Defining Professionalism

Political, academic, and business leaders have recognized the importance of professionalism and described its characteristics. Justice Louis Brandeis [1] believed a profession had three features: training that was intellectual and involved knowledge, as distinguished from skill; work that was pursued primarily for others and not for oneself; and success that was measured by more than the amount of financial return. Other writers [2-4] have emphasized the importance of self-regulation and autonomy in clinical decision making as hallmarks of the medical profession. Some have noted the existence of a code of ethics that sets forth a standard of conduct [5, 6]. This paper considers medical professionalism and its inherent dependency on a formative community.

As a working definition, medical professionalism is a set of values, attitudes, and behaviors that results in serving the interests of patients and society before one's own [7, 8]. Honesty and integrity are values essential to medical professionalism. The professional physician has an attitude of humility and accountability to patients, colleagues, and society. Professional behaviors include a nonjudgmental and respectful approach to patients, the pursuit of specialized knowledge and skills with a commitment to excellence and life-long competency, and a collegial and cooperative approach to working with members of a health care team in the delivery of patient care. Lastly, community service and public leadership reinforce the responsibility of physicians to fulfill the goals set forth for the profession by the public. In exchange for putting the interests of the patient and public first, physicians are accorded trust, respect, and the confidentiality of patients.

The Education Community

Although many factors threaten professionalism in medicine today, perhaps most destructive is the gradual disintegration of the education community, which hinders the transmission of values and behaviors. Physician socialization requires the assimilation of values into a personal framework. Similarly, professional conduct is shaped through interactions—or the lack thereof—with faculty, peers, and patients [9-11]. Because the learning of values and behaviors best occurs in a community with explicit expectations, medical professional education requires role models. The traditional model of medical education implemented by Osler and Halsted [12] emphasizes active learning by students working in the clinics and on the wards under the close supervision of full-time faculty. Embedded in that tradition is a community of physicians who uphold similar values and behaviors.

The presence of an education community in medicine is precarious, yet its existence is essential to the profession. John Gardner, former Secretary of the Department of Health, Education, and Welfare, recently described the future of a community:

If the community is very lucky—and few will be in the years ahead—its shared values will be embedded in tradition and history and memory. But most future communities will have to build and continuously repair the framework of shared values. Their norms will have to be explicitly taught. Values that are never expressed are apt to be taken for granted and not adequately conveyed to young people and newcomers. Individuals have a role in the continuous rebuilding of the value framework, and the best thing that they can do is ... to exemplify them [13].

The loss of an education community in medicine and the threat to the assimilation of professional values, attitudes, and behaviors have been accelerated by the specialization of medicine, the service demands of residency caused by the economics of health care, and the faculty reward system.

First, specialization has contributed to a diminishing sense of a shared value system and a weakening of the relationships among the faculty and housestaff and medical students. Over the past 30 years, the size of the clinical academic faculty increased more than 600%, in part to expand the delivery of specialized medical care [14, 15]. Feelings of collegiality and commonality among a core teaching faculty within a small department have been replaced by closer affiliations to and identification with the goals and values of a specialty division, a research team, or a clinical practice group. Specialization also has fostered self-interest and, at times, intense competition among physicians for patients, institutional resources, and control over diagnostic and therapeutic technology [16]. Furthermore, with the expansion of fellowship training, the specialty-oriented faculty in academic medical centers shifted the focus of teaching to fellows. In 1990, in internal medicine alone, more than 8000 fellows were engaged in subspecialty training [17]. The apprentice relationship that united the senior clinician and house officer now exists between the attending faculty and fellows. The layering of fellows between residents and faculty jeopardizes mentoring of residents and medical students, which is critical to fostering professionalism and sustaining an education community.

Second, the faculty reward system that favors publication and presentation rather than teaching also has undermined the education community [18, 19]. Travel by airplane has facilitated the process, as has the continuous growth of medical journals. Before air travel and national funding of basic science research, faculty rarely left an institution. They wrote papers on the train and only occasionally submitted a grant application. Otherwise, they spent most of their time teaching residents and medical students, caring for patients, and leisurely doing research. Whereas residents face increased pressure to admit more patients, the faculty face increased pressure to do research and publish, to participate in national medical organizations and research conferences, and to accept visiting professorships. Lost from the hospital wards is the constant presence of the master clinician-teacher, a person essential to maintaining an education community [20].

