Definition

Evidence in literature suggests that professionalism is a set of attributes, including empathy, resilience, life work balance and punctuality and communication skill (Birden, 2012). Epstein and Hundert’s definition of professionalism suitably brings together competence to the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, reflection in daily practice for the benefit of the individual and community being served (Epstein & Hundert, 2002). The Association of American Medical Colleges (AAMC) asserts that physicians must be altruistic, knowledgeable, skillful and also dutiful (Medical School Objectives Project Writing Group, 1999).

Perhaps the main referent of professionalism is certainly the “Physician Charter” of 2002. It defines, professionalism as the basis of physicians’ contract with society (Vivanco & Delgado-Bolton, 2015). Correspondingly, its contents propose the following,

Noticeably, within 15 months after its release, the “Physician Charter was supported by 90 specialty societies” (Blank et al., 2003).

The American Board of Internal Medicine (ABIM) certification program covers “ethics and professionalism” (Blank et al., 2003).5 Professionalism is an important core competency of doctors (Mueller & Tighe, 2007), indicating that the classification and meaning and/or definition of professionalism is also subjected to circumstantial and temporal changes. The Accreditation Council for Graduate Medical Education (ACGME) lists six general competencies (Project AO).

1. Interpersonal
2. Communication skills that result in effective information exchange
3. Teaming with patients, their families, other health professionals
4. Professionalism, as manifested through a commitment to carrying out professional responsibilities
5. Adherence to ethical principles
6. Sensitivity to a diverse patient population

Competence in these areas not only necessitates that training programs support developing competence, but also that they evaluate students’ professionalism. These efforts also stress the importance of training and assessment (Mueller, 2009). The field of medical research, with assessment purposes, advocates that professionalism is a type of knowledge reached from a starting point of three essential bases: clinical skills, communicative skills and an appropriate understanding of ethical and legal framework of the professional behaviour (Vivanco & Delgado-Bolton, 2015). These three elements are the grounds upon which the founding characteristics and core values of medical professionalism are built (Stern, 2006):

• Excellence
• Humanism
• Accountability
• Altruism

This definition introduces the idea of professionalism as a virtue to which physicians continue to aspire and provides a bridge to medical ethics. In this definition, excellence, humanism, accountability and altruism act as aspirational principles more than a normative framework that provides an assessment tool of observable professional behaviours.

Dr. Nagina Khan, PhD

Importance of Professionalism

Professionalism influences health care professionals at different levels in multiple ways. For example, there is a link between professionalism and burnout, one of the common issues faced by many physicians and nurses as well as medical students. Burnout has detrimental effects not only on their lives but also on the quality of their patient care (Davis et al., 2021). Dyrbye et al. (2020), in fact, supported that burnout is linked to unprofessional behavior.

Interestingly, according to Gradiski et al. (2022), two components of medical professionalism, lifelong learning and empathy (i.e., empathic engagement in patient care), correlated negatively with burnout. Davis et al. (2021) also revealed the relationship between residents’ professionalism (i.e., professional conduct and accountability) and burnout.

Professionalism warrants serious attention. It is imperative that professionalism education is provided as early as possible to protect health and wellbeing of future health care professionals, thereby ensuring the quality and safety of patient health care.

Fatima Isa

Professionalism Lapses

Significance of Professionalism Lapses
Research done by Maxine Papadakis, et al. (2005) in a large case-controlled study looking at graduates from UCSF from 1943 until 1989, showed that those who were disciplined by the State board for professionalism were more likely to have had professionalism citations in their medical school files. While a lapse in professionalism during training is not strongly predictive of future censure, it may often signal underlying problems to be addressed. 

Professionalism concerns arising during training should be seen as opportunities to help learners achieve success in professional identity formation and progression along the “life cycle” from novice to expert. Simply ignoring or sweeping these issues under the rug can lead to a pattern of behavior and future problems for that individual. Brenner et al. (2010) also found that negative phrases about student’s behavior in medical school showed a strong correlation to poor performance in residency.

Defining Lapses in Professionalism
Professionalism has been identified as a core competency for medical school and residency training, and for many health professions training programs. There is no single definition of unprofessional behavior as it relates to academic, clinical, research, and social domains of activity. Lapses tend to be stratified according to level of concern and addressed appropriately. 

Common Professionalism Lapses
Ziring, et al. (2015) surveyed all AAMC accredited medical schools asking each to report the three most common professionalism lapses at their schools. The lapses were then grouped using Papadakis’ categorization based on behavioral domains (3) as follows, listed in order of most to least frequent:

1. Responsibility (for example, arriving late or not attending assigned activities, missing deadlines)
2. Relationship with health care environment (such as testing irregularities/cheating, falsifying data, impaired communication with team)
3. Diminished capacity for self-improvement (such as arrogant, hostile or defensive behaviors)
4. Relationships with patients, including communication with patients

Some professionalism lapses were cause for dismissal at some of the medical schools. These lapses included committing a felony, falsifying patient information, falsifying information on a medical school or residency application, and forging a prescription.

Root Causes
Although health professions schools attempt to select for qualities of integrity, compassion, respect for others, altruism, and commitment to social justice, there are many factors that can compromise professional behaviors. It should not be surprising that lapses in professionalism occur given that trainees have never been placed in the complex and often stressful environment of clinical practice. Trainees are likely to encounter problems, situations or dilemmas that are: novel, exceed level of competency, require a high level of moral reasoning or are in direct conflict to their own best interest (such as sacrificing time in order to place a patient’s needs above their own).

