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Zachary Ryder MD, Lauren James DO, Sandra Lucio DO, Anne Louise Stewart MD, Daniel Lavin DO, Shadi Lavasani MD, Nicholas Arnoudse MD, James A. Bourgeois OD, MD
Image courtesy: Ana Hategan
What is true about professionalism?
The concept of professionalism is an age-old idea that crosses generations and professions. It serves to guide, regulate, and limit one’s actions within a profession. Despite its age and widespread application, there is no standard definition for what professionalism entails. The particular recipe for what defines professionalism is unique to the situation and can vary greatly across various “professions.” Within medicine, there is variability and ambiguity among individual specialties, generations, and practice settings. Borrowing from the U.S. Supreme Court Justice Potter Stewart, professionalism exists in so many unique combinations that his famous phrase, “I know it when I see it,” might be a good place to start.
In fact, in the U.S.A, professionalism was first included in the ACGME six core competencies in 1999 (NEJM Knowledge+ Team, 2016), and the National Board of Osteopathic Medical Examiners (NBOME) seven osteopathic competencies in 2006 (NBOME, 2011). The concept of professionalism within medicine has led to an explosion of literature with the lofty ambition of defining, teaching, and cultivating professionals within U.S. medical residencies. Much of the original focus on medical professionalism stemmed from the work of the “Skills of the New Millenium” project from the RCPSC, which ultimately led to the CanMEDS Roles framework in 1996 (CanMEDS, 2018).
The difficulty in creating a comprehensive and easily digestible definition has led to scores of definitions, curricula, and assessment programs with the common goal of increasing professionalism within the ranks of medicine. Still, decades later, a common definition, curriculum, and standardized assessment has proved elusive. A common understanding and guide for professionalism in all things medicine simply does not exist. Instead, a generalized framework of common ideals, behaviours, and responsibilities, is likely the best starting point in the pursuit of professionalism in medicine. Our goal within this section is to highlight some of the existing guides and programs for teaching professionalism within medical residencies.
“Residents must demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles. Residents must develop and acquire a professional identity consistent with values of oneself, the specialty, and the practice of medicine. Residents are expected to demonstrate compassion, integrity, and respect for others; sensitivity to diverse populations; responsibility for patient care that supersedes self-interest; and accountability to patients, society, and the profession.“
In addition:
“Professional behaviour refers to the global comportment of the resident in carrying out clinical and professional responsibilities. This includes:
Historically, medical training has focused on the knowledge, tangible skills, and to a lesser degree, the obvious empathic components of professionalism. These are cultivated and measured from the undergraduate level through the end of a physician's career, which can dictate one's opportunities for residency, fellowship, and lifelong career. More recently, there has been recognition of the need to define and teach other components of professionalism within medicine. While there has been progress, there has been noted difficulty in defining and measuring these more ambiguous attributes of professionalism. A rather straightforward approach recognizes individual “professional” behaviours. A good example of these behaviours is included in a recent article from the Journal of Anesthesia and Intensive Care, which lists a set of 22 individual professional behaviours or “professional behaviour themes” according to a small cohort of surveyed intensive care fellows. Interestingly, skill and knowledge based behaviours were ranked much higher in importance than the qualities of honesty, altruism, and accountability (Van Mook et al, 2011). Regardless of their ranking of importance, the list covers a broad range of professional behaviours.
Unprofessional behaviours are often easier to recognize and identify. For example, tardiness, lack of preparation, and discrimination would be considered unprofessional by most. However, there are still disagreements when it comes to defining unprofessional behaviours. For example, the use of mobile electronics, the content of social media postings, and even personal appearance, can be judged differently depending on the background, training, and generation of the interpreter (Brissette et al, 2017). However, more egregious acts like cheating, lying, posting patient data on social media, making disparaging comments about the healthcare team, or neglecting pages or other on-call responsibilities are more likely to be identified as unprofessional (Fargen et al, 2016). Interestingly, even some of these behaviours are open for interpretation. A recent study polled a cohort of general surgery residents and found that 22% of respondents would consider or had already used memorized questions from previous tests to prepare for the ABSITE (Phillips et al, 2017).