Third, the service demands of residency, driven by the economics of health care and combined with the loss of senior clinician role models, have contributed to a lower standard of professional conduct on the clinical wards [9, 20-23]. Previously, the attending physician was both a master of the art of medicine and its knowledge base. Residents worked hard, yet the attending physician expected them to serve as exemplary role models to medical students. Today, the attending physician does not have time to conduct a thorough history and physical examination, including a social history, at the bedside. Similarly, residents spend between 17 and 31 minutes evaluating a new patient when on call at night and 25 minutes during the day [24-26]. Worse yet, physicians-in-training now often encounter a patient for the first time on the operating table [27]. That more acutely ill patients are admitted to and discharged from the clinical wards more quickly ("sicker and quicker") means that residents experience the anxiety with less gratitude and positive reinforcement for their professional service [28-30]. In the context of "lightning rounds" and the demands of a busy clinical team, a substantial number of medical students reveal that they have documented in charts physical examinations of patients that were not done (unpublished data). Nearly all medical students report hearing residents and faculty refer to patients in derogatory terms, and usually think such terms are inappropriate ([31]; unpublished data). Confidentiality, and at times the desires of patients, go unheeded. When queried, residents reported that after they had made a mistake, only 24% notified the family, and only 54% told a supervising physician [32]. Physicians-in-training notice the professional and unprofessional conduct of more senior clinicians. This is how they learn the behaviors—good and bad—of doctoring.

Unlike the harried resident or burdened faculty, the master clinician regarded teaching and patient care as a calling. The relation between the loss of community and the deprofessionalism of medicine is best understood when considering the difference between a calling and a career. When one enters a profession as a calling, one assumes a definite function in a community and operates within the civic and civil rules of the community [2, 33, 34]. When a profession becomes a career, the orientation is to impersonal standards of excellence, operating in the context of a national occupational system. To follow a profession has come to mean to "move up and away." Consequently, the goal is no longer participation in a local community but rather "the attainment of ‘success,’ and success (depends) for its very persuasive power on its indefiniteness, its open endedness, the fact that whatever ‘success’ one had obtained, one could always obtain more" [33].

The same system that deemed National Institutes of Health grant awards and peer-reviewed journal articles to be the standard of excellence may have diminished medicine as a calling and as part of a community. Research became subject to the review of authorities outside of a home institution. Although this provided a national standard of quality, it contributed to the faculty's pursuit of "outside" funding. Additionally, patient referrals to academic medical centers for sophisticated diagnostic technology and medical therapeutics put distance between the physician and a local patient population. Divorced from a local community, medicine gradually lost its professional "calling" and became more and more a "career."

Suggestions for Reaffirming Professionalism

Given the importance of medical professionalism and the decline of the education community, which is critical to fostering professional values, attitudes, and behaviors among physicians, what are we to do? I suggest four steps: 1) Create an education community focused on a core teaching faculty, continuity of care within a stable patient population, and structured learning time; 2) develop programs for role modeling and mentoring, and reward activities among the faculty that support these programs; 3) implement a curriculum on medical professionalism, including seminars and community service activities, and an academic commitment to teaching professionalism; 4) evaluate physicians-in-training and faculty on their professional conduct.

Creating Community in the Hospital and Clinic

The in-patient hospital environment may, in fact, be unable to sustain an education community. To enhance the possibility that it might, however, faculty, residents, and nurses should be grouped together into teams or firms that follow a stable panel of patients inside the hospital. Patients assigned to a firm should be admitted consistently to one or two wards, thereby benefiting from the continuity of care by nurses who know the patients well. Residents working with a small group of faculty and nurses would potentially interact more with senior clinicians. Residents also could establish ongoing relationships with the nursing staff and maximize the potential for the development of teamwork and collegiality. By creating smaller teams of physicians and nurses, the opportunity would exist for greater expectations of and accountability for professional behavior. Collaborative patient care practices, which put the patient first and where all members of the clinical team are included in the decision-making process, are another way to build a sense of community in medicine as well as strengthen the values and behaviors of medical professionalism [35-37].

