Medical Professionalism – A State of the Art

Given that members of guilds had achieved mastery of a specialised knowledge base, it provided justification for them to receive special treatment, rewards and respect.

In this article, I describe four conceptual lenses that can be used to consider and analyse professionalism as well as lapses in professionalism.

1. Social contract

It is important to underline that the guilds and their offspring – the professions – represent social constructions. Their members enjoy privileges, conferred on them by society primarily for society’s benefit and, as a quid pro quo, they are expected to meet certain obligations. This implicit bargain has been called a “social contract”. It defines, in broad terms, the mutual expectations between society and the medical profession. The social contract is an important lens through which one can understand professionalism.

2. Ethics or bioethics

This is probably the one most commonly associated with professionalism. Codes of conduct as well as statements describing the desired personal attributes of doctors and normative set of behaviours abound in the literature. Ethics and professionalism are intertwined and inseparable.

With respect to medicine, three major ethical theories have guided its practice:

• deontology: moral action is guided and constrained by principles and rules, including laws; these create professional duties
• consequentialism: (a subcategory of utilitarianism) the ends justify the means. Outcomes where benefits outweigh risks and harms, and are considered good for patients and society, provide the ethical compass of practice
• virtue ethics: the moral character of the doctor is seen as the guarantor of good and right behaviour.

In contemporary contexts, in western countries such as Australia, the profession has tended to lean on a deontological approach. An archetypical expression of the nexus of professionalism with duty or rule-based ethics is the ‘Charter of Medical Professionalism’. Created in 2002, the Charter identifies a set of 10 professional responsibilities; they are expressed as personal commitments (e.g. ‘commitment to patient confidentiality’).¹

3. Competencies

This is an increasingly popular framework for describing and codifying professionalism. A competency refers to a doctor’s ability that is itself related to a specific activity; one that integrates knowledge, skills, values and attitudes. Critically important to the definition is that a competency must be specified in behaviourally measureable ways. An example of a competency within the ‘domain of competence’ called patient care is, “The physician gathers essential and accurate information.” Competency-based education (CBE) is now widely accepted as the organising principle for numerous graduate medical education programs, including many in Australia. It should be recognised that CBE is not without controversy and has many detractors. In the context of assessing and promoting professionalism, the requirement that competencies be subject to measurement represents an inherent challenge.

Many opinion leaders believe that personal dispositions such as curiosity, courage, creativity, commitment, compassion, and tolerance of uncertainty do not yield readily to measurement. Competencies, and their related entrustable professional activities, may indeed be useful in understanding basic professionally-based activities. However, a tension exists between the reductionism implicit in CBE and the inescapable nature of professional medical practice, i.e. one that is dynamic, unpredictable, nuanced, richly contextual and holistic. This tension suggests the need for caution in equating competencies too tightly with professionalism.

4. Professional identity

The most recent evolution in the teaching of professionalism revolves around the concept of professional identity formation. This refers to the idea that individuals, during the enculturation process of medical education, become a certain kind of person – that they acquire the identity of a doctor. In the words of the American sociologist Robert Merton, they come to “think, act and feel like a physician”.² This is not to imply that medical students and doctors in training are obliged to disavow the core sense of who they are as individuals as they gradually transform into independent specialist practitioners.

Clearly, there are aspects of one’s personal identity that are enduring; medical education generally does not efface these characteristics. However, the concept represents an acknowledgement that medical educators do not only teach knowledge and skills; they also instil values and attitudes. In short, they transmit a culture wherein students develop an identity as a professional. Thankfully, most of the time the new identity is well aligned with pre-existing values, beliefs and predispositions, and the process is therefore not one of deformation. Nonetheless, the journey may not be entirely free of tribulations or painful moments. Learners and novice doctors need emotional support and guidance during the entire educational trajectory for their personal wellbeing and for effective integration of professionalism into their personas. Furthermore, educators must remain mindful that nurturing a professional identity must include attention to the attitudes and skills supportive of inter-professionalism and necessary for teamwork.

Defining professionalism

The four lenses considered so far – social contract, ethics, competencies and identity – all have clear roots within the profession. However, they are not generally part of the discourse of laypersons. The word ‘professionalism’ evokes a variety of meanings. A layperson will often use it to refer to the qualities of an individual – someone who executes tasks and discharges responsibilities with consummate skills, finesse, and sensitivity.

With respect to medicine, the skills and sensitivity the patient expects the most is that the doctor will listen to them and treat them in a way that respects their dignity. For a patient to feel as if they were heard and recognised as an individual worthy of respect is the indispensable quality of an encounter experienced as having been highly professional. It is noteworthy that the words and adjectives that we in the profession use are often quite different to those used by patients, even though the concepts are fundamentally aligned.

If we, members of the medical profession, as well as all of those working in institutions related to and supportive of the profession, such as organisations like MDA National, are to successfully aspire to the ideals of professionalism, we need to understand evolving conceptions of professionalism whilst never being wilfully blind to the patient’s perspective. I would argue that attentive listening, dignity-preserving care and the maintenance of competence, in all its facets, are the ‘summum’ of professionalism.

Prof J Donald Boudreau (Guest writer)
Clinician, Respiratory Medicine
Associate Professor, Department of Medicine
McGill University, Montreal, Canada

Prof J Donald Boudreau previously served as Associate Dean of undergraduate medical education and is currently a core member of the Centre of Medical Education, a unit focused on research in health professions education. He is a Professor of the Arnold P Gold Foundation which is dedicated to the promotion of humanism in medicine. He is also co-author of a book which has been published by Oxford University Press: Physicianship and the Rebirth of Medical Education.

References

1. Medical Professionalism in the New Millennium: A Physician Charter. Ann Intern Med. 2002;136:243-46.
2. Merton RK. Some Preliminaries to a Sociology of Medical Education. Preface. In: Merton RK. Reader LG, Kendall PL. eds. The Student Physician. Cambridge, MA: Harvard University Press. 1957: vii-ix.