What is true of unprofessional behaviour?
It is worth noting there is a distinct difference between the idea of professionalism and “professionalization” (Chaukos et al, 2016). The latter refers to the development of one’s identity as a physician, specifically as it relates to learning and operating within the culture of medicine. The behaviours and expectations of the profession of medicine can be at odds with the ideals of professionalism. For example, there are cultural expectations of expected duties, which can be at odds with ACGME rules involving duty hours. Often, there is an unspoken expectation to complete all aspects of patient care regardless of the limitations with respect to duty hours. Recently, a national survey queried 6,000 residents across a range myriad of specialties on a variety of topics and found that 43% of respondents falsely reported duty hours (Heubel, 2015). While the individual reasons for falsifying duty hours are assuredly varied, it is likely that the training environment placed a higher emphasis on performance and duty as opposed to honesty. In another example, Canadian medical students were asked to comment on another clash of professionalism and professionalization. Would they allow a physician her requested time off after facing a series of obstetrical disasters, resulting in compassion fatigue? Respondents ultimately struggled, as asking for time off was generally seen as avoiding or skirting responsibilities (Cruess et al, 2014). In this case, the expectation to compartmentalize and sometimes ignore emotional fatigue in the medical culture, directly contrasts the professional ideal of recognizing one’s own limitations physically and emotionally so that patient care is not affected.
Professionalism is just as difficult to embody as it is to define. It is the embodiment of some of the loftiest character traits, including empathy, sympathy, respect, knowledge, and altruism, but at its core, professionalism can be condensed down to the commitment to patient centered care on a micro and macro level. From washing your hands, to considering a patient’s cultural background, to being up to date on clinical advances, to advocating for your patient on a legislative level, if it is done with the compass pointed at the patient, professionalism is indisputable. A physician has to be committed to constant self-reflection and change and can spend an entire career trying to embody this ideal, thus fostering and developing it early in residency and training is important to the future of the profession.
In physics, resilience is the ability to “bounce back” from any hypothetical “blow” or “hit.” The more a substance can keep its form in this setting, the more resilient it is. In physiology, resilience is the ability to maintain homeostasis despite disruption in equilibrium. In residency, resilience is the ability to maintain professionalism in the setting of repeated stressful emotional and physical encounters.
Resilience factors have been defined as mindfulness, self-awareness, empathy, time management, and positive psychological approaches (Chaukos et al, 2016). Without these skills, a recent meta-analysis has explored the idea that professionalism suffers via physician burnout. In fact, physicians experiencing burnout are two times as likely to be involved in a patient-safety incident due to low professionalism, defined as low empathy, poor quality of communication, and non-adherence to treatment guidelines (Panagioti et al, 2018). All of these described lapses are not patient centered. Low professionalism due to burnout and lack of resiliency is more common in residency and those within the first five years post training (Panagioti et al, 2018), highlighting the importance of teaching and practicing resilience during residency to increase patient centered care, patient satisfaction, and physician self-satisfaction. Resilience, and therefore professionalism, can flourish with a strong professional identity, mentorship, and proper monitoring or feedback.
In order for medical professionals to have legally fixed autonomy, there needs to be a contract-like relationship of credibility and trust between the state and the medical community. A prerequisite for this relationship’s success is that the members of the profession be convinced of the intrinsic values of their profession as well as the duties connected with it (Heubel, 2015). The physician identity comprises the values of compassion, service, altruism, and trustworthiness.
Check out the tabs below to learn more about each value with the following descriptions from the College of Physicians and Surgeons of Ontario.
Individual physicians serve their patients by assessing, diagnosing and treating patients, and through rehabilitation and habilitation, palliation, health promotion, and disease prevention. However, medicine is more than procedures and physicians are more than purveyors of technology. Compassion is fundamental to the relationship between the patient and the physician. Compassion is defined as a deep awareness of the suffering of another coupled with the wish to relieve it.
