Professionalism

Introduction

• A professor strongly urges his preclinical students to attend a session on the doctor–patient relationship because one of his patients is going to participate. ‘You will learn more from her story than from any textbook,’ he states. The session is one day before a pharmacology examination, and he is disappointed when only a third of the class attends.

• A resident physician feels uncomfortable when she laughs at a joke her senior colleague makes regarding the appearance of one of the patients.

• An attending physician sees a student speak rudely to a nurse because she had failed to draw a set of blood cultures prior to the patient’s first dose of antibiotics. The student snaps, ‘Now we’ll never know what this poor patient has, and it’s because of your incompetence!’ The physician wonders how to handle the student’s outburst.

• A junior faculty member is embarrassed when he learns that a friend posted photos of him on a social networking page. In the photo he is clearly inebriated and the picture is labelled ‘Dr Phillips – at it again!’

All of these scenarios represent issues of medical professionalism. While professionalism has become a buzzword in the medical education literature, training in professionalism still largely occurs through subtle mechanisms like role modelling and socialization and is influenced profoundly by institutional, cultural and socioeconomic forces. The goals of this chapter are to provide a working definition of professionalism and examples of how to teach and evaluate it. How to remediate unprofessional behaviours is an evolving area that is beyond the scope of this chapter.

Helping future and current doctors to meet professional standards should be one of the central missions of any medical education endeavour. Concerns about physicians’ conflicts of interest (Campbell et al 2007) and evidence that certain behaviours in training are correlated with future loss of licensure for issues of professionalism (Papadakis et al 2005) demonstrate the need to teach and evaluate professionalism formally. Moreover, disruptive behaviours by physicians may be linked to poor team performance, patient dissatisfaction, increased litigation and medical errors (Joint Commission 2008). Medical schools, graduate medical education programmes and professional organizations have advocated formalizing the education and evaluation of professionalism (General Medical Council 2006, Accreditation Council for Graduate Medical Education 2008).

Defining professionalism

Educators and regulatory bodies have attempted to define professionalism to facilitate discussion and scholarship, as well as for teaching and evaluating trainees and physicians. From the day that a student enters medical school, he or she begins the process of becoming a professional. Being a professional means many things, including internalizing and adhering to a set of values, behaving according to standards that define acceptable medical practice and being ultimately accountable to the patients he or she serves. These attributes of the ‘professional’ create an identity distinct from personal identity (Mostaghimi & Crotty 2011). With this identity is a set of expectations for behaviours and appearance, as well as entitlements. A recent review formulated three ways of thinking about professionalism: as an individual trait, as the result of an interpersonal process and as a social phenomenon. Each of these approaches has advantages and drawbacks and can inform how professionalism is taught and assessed (Hodges et al 2011).

“The central act of profession … is an active, conscious declaration, voluntarily entered into and signifying willingness to assume the obligations necessary to make the declaration authentic.”

Pellegrino 2001

Edmund Pellegrino (2001) defines the medical professional as one who:

‘declares aloud’ that he (or she) has special knowledge and skills, that he (or she) can heal, or help, and that he (or she) will do so in the patient’s interests, not his (or her) own.

Herbert Swick has noted that these two dimensions of professionalism, expertise and a commitment to apply that expertise for the good of others, may be out of balance in today’s environment, with serious consequences to the legitimacy of the profession in the eyes of the public. The rapid advances in medical knowledge and technology have caused the medical profession to become ‘more closely linked to the application of expert knowledge and less closely linked to the functions central to the good of the public they serve’ (Swick 2000). He argues that without its public and social purpose, medicine as a profession risks losing its ‘distinctive voice’ that inspires society to trust in the profession and allow it considerable latitude to regulate itself. Swick states that to try and restore the balance, one must begin by defining professionalism by what physicians actually do: ‘how they meet their responsibilities to individual patients and communities.’

Behaviours that are common to several proposed definitions and discussions of professionalism (ABIM Foundation 2013, Epstein 1999, Stern 2006, Swick 2000) include the following:

• Fiduciary obligation: in offering their skills and expertise, physicians are expected to subordinate their own interests to the interests of their patients.

• Responsiveness to societal needs: physicians are expected to understand and address society’s pressing health needs, including access to care.

• Empathy: physicians are expected to demonstrate that they understand their patients as persons who are often in a state of vulnerability.

