows!
Hall: I believe the public knows an unprofessional physician when they see one. My guess is people talk with their feet and leave the physician who acts disrespectfully or without the patient’s best interest at heart. If the behavior is egregious, then the public will make a complaint to the Medical Licensing Board.
Jacobs: What has been easy or difficult for you on your journey of being a professional?
Shelton: There was a specific instance where, despite robust peer review, a mistake was made in a new model for which I had oversight. The financial impact was not insignificant. We worked with the client to disclose and quantify the error in a timely manner.
To learn from this experience, I tried to understand how this could have been prevented. I reviewed relevant ASOPs and the Code of Conduct. There was not an approved ASOP on modeling, though there was an exposure draft that I consulted. Because actuaries work on a variety of different models that vary widely by practice area, the exposure draft was very broad. Therefore, I consulted the ABCD. The board member with whom I worked was prompt in responding, fostered an open dialogue and provided good insights. In the end, I had followed the applicable ASOPs and adhered to the Code of Conduct. Going through this process gave me a deeper appreciation for professionalism as an actuary.
Lundgren Lewis-David: Starting my legal career at age 24 (and being 5’2’’), I looked about 14 years old. Advising clients in their 40s and 50s was a challenge because they saw a reflection of their kids when they looked at me. I had to make sure to be especially professional, extremely well-prepared and very forward-thinking about their specific business needs.
In addition to being the youngest (and often the only woman) on the executive team for the early half of my career, I had to find my own style to ensure my professional attorney role stood apart while still being on the overall leadership team. At my company, we use culture principles—two of which are called Leadership Shadow and Assume Positive Intent—and they have been very helpful in increasing my self-awareness. This in turn helps me maintain the level of professionalism to which I aspire, as I am conscious of how others will perceive my behavior and tone. I also now recognize that a frustrating situation is not helped by reacting emotionally—instead, I should assume the other person had positive intent.
Hall: I never in a million years would have thought that I would be involved with a case of “wrong-side surgery.” From that case, I reconfirmed how important trust is in the doctor-patient relationship. But what I learned for the first time is integrity isn’t something we are born with; it is something we need to work on every day. Integrity is being whole. It is being true to your best self even when it is inconvenient, uncomfortable or, worst of all, terrifying! Integrity is about ownership of your own performance. Part of professionalism is realizing that you are not always going to be right; so, it’s critical that you make sure you are trying each time to care for the patient the way you would want to be cared for. (Even better would be to care for the patient the way they want to be cared for.)
Jacobs: Is there anything else you want to say about the topic of professionalism?
Hall: Professionalism in medicine is the only thing that makes medicine a calling. If professionalism disappears, then it will just be a job. When you are asked what you do for a living and instead of saying you are a doctor you reply with where you work, then it has become a job.
Jacobs: Since you are all in the health care space, what do you wish consumers knew about the doctors, attorneys and actuaries who work in that arena?
Shelton: We really are working for the best interest and financial stability of the industry. Most health actuaries care deeply about the affordability and quality of the health care industry, and we are heavily involved in developing products and engaging in initiatives to address these issues.
Lundgren Lewis-David: Working in the health care space as an attorney is incredibly challenging—at times exciting and other times very stressful. We are in now, and have been for some time, one of the most disruptive and fast-changing regulatory health care law environments ever. Literally, the laws and regulations governing the businesses I support change every day! Moreover, because we operate different product lines in the commercial and government space under difference licenses, we have more than 50 state regulators (different regulatory agencies in each state). It takes a team of highly engaged attorneys, compliance staff and other legal professionals to stay on top of all the changes and their impact on our members, providers, business partners and internal operations. At the end of the day, ensuring the business understands what we are obligated to do by law is an important part of helping the company best serve our consumers.
Hall: I want people to remember to ask the questions: “What would you do… What hospital would you go to… What specialist would you see… if it were you or your mother or your husband?”
This takes out all of the extraneous noise and reminds the physician that the insurance, the coding and the electronic medical record are secondary to the needs of the patient.
You’ve now heard from three different professionals from three completely different walks of life. Yet, professionalism runs deep in each of them. We see that there is no “joke” when an actuary, a doctor and a lawyer walk into a bar together. Instead, we are left assured and optimistic knowing that these professionals are working in the financing and delivery of health care in the United States.
Let us all lift a glass to professionalism.