Service means working for the benefit of another. To serve their patients, physicians must be competent in the medical areas in which they practice. Service is not only competence; it is also putting the patient first. A physician has professional responsibility to their patients, individually and collectively; their patients’ families; their own practice; and the health care system. However, at any given time a physician’s primary responsibility is to the individual patient before them.
Altruism, as a principle of action, is the highest commitment to service. Altruism in medicine is defined as practising unselfishly and with a regard for others.
Trustworthiness is the cornerstone of the practice of medicine. It is the demonstration of compassion, service and altruism that earns the medical profession the trust of the public. This trust manifests itself in the social contract between the profession and the public, as well as the relationship an individual patient has with his or her physician. Maintaining trust is an important aspect of medical professionalism. Patients must be able to trust that the physician will always uphold the values of the profession; in the absence of the trusting relationship the physician cannot help the patient and the patient cannot benefit from the relationship.
While these values may be at the forefront of trainees at the start of their career, the toll of training may make it more difficult for the resident to behave in a manner consistent with these values. Building resilience and preventing burnout allows residents to practice these values more successfully and consistently.
Professionalism skills are not intuitive and may not be properly developed if left to observation alone.
Professional behaviour results from a series of personal negotiations specific to the context of each situation (Cruess et al, 2014). Because each physician will resolve these internal conflicts differently, the interpretation of professionalism is shifted to an emphasis on “being” rather than “doing.” A physician’s identity develops in stages over time during which the characteristics, values, and norms of the medical profession are internalized, resulting in an individual thinking, acting, and feeling like a physician (Cruess et al, 2014). This includes more than the “momentary” mastery of a particular clinical skill or experience. There are plenty of opportunities during residency to expand medical knowledge and skills. The training program must create a curricula that will help residents formulate their professional identity as well. Teaching of professionalism through observation and modeling is not sufficient. There has to be a combination of implicit and explicit teaching through self-reflection and experiential learning (Cruess & Cruess, 2012).
Which method helps residents improve their professionalism skills?
Specific behavioural benchmarks can be developed and utilized for evaluation with available methods including patient/nurse surveys, faculty observation, objective structured clinical exams (OSCE), ethical reasoning tests, and completion of administrative tasks (Nichols et al, 2014). An additional way to develop both professionalism and interpersonal/communication skills is by having residents participate in OSCEs with various domains (Hochberg et al, 2016). Potential examples could include how to correctly use a language interpreter, how to explain a medical error, how to effectively deliver bad news to patients, or how to properly explain a health care proxy to a patient. This curriculum could be repeated yearly to improve residents’ professionalism skills throughout their time in residency. These OSCEs could also improve other skills like altruism and patient sensitivity.
Reflective practice is a process in which an individual thinks critically about a thought, experience, or action with the ultimate outcome being increased self-awareness and professional competence. It is assumed that reflecting on one's own actions and thinking critically can improve one’s own performance (Kung et al, 2015). Residents can perform a self-reflection analysis regarding perceived difficult patients and then develop a plan to care for these patients in an unbiased manner.
Residents can also develop professional identity by reading specific journal articles regarding professionalism which could then facilitate mentored small group discussion and reflection (Regan et al, 2016). Content could be presented during didactic sessions.
Another method that can be used to develop professionalism is medical improv (Watson & Fu, 2016). Medical improvisation aims to create a safe and lighthearted learning environment while also teaching skills like adaptability, spontaneity, reflective process, and teamwork. It can teach trainees what they can “say” through body language and vocal inflection and focus the observers on what they can “hear” through nonverbal communication.
Finally, professional and professionalism development can be much enhanced by “celebrating diversity.” There is much to be gained from professional relationships and collaborating with physicians of other specialties, other health professionals, and members of other universities and institutions. Indeed, professional development is much enhanced by close working relationships with professionals whose professional experience is “deliberately different” from one’s home department and institution. Specific examples of this include teaching other specialties and other professionals and collaborating with members of other institutions on research and other academically collaborative activities. Working in good teams helps.