• Respect for others: physicians are expected to demonstrate a deep respect for a patient’s culture, autonomy and confidentiality. Physicians should also respect the contributions of other professionals in the care of patients.

• Accountability: physicians are expected to adhere to standards of practice and commit to measures that ensure that all members of the profession meet these standards. As a corollary, the profession has an obligation to regulate itself in terms of setting up standards for licensure and certification.

• Commitment to quality and excellence: physicians are expected to maintain their knowledge and skills and analyse their practices to be able to deliver state-of-the-art care.

• Ability to deal with ambiguity and complexity: physicians are expected to be able to engage in medically and morally complex situations and be willing to make judgements even in the face of limited data.

• Reflection: physicians must be open to critically examining their own practices, skills, and limits.

Delineating the behaviours and contexts that define professionalism can facilitate a staged, level-appropriate curriculum.

The above elements are often combined and re-sorted under a variety of different headings. For example, humanism, which can encompass altruism, empathy, respect for others and reflection, has been identified by some as a core element of professionalism (Stern 2006). Additionally, ethical and legal principles can inform professionalism, and communication skills can be a manifestation of it (Stern 2006).

Professionalism: How to teach it

Professionalism is multifaceted and dependent on context. How one might respond to a nurse’s phone call for a minor concern when well-rested on a small inpatient service, might differ strikingly from how one might respond when covering a large complex service in the middle of the night. So teaching professionalism cannot be easily compared to teaching the knowledge of medicine: it is not as simple as identifying the principles of antibiotic treatment and expecting students to apply them rationally. In addition, the professional issues to be taught change depending on the level of the trainee: from cheating on tests by a medical student, to copying notes in an electronic chart by a physician in postgraduate training, to misrepresenting patient findings in order to justify procedures limited by insurance by a practising physician. As such, while the principles of professionalism should be clearly articulated at a programmatic or institutional level, the ‘teaching’ of professionalism occurs best in real-life contexts or high-fidelity simulations. Some suggestions for teaching professionalism are detailed in the following paragraphs.

Most medical schools offer courses on doctoring or clinical skills that cover ethics, the rules that govern doctor–patient relationships and moral reasoning (Self et al 1992, Stern & Papadakis 2006) (see Chapter 31, Ethics and attitudes). There are underlying principles, historical precedents and decision-making models that can be learned, even in the most noninteractive style of formal lectures. Some courses use team-based learning techniques that require students to be collaborative and accountable to fellow students in order to foster the professional attitudes and behaviours requisite for the multidisciplinary care of complex patients (Stern & Papadakis 2006). Whether the principles learned in this way lead to changes in practice settings has yet to be shown.

Some educators have used literature, art and film to teach elements of professionalism. The development of empathy and respect requires an ability to imagine the viewpoints of others. Reading patient narratives or watching films depicting patient–doctor interactions, combined with guided reflection, is intended to lead to a better understanding of the patients’ perspective and, in turn, greater empathy (Charon 2001). Hafferty (2000) has called for even more explicit coursework in professionalism that draws on sociology, history, economics and cultural studies.

Role modelling and mentoring

Role modelling and mentoring are powerful forces in the development of trainees’ professional identities. Mentoring is a more formal relationship in which a senior and established member of a community takes a special interest in the personal and professional growth of a specific trainee (Grady-Weliky et al 2000) (see Chapter 17, Mentoring). Role modelling happens in more day-to-day situations and does not necessarily have the length or intensity of a mentoring relationship. Trainees model their behaviours and actions on those who they see around them through a process of emulation or socialization (Hafferty 2000). Role models can be positive or negative. Negative role models serve a purpose to inspire students to ‘never act like Dr X when I graduate’ (Branch et al 1993). Role modelling may be enhanced with explanation or by making actions explicit. A faculty member can behave in a fashion he or she expects to be modelled, but the modelling may go unnoticed or misinterpreted. For example, a physician may model a behaviour, like washing hands, to teach the importance of preventing nosocomial infection and demonstrating respect to the patient, yet a student may interpret the behaviour as the physician’s concern about contracting disease. Therefore, learning through role modelling is haphazard and the lessons learned may not be those the teacher intends. Following the lead of other professions, the principle of reflective practice (Schön 1983) encourages the demonstration of a behaviour, then the explicit discussion of the behaviour as a more certain method for transmitting professional behaviours. This pattern of ‘explicated’ role modelling has potential for increasing the positive impact of the best teachers (Stern & Papadakis 2006).