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Dr. Tim Wilkinson had a problem. He wanted to create a blueprint for assessing professionalism in medicine. Like many doctors, he views professionalism as central to the practice of medicine, and it is invariably easier to improve something if you can assess it. But to measure professionalism, you first need to define it. That was the problem.
“There didn’t seem to be a clear definition,” says Wilkinson, associate dean of medical education at the University of Otago in Christchurch, New Zealand. “One of the problems we faced is that, on the one hand, it could include everything you need to know to be a good doctor, but that isn’t very helpful. Then there were some who said you just had to be reliable. We tried to find a middle ground of what are the core elements.”
After wading through the considerable volume of literature on medical professionalism, Wilkinson and two colleagues classified these elements into themes and subthemes (Acad Med 2009;84:551-8). These were organized into five clusters: adherence to ethical practice principles (honesty, integrity, confidentiality, etc.); effective interactions with patients and with people important to patients (courtesy, empathy, respectful, etc.); effective interactions with other people working within the health system (teamwork, patience, maintain professional boundaries, etc.); reliability (accountability, punctuality, organized, etc.); and commitment to autonomous maintenance and continuous improvement of competence (lifelong learning, seek feedback, reflectiveness, etc.).
“A commitment to improve, to my mind, if you had to give away everything else, that would be the one I would keep,” says Wilkinson.
Another way of viewing professionalism, as opposed to breaking it down into discrete and measurable skills and competencies, is to think of it as a state of mind, says Michael Yeo, a philosophy professor at Laurentian University in Sudbury, Ontario. “Professionalism, in its essence, is an attitude whereby you assume a particular role,” he says. “I subordinate my personal identity to the role — that is, essentially, what I think professionalism comes down to. If the core idea is symbolically putting on the white coat, you are able to put aside your own identity. Maybe you bite your tongue. Maybe the person you are treating is someone you dislike. You are prepared to put that aside.”
Though the language does indeed vary widely in definitions of medical professionalism, the “professional ideal,” which is essentially bound to the moral norms of the profession, is “professed with quite remarkable consistency by the profession in its codes of ethics and in various policy and regulatory pronouncements,” Yeo has suggested (Can Fam Physician 2009;55:968,70). “I also submit there would be considerable agreement among FPs [family physicians] about how to recognize a physician who exemplifies the professional ideal, just as there would be agreement about how to recognize a good physician,” he wrote.
Dr. Renate Leong isn’t so sure about that. “There are some very core issues that we don’t agree on — what it means to be ‘good,’ to start with,” says Leong, a staff physician in the department of family and community medicine at St. Michael’s Hospital in Toronto, Ontario, and an assistant professor of family and community medicine at the University of Toronto.
When the conversation moves from abstract talk of ethical and altruistic care into specific clinical situations, opinions on what is professional often vary, Leong has suggested (Can Fam Physician 2009;55:969,71). It is not uncommon, for example, for physicians to stretch the truth on forms for limited-use medications so their patients can afford expensive drugs, she wrote. That could be considered putting patients’ best interests first, or it could be considered a threat to the sustainability of the entire health care system.
Physicians also have different opinions on the limits of altruism in their work. Should it really be considered unprofessional for doctors to refuse to put their lives at risk in an emergency situation, such as the 2003 severe acute respiratory syndrome (SARS) outbreak, if they have inadequate safety equipment, a lack of information about the problem and no form of recompense for their families if they die? Some might “consider such a duty, although honourable, to be unreasonable — akin to expecting firefighters to go fight a fire without appropriate equipment,” wrote Leong.
Doctors also hold different moral values on matters such as abortion and quality of life. Does that mean physicians who come down on one side of a particular health issues are “good” doctors and those on the other side are “bad” doctors? “There is going to be some variety because we don’t have a uniform definition of ‘good,’” says Leong. “And the day we have a uniform definition of ‘good,’ that’s when things get scary. Unless you are in heaven, that sounds like communism.”
The quest to define professionalism isn’t made any easier by the fact that, like the field of medicine itself, the definition changes over time. Attitudes have changed, for instance, about the number of hours physicians, residents in particular, should work without rest. Working fewer hours, even if it benefited your health and family life, might have been deemed unprofessional once, but many younger doctors have different views on that aspect of professionalism.
“Prior generations put a lot of emphasis on continuity of care. That was a core value of professionalism and people would spend days at work, sometimes at the expense of their own lives. Now we have a generation of doctors that see professionalism as including self-care,” says Dr. Pier Bryden, a psychiatrist and the faculty lead in ethics and professionalism for undergraduate medical education at the University of Toronto. “There is a link with professionalism. People tend to not be at their best when they are sleep-deprived and physically stressed.”
Still, despite the challenges of putting the evolving and somewhat esoteric concept of medical professionalism into words, many health care organizations have given it their best efforts. The American Board of Internal Medicine has its physician charter for medical professionalism, which stresses the fundamental principles of patient autonomy, primacy of patient welfare and social justice (www.abimfoundation.org/Professionalism/~/media/Files/Physician%20Charter.ashx). The Canadian Medical Association considers the three major features of medical professionalism to be clinical independence, self-regulation and the ethic of care (http://policybase.cma.ca/dbtw-wpd/Policypdf/PD06-02.pdf). According the CanMEDs framework, developed by the Royal College of Physicians and Surgeons of Canada, the professional role of physicians is defined as a commitment to “the health and well-being of individuals and society through ethical practice, professionled regulation, and high personal standards of behaviour” (www.royalcollege.ca/shared/documents/canmeds/the_7_canmeds_roles_e.pdf).
Of course, many of the principles oft-mentioned in medical literature on professionalism are markedly of the motherhood and apple pie variety, generic tenets that no one would disagree with and are applicable to any profession. Good luck finding a statement of values in any professional workplace that opposes integrity, respect, reliability or any other feel-good fodder for an inspirational poster.
What has traditionally separated physicians from other professionals, however, is a strong sense of altruism. Although lip service is paid to putting the clients’ needs first in the business world, it is generally accepted that the bottom line is the top priority. But medicine, many doctors would attest, is supposed to be different. The needs of the patient should always trump the financial priorities of the physician. Every skill, every decision, every morsel of scientific knowledge — all are to be used to better serve patients.
“In one sense, doctors are technicians. They are body mechanics. A lot of that involves just technical and biological know-how. But the critical part, the ethical part, is the commitment of doctors to put their technical knowledge at the service of their patients. That is the fundamental principle of the practice of medicine. The needs of the patient take precedence over your own economic practices,” says Dr. Arnold Relman, professor emeritus of medicine and social medicine at Harvard Medical School in Boston, Massachusetts, and former editor in chief of the New England Journal of Medicine. “You should not be an entrepreneur. If you want to get rich, fair enough, but go into a different field. Medicine is not a place to get rich. It’s a social service.”
Editor’s note: Second in a multipart series on medical professionalism.
Part I: The “good doctor” discussion (www.cmaj.ca/lookup/doi/10.1503/cmaj.109-4200).