You Keep Using That Word

I. Love. The. Princess. Bride. The story, the characters, the actors playing the characters, its infinite quotability; it is one of my top ten all-time loves. (The movie is amazing, and if you love it too, get thee to the library and check out the book. Fantastique.)

One of its most easily recognized quotes: "You keep using that word. I do not think it means what you think it means." The word I've been grappling with lately? Professionalism. Not because we're misusing it the way Vizzini misuses "inconceivable" (blissfully unaware and entirely confident), but because what it used to mean no longer fits the world of academic medicine.

What It Was Supposed to Mean

The Oxford Dictionary defines "profession" as "a paid occupation, especially one that involves prolonged training and a formal qualification." Technically correct. But in medical school, I learned something richer: a profession is self-policing, holding itself to a high standard commensurate with its stakes. And medicine's stakes don't get much higher. We operate under a social contract: society grants us autonomy, self-regulation, and professional status, and in exchange, we commit to trustworthiness, competence, and devotion to the public good.

The UK Royal College of Physicians puts it this way: medicine is "a vocation in which a doctor's knowledge, clinical skills, and judgment are put in the service of protecting and restoring human wellbeing."

That's a beautiful definition. It's also, increasingly, an act we're all implicitly agreeing to perform.

Where It's Breaking Down (From Both Directions)

Here's what I see: physicians buried in administrative work, unable to spend the time with patients that genuine relationship-building requires, scraping for resources to teach the next generation, looking for every possible hack to compress more work into the same hours. That's not a profession operating under a sacred social contract. That's a workforce running on fumes and guilt.

But I want to be careful not to let anyone off the hook here, including us.

In 2001, the Boston Fire Department's commissioner replaced unlimited sick days with a strict cap of 15, docking pay for anyone who exceeded it. The firefighters' response? Sick calls on Christmas and New Year's Day increased tenfold. The following year, when holiday bonuses were canceled as further punishment, firefighters claimed 13,431 sick days, up from 6,432 the year before. As economist Samuel Bowles wrote, when people are treated as untrustworthy, they become untrustworthy.

That dynamic is alive in medicine. When a patient’s parents come into rounds suspicious that I'm withholding something, and I walk in braced for the ChatGPT they’ve got cued up on their phones, we've already lost something before anyone says a word. The contract erodes from both ends.

The Uncomfortable Question I'm Sitting With

Here's what strikes me hardest: how are patients supposed to believe we're committed to protecting their wellbeing when we can't protect our own? We're playing "do as I say, not as I do" with people's lives. We are asking for trust we haven't fully earned back, not because we're bad doctors, but because the system has made it nearly impossible to be the doctors the contract calls for.

And I'll be honest: when I started turning this over, I was ready to take on the patriarchy. I've been giving lectures on imposter syndrome lately, and on how systems designed by and for one kind of person will always make other kinds of people feel like they don’t measure up. It's hard not to wonder whether the original definition of "professional" (and who gets to decide when someone falls short of it) was built by people who look nothing like most of medicine today. I’m not out to viciously badmouth my academic medicine forefathers; they were able to do what my foremothers did not have the chance to, and I have benefited from it. But there’s something there I need to work out about how professionalism seems to be presenting itself today.

The definition may need to change. Maybe it's not about reclaiming professionalism, but reimagining it entirely.

I'm going to come back to that next week. But for now, I keep landing on one quiet, uncomfortable truth: patients are watching how we treat ourselves and each other. And what they seem to be saying, gently (and then not so gently) is: Doctor, you first.