The ambulatory care setting may be more supportive and conducive to an education community. Two of the three essential components—a core teaching faculty of physicians and continuity of patient care experiences—exist in many resident clinics. Because the interaction between faculty and residents may be the most important component of teaching in clinical medicine, faculty preceptors should work with the same group of residents throughout residency training to provide the opportunity to form mentoring relationships. To enhance knowledge and skills in patient care management, faculty and residents could integrate their clinics, creating a team of junior and senior clinicians to follow a panel of patients both in and out of the hospital.

Structured learning time and clinical supervision of residents and medical students are essential to creating an education community [38-40]. Medical students and residents do not master the skill of integrating the science and management of disease by daily completing a list of nonphysician tasks. To integrate knowledge with experience, physicians-in-training need informal and formal instruction, time for reflection, and time for reading. Learning excellence in patient care requires superb clinical role models who uphold the patient as a person and who show that being a physician demands dedication to patient care and continuous learning over one's lifetime [41].

Fostering Role Models and Mentors

In addition to the necessary structural changes of residency training, one way of fostering an education community is to institute programs for role modeling and mentoring [42, 43]. A role model serves as an ideal to which one can aspire. A mentor serves another purpose, that of establishing a more intense relationship with a younger trainee, which helps the protege learn attitudes and skills difficult to assimilate [43, 44].

Many people consider mentors an important element in career advancement [43, 45]. However, we should look at the mentor not solely in terms of facilitating the careers of junior colleagues but instead in terms of reaffirming a commitment by the senior faculty to the personal and professional well-being of residents. In this capacity, the mentor becomes integral to building an education community with shared traditions and expectations.

The term "mentor" arose from Homer's Odyssey as the name of Odysseus' trusted friend Mentor who, in Odysseus' absence, nurtures, protects, and educates Odysseus' son, Telemachus [43]. Mentor introduced Telemachus to other leaders and guided him in assuming his rightful social and political place. Mentor's instruction went far beyond the teaching of specific skills; it encompassed personal, professional, and civic development, that is, development of the whole person to full capacity, and integration of that person into the existing community through socialization of its norms and expectations.

The characteristics of a modern-day mentor are derived from Mentor's relationship with Telemachus. Mentors assist the protege in defining goals, help develop the talents that enable the protege to reach maximal potential, teach the skills and knowledge of a discipline, share social and professional values and behaviors, and protect the protege until he or she can sustain autonomous work. Furthermore, a mentor functions as a means to enter a community of people with a similar tradition [43].

Other traits of a mentor include experience and empathy [44]. Experience, particularly the introspective understanding gained through successes and failures, breeds wisdom. Wisdom then enables the mentor to help the protege sift through difficult professional and personal issues in clarifying a life direction. Empathy, on the other hand, reminds the mentor of the need for support during the education process. Important in becoming a physician are those times when in the midst of pain someone offers a helping hand, or when an admired person spends an afternoon sharing something personally meaningful. Other meaningful experiences center around planned social gatherings such as when an attending physician invites a team of medical students and residents to dinner. Mentoring cannot create these moments, but it increases the likelihood that when a resident feels alone, he or she can turn to someone who has been there and knows the anxiety of uncertainty. Because mentoring takes time, faculty promotion should reward such activities.

Teaching Medical Professionalism

Professionalism is best learned from those clinical faculty who put the patient first. Additionally, seminars on medical professionalism focusing on a core set of professional values, attitudes, and behaviors that capture aspects of a physician's relationship and responsibility to the patient and to society could be incorporated into the medical school and residency curricula (Appendix). After more than a year developing a curriculum on medical professionalism, and with experience conducting components of it with medical students, residents, and faculty, I offer some suggestions. The topics and examples in such a curriculum should be drawn from the daily lives of practicing physicians and those in training to make the ideas relevant both personally and professionally. The curriculum should provide opportunities for self-reflection because if professionalism is to be renewed, it must be integrated into a physician's value system. Didactic sessions combined with small group discussions and structured readings help to provide a theoretical context and an enriched understanding of medical professionalism. Lastly, the curriculum should help the physician recognize the great challenges that exist in meeting professional standards. Through definition, reflection, and dialogue among faculty and physicians-in-training, a curriculum on medical professionalism can assist medical students, residents, and faculty to retain and reclaim some of their original altruistic motivations for entering medicine as a profession and as a calling.

