TopicsEthics and Professionalism
How you define professionalism depends on when you were born. Physicians trained in the 20th century take a heroic view: being a professional means working painfully long hours, heedless of your own needs, to care for those in pain. It demands herculean effort and those who fail to measure up must be held accountable.
These Baby Boomers take a dim view of younger colleagues who demand reasonable hours and a healthy work-life balance. When Gen-Xers talk about avoiding burnout and learning from mistakes instead of punishing those who make them, senior staff hear whining and a dereliction of duty.
This conflict over what it means to be a doctor has sparked intense interest in the definition of medical professionalism. There were fewer than 20 articles on the subject in 1972. Thirty years later, there were ten times as many, and the trend shows little sign of abating.
In 2002, three prestigious professional groups collaborated to create a “Charter on Medical Professionalism,” which they “intended to be applicable to different cultures and political systems.” Later, the Accreditation Council of Graduate Medical Education revised its Common Program Requirements to include professionalism as one of six core competencies. And just last year, the Royal College of Physicians published “Advancing medical professionalism,” a 123-page report “to help doctors improve their professionalism in practical ways.”
There are differences among these efforts. The Charter cites patient welfare, patient autonomy and social justice as the fundamental principles of professionalism, while the UK report describes medical professionalism as the fulfillment of seven different roles: healer, patient partner, team worker, manager/leader, advocate, learner/teacher, and innovator.
But there is a great deal of overlap as well. To varying degrees, these and virtually all other discussions of medical professionalism mention a familiar catalog of virtues and behaviors, including lifelong learning, clinical competence, professional boundaries, physician well-being and management of finite resources.
As helpful as these efforts are, some experts find them unsatisfying. In his 2005 article, “Medical professionalism and the generation gap.” Lawrence G. Smith, MD suggested that “these attempts to define professionalism as a set of virtues, obligations, and behaviors fall short of capturing its essence.” Underlying all the definitions, including those of Baby Boomers and Gen-Xers, he wrote is “the transformation of ‘lay person’ to physician.”
What’s needed is a new identity.
As Stephen Schenthal, MD and CEO of PBI Education, puts it, “Becoming a professional doesn’t just mean mastering certain skills and knowledge or behaving in prescribed ways while on the job. It means assuming a whole new identity for the rest of your professional life.” Smith points out that physicians are called “doctor” regardless of where they are or what they are doing. The title reflects society’s belief that they are no longer simply an individual. They have become a physician.
This fundamental understanding of professionalism transcends the limited perspectives of both sides in the generational conflict. It calls on Gen-Xers to accept that their commitment to work-life balance does not negate their commitment to being a physician. “Accepting this role colors all of one’s perceptions and opinions, setting standards for behavior,” writes Smith. “Once this transformation occurs, it is impossible to believe being a physician is “just a job.”
Boomers, too, are asked to look beyond their equation of professionalism with hardship. As Smith suggests, the physician’s goal is excellence, not endurance. Those who keep themselves sharp by taking time for themselves are not abandoning their professional identity, they are embracing it.
Regulators play a crucial role.
Although being a doctor does not necessitate working day and night, it does demand constant vigilance. The role of physician does not end when the white coat is slipped off at the end of the day. “A professional represents the profession 24/7,” says Schenthal. “Being a doctor is a privilege that entails full-time accountability.”
By articulating standards, accepting complaints and holding hearings, boards support this core responsibility of professionalism. The vast majority of physicians will never be disciplined for misconduct, but knowing that they may be called on at any time to justify their actions, fosters the self-monitoring so essential to the role of physician.
It’s only when this self-regulation falters that board discipline takes over, says Catherine Caldicott, MD and a senior faculty member at PBI Education, “It’s the regulators’ duty, by virtue of their mission to protect the public, to step in and impose regulation on the professional whose own self-regulation has broken down,” she explains.
Board discipline is also critical to the recovery of those who do step outside of their professional identity, adds Schenthal. “Just as medical conditions that don’t cause pain tend to go untreated, violations that don’t cause pain tend to persist,” he explains. “Board discipline that is sufficiently impactful can spark meaningful change. A slap on the wrist rarely does.”