Medical Education
Sep 2002
What does it mean to be professional? Is it the way you dress for clinic? How you obey your manners? If you are a "good person," does that mean you know all that you need to know to be a "good doctor?" If your mother raised you well, are you all set? The Accreditation Council on Graduate Medical Education says that residents need to be competent in professionalism, and the Liaison Council on Medical Education recommendations for medical schools won't be far behind the residency programs. "A scout is trustworthy, loyal, helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean, and reverent." Does professionalism mean to say the same of a doctor? If not, then what is professionalism?
After a year as a fellow in the American Medical Association's Institute for Ethics, I am still a beginner in the field of medical professionalism. To attempt a complete definition at this point would be both daunting and redundant. Several authors have explored different aspects of professionalism, and some useful references are listed at the end of this article. Instead, I will provide a beginner's guide to professionalism and include some of my own thoughts along the way.
Three Domains of Professionalism and How They are Related
Although there has been an explosion of literature on medical professionalism in the past 10 years, it would be a mistake to think that this is a new concept. Paul Starr's Social Transformation of American Medicine has influenced thinking since the mid 1980s. Eliot Freidson has been writing on the sociology of medicine since the 1970s, and George Engel published on the "care and feeding of the medical student [as] the foundation for professional competence" in a 1971 Journal of the American Medical Association article. Different fields and diverse opinions have been brought to bear on professionalism, expanding the term to cover a broad set of ideas. The results of these varied analyses can be categorized into three domains: habits of practice, habits of group maintenance, and habits of mind.
Habits of practice or activity include matters of dress, address, decorum, and etiquette. They are the ways in which physicians behave toward patients and toward each other. A breakdown in the latter during an epidemic at the Manchester Infirmary's Fever Hospital lead Thomas Percival to write one of the original codes of ethical conduct, Medical Jurisprudence in 1792, which set up a system of rounding and attending physicians that is maintained today in many hospitals. Habits of practice involve "behaving like a doctor," and can be taught by example. The Aristotelian "teach virtue by being virtuous" applies here, mainly because an internalization of reasons and justifications is unnecessary. Proper dress, white coat, "Good morning Mrs. Jones, what brings you in today" are justifiable behaviors, but both their performance and their effect may occur without regard to the actor's mindset. This does not diminish their importance.
Habits of group maintenance are activities and values that work toward maintaining the socially granted power of the medical profession. These powers are informed by an elusive and tacit social contract between physicians and the general public, and include self-regulation, exclusivity of practice (non-competition), financial compensation, and control over physician supply. Many of the social responsibilities of the physician either derive from the social contract, or serve to maintain it. Charity care, public health and hygiene, health education, and political action are examples of habits of group maintenance. The rise of organized medicine on the national, local, subspecialty, and hospital levels has allowed responsibility for some of these habits to become institutionalized or spread over a collective group of physicians. Maintaining the social power of the profession is a high-stakes and non-trivial endeavor. Social prestige, financial reward, physician autonomy, and public legitimacy are not easily regained once lost. Recruitment of new students and the future quality of medicine depend on the current professional behavior of physicians and the socialization of trainees.
Beyond these two sets of habits is a third domain of discourse on professionalism that I think addresses the foundations of professional action. Habits of mind are the reflective, cognitive, and philosophical schemata that inform medical practice and medical behavior. They are characteristic patterns of thinking that help physicians move from clinical information to clinical decision making and allow others to distinguish a professional from a quack. They may be explicit or tacit and "informal," and within medicine, some habits are better than others. Habits of mind—cultivating clinical mindfulness; reflection in daily practice and education; the model of medicine (biomedical, biopsychosocial, relationship-centered, or others) that we teach and practice; emotional intelligence—are what lead to habits of action whether we are aware of them or not. In both ethics and professionalism (different branches of medical behavior), it is not enough to intuit one's way to a course of action. The traditional standards, values, and goals of the profession must be taken into account. They are applied by the physician not in a cookbook manner, but more like the style of a gourmet chef; the ingredients and techniques of a school are known and the outcome is recognizable, but each dish is distinct.
Habits of mind can be taught only by practice. The student may not be able to recognize the habits of mind used by an exemplary practitioner because they may be subtly employed or seamlessly integrated into the physician's behavior. The role of a mentor is to make explicit the reflective components of his or her medical practice, and to encourage students to practice and learn their own habits of mind. John Dewey's pedagogy of study + experience + reflection = education seems appropriate to this mode of teaching and learning.
Where and When?
Ethics can be described as an activity, not purely a set of rules. In this light, ethics are not timeless. The values of the profession are relatively unchanging, but the process and activity of using those values to meet today's challenges is a necessarily dynamic process. Seeking a reflective equilibrium between principles and dynamic action makes professionalism an activity as well. Moving beyond rules of social conduct, professionalism becomes living, vibrant, and a daily part of medical practice.
Some make an appeal to personal virtue in the area of medical professionalism. They cite the noble and ancient history of the profession, and its link to other "helping professions" such as law, education, and ministry. Contemporary professionalism in a culturally diverse society moved beyond personal virtue when Percival appealed to a collective commitment to patients, the public, and their health as the raison d'être for his code of ethics and behavior in 1792. He saw that conflicts of personal morality and individual virtues end in a quagmire in the clinic. An appeal to nobility is the end, not the beginning, of hope for the future of the profession.
Contemporary professionalism is a group activity, one practiced in the company of others. It is more about everyday behavior than the actions one takes when no one else is looking, or how one holds up in a rare or distinct crisis. It has little to do with whether or not you run red lights late at night. It is about demonstrating the values of the profession. If we claim to support certain traditional values, then we should embody them in daily and public practice. An emphasis on what goes on in the solitude of the individual practitioner's heart leads to a pessimistic professionalism, and there is no room for that in today's medicine.
So, professionalism includes practice, education, reflective and applied ethics and demonstrating the values of the profession in all of our health care relationships. Sure, your necktie and white coat and what your mother taught you are in there, but there is a lot more to professionalism and a lot more at stake.