The broader goal of consolidation of professional identity can be much assisted by structured mentorship by more senior faculty who are charged with engaging residents on broad goals of professional development. Specific areas for mentor-mentee dyadic relationships include topics such as what (if any) subspecialty to pursue, whether to seek full time clinical employment vs. an academic position, and whether/how much to engage in research and other academic activities. The practice of mentorship may allow for positive “professionalism” models in faculty members to be closely available to residents to emulate. In order for mentors to be good role models, there must be assessment of their professionalism with positive and negative consequences as well. Examples where faculty members illustrate and explain positive responses to challenging clinical, educational, and administrative challenges may encourage thoughtful reflection by residents in preparation for their own eventual roles in such circumstances. “Mentoring relationships with their inherent reciprocity lead to personal growth, interdependence and connectedness among the pairs” (Britt et al, 2017).
It may be very helpful early in training to identify a faculty member one can admire and identify with, and seek mentorship advice from such a figure. Sophisticated departments will recognize this developmental need, and take administrative steps to encourage mentoring in a structured and supported way. A creative way to match a mentee with a mentor is through a process called speed mentoring, which has been derived from the speed dating concept. For an hour, each mentee can meet with one of five mentors for 10 minutes each. Specific multiple-choice questions can be supplied but participants can supply their own open-ended questions. The ultimate goal is for mentees to find a mentor that they would like to continue a mentoring relationship outside the session. This activity can lead to a higher level of satisfaction in the mentor/mentee relationship than randomly matching pairs (Britt et al, 2017).
Another area of professional development to address during residency is the important act of “balance” among the various roles in a physician’s life. Two important areas of balance are the “intraprofessional” balance among the various, often competing areas of patient care, skills acquisition, academic development, and administrative skill building, as well as the “social” balance between all professional time and other important areas in life, such as time for spouse, children, extended family members, community, and society at large. These challenges will inevitably be specific to the individual physician, but here as in other areas, seeking the models of mentors as well as mentor advice on specific challenges of balance in professional and life roles can prove to be valuable.
The mentor can share personal developmental experience that had been good for his/her own professional development (this will often include reminiscence about the mentor’s own productive mentor/mentee relationship in his/her own training). Active participation in such mentor/mentee relationships may serve as a bit of a “cushion” if future challenges to the resident’s professionalism were to ensue.
Institutional support is required to support a successful curriculum for professionalism. There should not be any barriers since ACGME requires residents to meet a professionalism milestone. Within each department, it might be helpful to designate one faculty member to be responsible for leading the design and implementation of the professionalism program. Once a program is created, it would be in the benefit of trainees to be exposed gradually to the new structures. As mentioned above, it is important for residents to be immersed in this program throughout the stages of medical education, particularly in residency but also during medical school. Just with medical knowledge, there needs to be a cognitive base for professionalism. Medical schools are a great place to lay the foundation of what it means to be a physician.
The one-minute mentor. This was a pilot study assessing medical students' and residents' professional behaviours through recordings of clinical preceptors' immediate feedback (Topps et al. 2009). It created a study where six medical students and three residents allowed their attendings to record a one-minute blurb of feedback about their professional behaviour. The attending’s comments were graded by five evaluators for competence (learner’s performance) and confidence (how confident the evaluator was that the comments were clear, objective, and relevant). Then the students/residents and evaluators were surveyed for feedback. There was good interrater reliability for competence scores. Students found the method helpful for receiving feedback. Evaluators found it helpful to have a relatively objective approach but found grading the comments time consuming. Training of supervisors is required to help them provide useful feedback based on defined goals. Validity was not confirmed (Topps et al. 2009).
“Feedback is essential to improve professionalism”. The anesthesia department at the University of Iowa used the “de Oliveira Filho” clinical supervision scale to assess how faculty anesthesiologists supervise residents (numerical responses to nine items also with comments) (Dexter et al, 2017). They performed a content analysis of evaluations to test two hypotheses: (1) that the scale assesses attributes of professionalism, (2) that the scale does not assess all attributes of professionalism. Results showed that both hypotheses were satisfied, the scale did reflect some attributes of professionalism but also multiple attributes of professionalism are not elements of the supervision scale. Cohort included all residents’ evaluations of all faculty over a 2.5-year period. Daily emails were sent to residents where comments and scores were confidential. The scores were averaged and comments were searched for key words related to professionalism (both positive and negative) and then related to ACGME requirements for professionalism (Dexter et al, 2017).