Many additional factors set the stage for lapses to occur. On an individual basis, these include situational and life stressors that drive more reactive behaviors. Students may lack self-awareness or social awareness. Certain personality or coping styles are less well suited to meeting professional demands. At times, cultural values may be in conflict with professional expectations. Students’ moral development may not have advanced sufficiently to internalize professional principles and duties. Unrecognized or untreated anxiety, mood disorders, or substance use disorders are also key contributors to unprofessional behaviors.

There are systemic factors as well. Trainees at times are exposed to stressful and negative learning environments (negative hidden curriculum). They are also sometimes engaged in clinical environments tainted by burnout, negative bias, and patient stigmatization. Negative role-modeling, moral injury and distress, and learner mistreatment erode the learner’s understanding of professionalism standards of behavior.

Remediation

Approach to Remediation
Given the enormous range in type and severity of potential professionalism lapses, an intentional and stepwise approach is supportive for faculty and administrators. One approach is outlined here. Ideally, the backdrop is an institutional culture that places high value on early identification for appropriate intervention. The type of intervention and institutional action ought to be commensurate with the level of egregiousness of the unprofessional behavior, ranging from informal counseling to criminal prosecution.

Regarding most lapses in professionalism which do not rise to the level of “egregious” behavior and when there has only been a single event or issue that has occurred, simply making the learner aware of the issue through a conversation about the lapse and what the expectations are in the learning environment is often sufficient. This conversation alerts the learner to the fact that the behavior was noticed, that it does not “fit” with the accepted code of conduct of the school or training program, and the expectation is that the learner should be “on notice” about future behaviors. Formal remediation may not be necessary if the learner acknowledges the issue, is able to demonstrate understanding and appreciation that what they did is not acceptable, understands the personal circumstances that led to the lapse, and knows how to behave differently in the future. Faculty ought to be mindful, however, of being overly dismissive of minor lapses that may fall into larger patterns or signal serious root causes of concern.

Remediation Process
Chang (2015) describes a five-step strategy as a framework in approaching lapses in professionalism with learners. These steps are:

1. Early identification
2. Objective data
3. Shared understanding
4. Learning plans
5. Measuring outcomes

This five-step strategy can be applied to a variety of approaches that address specific lapses. In general, remediation strategies can be regarded as fitting into three major categories: experiential learning, structured reflection, and coaching.

Defining Success 
For most schools or residency programs, “success” is generally defined as not hearing about further problems with the identified student or trainee. There is also typically a general sense from the person(s) involved in the remediation process as to whether the student or trainee “got it” – whether there appeared to be an understanding, and incorporation of the feedback and processing with regard to the professionalism lapse. This sense should be supported by detailed notes from the meetings between trainee and advisor. It is helpful to agree that the terms of a behavioral contract spelling out the conditions of successful remediation have been met. While this system is not ideal, most schools do not report other ways of determining whether the remediation was successful. It is difficult to know whether the remediation generalizes to other situations or prevents future lapses.

For more information and resources, go to: https://bit.ly/ProfessionalFormationSignUp and register to access the Professional Formation module on remediation.

Susan Stagno MD, Kathy Cole-Kelly, MS, MSW & Steven Rosenzweig, MD

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References

1. Birden, H. H. (2012). Professionalism in medicine. What is it and how can it be taught? (Doctoral dissertation, University of Sydney).
2. Blank, L., Kimball, H., McDonald, W., Merino, J., & ABIM Foundation, ACP Foundation, and European Federation of Internal Medicine (EFIM). (2003). Medical professionalism in the new millennium: a physician charter 15 months later. Annals of internal medicine, 138(10), 839-841.
3. Davis, C., Krishnasamy, M., Morgan, Z. J., Bazemore, A. W., & Peterson, L. E. (2021). Academic Achievement, Professionalism, and Burnout in Family Medicine Residents. Family Medicine, 53(6), 423–432.  https://doi.org/10.22454/FamMed.2021.541354
4. Dyrbye, L.N., West, C.P., Hunderfund, A.L. et al. Relationship Between Burnout, Professional Behaviors, and Cost-Conscious Attitudes Among US Physicians. J GEN INTERN MED 35, 1465–1476 (2020). https://doi.org/10.1007/s11606-019-05376-x
5. Epstein, R. M., & Hundert, E. M. (2002). Defining and assessing professional competence. Jama, 287(2), 226-235.
6. Gradiski, I. P., Borovecki, A., Ćurković, M., San-Martín, M., Delgado Bolton, R. C., & Vivanco, L. (2022). Burnout in International Medical Students: Characterization of Professionalism and Loneliness as Predictive Factors of Burnout.  International Journal of Environmental Research and Public Health, 19(3), 1385–. https://doi.org/10.3390/ijerph19031385
7. Medical School Objectives Project Writing Group. (1999). Learning objectives for medical student education-guidelines for medical schools: Report i of the medical school objectives project. J Assoc Am Med Coll.;74(1):13–8.
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10. Project AO. General competencies. Chicago IL: Chicago IL, Accreditation Council for Graduate Medical Education.
11. Stern, D. T. (2006). Measuring medical professionalism. Oxford University Press.
12. Vivanco, L., & Delgado-Bolton, R. (2015). Professionalism.
13. Brenner AM, Mathai S, Jain S, Mohl PC. Can we predict “problem residents”? Acad Med. 2010 Jul 85(7):1147-1151.
14. Chang A. Alpha Omega Alpha Medical Professionalism Best Practices. Chapter 8: Clinical Skills Remediation: Strategy for Intervention of Professionalism Lapses. 2015. Pages 101-113.
15. Papadakis M. Alpha Omega Alpha Medical Professionalism Best Practices. Chapter 1: Introduction. 2015. Page 5.
16. Ziring D, Danoff D, Grosseman S, et al. How do medical schools identify and remediate professionalism lapses in medical students? A study of U.S. and Canadian Medical Schools. Acad Med 2015; 90:913-920.