A curriculum on medical professionalism should also provide experience in small group discussions, role modeling and mentoring programs, and community service activities that serve patients in a broader context. These community experiences should be developed in cooperation with the neighborhood leadership so a partnership can be built.

Evaluating Professional Conduct

A final area of importance is the evaluation of physicians-in-training on professional conduct and evaluation of clinical training in terms of how it enhances medical professionalism. Medicine is more than knowledge and skills. It is also a set of values and behaviors that manifests as an approach to patients and colleagues that enhances trust in and respect for the physician. By incorporating the evaluation of professional conduct into the medical education process, the faculty would show that professional standards are important to patient care and to the profession itself [46]. Furthermore, evaluation of the clinical training environment in terms of fostering professional values and behaviors may help direct the process of reform of residency training in a way that benefits patients, the public, and the profession.

Various evaluation strategies exist, and each should be explored in terms of its use in fostering medical professionalism. The faculty, particularly those who have a longitudinal teaching relationship with a medical student or resident, could evaluate the physician-in-training with a standardized evaluation form. Physicians-in-training could be evaluated on their interaction with patients through simulated patient examinations. Accountability to colleagues could be assessed through peer review [47]. Lastly, physicians-in-training and faculty could be queried about the degree to which professionalism was emphasized in their hospital or residency program.

Summary

Top Summary Author & Article Info References

Previous analyses on professionalism in residency have focused on the stresses of the training experience as a barrier to learning professional values and behaviors, along with the importance of mentoring and role models as a means to foster medical professionalism [8, 21, 23]. This article considers the education community and its role in transmitting professional values and behaviors, identifies factors that undermine its existence in the current academic training environment, and argues for strategies to reaffirm medical professionalism among physicians-in-training and faculty.

Building an education community committed to professionalism ultimately may preserve those aspects of the patient–physician relationship that many physicians cherish. Professionalism may foster a greater appreciation of the different members of the health care team and enhance patient care. With a focus on professionalism, the educational value of residency training may increase and thereby minimize the sense of isolation and stress and maximize the competency of future physicians. Lastly, by focusing on professionalism, physicians may understand that competition for prestige, wealth, and technical prowess undermines that which is valued most by society: trust in the judgment of physicians to act in the best interests of patients. Perhaps with new awareness, the profession will lead as servants and stewards of society.

Appendix

Medical Professionalism: A Curriculum Guide for Physicians and Physicians-in-Training

Core Topics

1. Professionalism: definition, origin, socioeconomic and political context

2. Putting the patient first

a. Conflicts of interest

b. Eliciting the patient's opinion, values, and decisions

c. Accountability to patients and colleagues

3. Honesty and integrity

a. Cheating and fraud

b. Chart documentation

c. Managing mistakes

4. Appropriate use of power and authority

a. Arrogance

b. Sexual harassment

c. Informed consent

5. Nonjudgmental approach to patients

a. Discrimination in health care

b. Treating patients with chronic illness, the acquired immunodeficiency syndrome, dementia

c. Professional risk

6. Humility and healing

a. The science and art of medicine

b. Communication: verbal and nonverbal

c. Trust and the doctor-patient relationship

7. Collegiality and collaboration

a. Peer review and mentoring

b. The learning team and the research team

c. Collaborative patient care

8. Life-long learning

a. Medical malpractice

b. Clinical competency and knowledge self-assessment

c. Professional standards and licensure requirements

9. Service to society

a. Servant leadership

b. Volunteerism

c. Health care reform

Each topic is framed by questions and a bibliography and illustrated further by specific behaviors drawn from the literature and the personal experiences of physicians and physicians-in-training. Components of the curriculum have been used with medical students, residents, and faculty.