A two-group randomized clinical trial was performed using 28 residents from the Cleveland Clinic Children’s Hospital. They were given multisource feedback questionnaires and were randomly assigned to either a feedback group or a control group. Only the feedback group had a coaching meeting monthly to create improvement strategies. They used their validated questionnaire to evaluate the extent to which weekly feedback from department chairs improves professionalism. They found a significant positive treatment effect, indicating that “monthly faculty feedback significantly improves residents’ self-assessment of their own professionalism”. “Professionalism is among the six core competencies to be taught and evaluated during medical residency programs in the US”. “In conclusion, results of our randomized study suggest that the multidimensional self-assessment associated with a feedback program improves self-assessment of professionalism with no effect on the perception of coworkers, faculty and patient's families (Papadakis et al, 1999).”
Off-colour joking may not be a bad way to cope. “Watson acknowledges that gallows humor - humor that takes traumatic, serious, or emotionally-painful subject matter (the most obvious example being death) and treats it in a satirical or carefree manner - may be an inappropriate coping mechanism used merely as a “cover for cruelty” or a means of inadequately dealing with pain, but she contends, ultimately, that “ blanket dismissals of gallows humor as unprofessional misunderstand or undervalue the psychological, social, cognitive, and linguistic ways that joking and laughing work (Panagioti et al, 2018).” She includes some counterexamples as well. Summing up, use of humor in medicine is complicated and may be either professional or unprofessional depending on the context.
There has not been any specific instruction on professionalism that has been established in medical training. There has also not been an established feedback process recognized in training. A mobile device application was studied in a pilot study to see if it had any bearing on how faculty gave feedback or understood professionalism. Information was gathered by two surveys: pre and post pilot study. This provided quantitative feedback. There were two statistically significant discoveries: faculty felt more knowledgeable about reporting procedures for professionalism concerns (p = 0.01), and they felt more comfortable assessing professionalism concerns (p = 0.04) (Shrank et al, 2004). There were also quantitative results gathered through semi-structured focus groups; however, not many faculty were able to attend, limiting its usefulness. In the end, this article shows that faculty members need development on professionalism assessment, and it shows that some education in this area can reduce barriers to assessment of professionalism.
Can professionalism be measured? The development of a scale for use in the medical environment has been accomplished (Foshee et al, 2017). The authors attempted to create a standardized scale to reliably rate professional behaviours within medical training. Interrater reliability of that scale was relatively high (Foshee et al, 2017).
A strategy for the detection and evaluation of unprofessional behaviour in medical students was implemented at University of California, San Francisco (UCSF) School of Medicine Clinical Clerkships Operation Committee (Cendan et al, 2017). It discusses implementation of UCSF’s expanded initiatives in identification and evaluation of unprofessional behaviour in clerkships. Initially poor performance in professionalism was not met with consequences, but if the student fell below “3” on 4 point rating scale on “interpersonal skills” including: professional attributes, self-improvement, relationships with patients, and interpersonal relationships with members of healthcare team, a more in-depth form concentrating on minimum standards a student must meet to pass clerkship regarding professionalism had to be completed. If two forms regarding unsatisfactory performance are generated throughout clerkships, students are placed on academic probation and receive mentorship and counseling but may be asked to withdraw if behaviours persist.
There is an innate connection between the resilience of a physician and his or her development and maintenance of professionalism. In one large systematic review and meta-analysis, the incidence of low professionalism doubled when physicians were burned out (Panagioti et al, 2018). This study also found that this effect was even more pronounced with residents or recently graduated physicians compared with later career physicians. Such findings highlight the need for emphasis on fostering resilience in the field of medicine. When deficiencies in professionalism (i.e., unprofessional behaviour) arise, it can be a “red flag” for burnout. If a resident physician or staff physician is noted to exhibit low professionalism, they should be quickly screened for burnout. If present, steps should be taken immediately to improve the burnout. At the same time, the incidents of low professionalism should be addressed. Low professionalism can represent problems for several reasons. Such behaviour may reflect poorly upon the institution as a whole, individual training programs, mentors and, ultimately, on patient care. As such, it is no wonder the ACGME has made it one of the six core competencies. Deficiencies, once identified, should be remediated as soon as possible.
It is essential that training programs ensure a targeted, structured approach is in place to address deficiencies as they are identified. Among emergency medicine program directors, a majority found that professionalism deficiencies were more difficult to remediate than the other competencies (Sullivan et al, 2011). The ACGME has created milestones that are specialty specific to assist residents in developing, among the other competencies, professionalism (Holmboe, 2016). These milestones can assist programs in tailoring a practice for remediating professionalism. In the Psychiatry Milestones, for example, one of the identified characteristics of what constitutes professionalism in the field is unsurprisingly “fatigue management and work balance” (Skeff, 2018). Noting that a resident or fellow “develops physician wellness programs or interventions” indicates they have progressed to the highest level. This is a good example of a goal to strive for, but does a resident or fellow need remediation for not developing a wellness program? It may be helpful to target the preceding levels of the milestones as ideal opportunities for remediation. For example, noting that the resident does not display “openness to feedback” should prompt action for change.
Feedback, which is emphasized by the ACGME for meeting milestones, is essential to successful remediation. In order for feedback to be effective, it should be prompt, specific, appropriately balance positives and negatives, emphasize reaction and reflection, and include an action plan (Cendan et al, 2017). When an unprofessional behaviour is witnessed (e.g., arriving late to rounds), a faculty member in the mentor role may not immediately record or address the behaviour. There may be a multitude of reasons for not acting immediately: desire to confront the behaviour at a later time when it can be done privately, more pressing clinical needs requiring attention, assumptions about the reasons for the behaviour, and so on. These reasons for delaying feedback are not necessarily wrong, but they do present a barrier to an opportunity for growth. Feedback can be provided in a variety of media. Direct feedback, either verbally or written, can facilitate a constructive approach to unprofessional behaviours. More indirect methods, such as a Web-based mobile system, can also be used to improve feedback to address unprofessional behaviour (Domen et al, 2017).
Click below on all of the characteristics of feedback errors in this case.
The role of the resident and faculty member in question is also emphasized here. When confronted with concerns regarding one’s professionalism (typically stated in the “negative” accusations of unprofessional behaviour, as positive rewards of successful acquisition of professionalism are less clearly defined and thus less frequently acknowledged and rewarded), a typical initial response may be to question the accusation and seek more data. This is not unreasonable, especially given the often nebulous nature of complaints. Absent a major patient safety or civil/criminal legal concern, which are infrequent, concerns regarding professionalism should be explicitly and specifically described (e.g., “on Wednesday, June 7th, you were 30 minutes late for a shift without excuse, leading to excess work time for your colleague who had to cover until you arrived”). Assuming the accusation is factual, the resident should explain extenuating circumstances, but fully accept without challenge the remedy called for by the chief resident or training director. While a traditional approach may be to enact punitive measures to address low professionalism, it is important to recall that burnout may be present. Taking a punitive approach against a resident or physician experiencing burnout (e.g., extra call shifts, additional clinical duties) may have a compound effect on burnout. Rather, a more inquisitive approach that takes into account possible burnout as a risk factor for low professionalism should be employed. Once “amends” are made, the resident should meet with appropriate authority figures to assure that the same error will not be repeated and make further amends to any colleagues inconvenienced by the resident’s error.
In the case of more egregious accusations, the resident may need to appeal to administrative or legal remedies to be sure one’s rights are being respected and that due process is followed in any administrative or legal proceeding. The resident needs to be able to present his/her own “side of the story” and, once any remedy is applied, reflect on his/her actions regarding the index episode with a structured response to assure that the error will not be perpetuated.
What is true about problems with professionalism?