Here, L. Maximilian Buja, MD, Professor of Pathology and Laboratory Medicine, McGovern Medical School, details the role and responsibility of medical education in medical professionalism
Professionalism is a core tenant of physicians and is the basis for the social contract that confers the respect and privileged status accorded to physicians by the public (Blyyny). The basic principles of medical professionalism are excellence, humanism, accountability and altruism.
Models of professionalism
The construct of professionalism has undergone a major change in the last few decades (Blyyny). The traditional model of professionalism focuses on virtues and ethics. In the 1990s, a different model of professionalism developed around behaviours and competencies. In the past decade, a third model of professional identity formation gained prominence. The models are not mutually exclusive, but rather complementary in contributing to the overall construct of professionalism. Clearly, medical education has a fundamental role and responsibility in the professional development of aspiring physicians (Buja).
The general norm among physicians is adherence to accepted standards of professionalism and ethical medical practice. Unfortunately, however, a minority of physicians exhibit a spectrum of deviation from such standards, the most serious of which lead to sanctions of variable severity from state medical boards (Kirk and Blank; Papadakis et al.). A strong association has been established between disciplinary action by state medical boards against practicing physicians and a documented lack of professional behaviour when those physicians were medical students. Pertinent untoward behaviours included the areas of irresponsibility, diminished capacity for self-improvement, and poor initiative. Without intervention and remediation, these types of behaviour during medical school have a strong likelihood of leading to disruptive physicians and problem professionals. On the positive side, such unprofessional behaviour is subject to remediation through structured educational programmes that incorporate professional intervention, monitoring and follow-up.
A few medical students should not be allowed to graduate from medical school because of behaviour they manifest as students (Santen et al.). The number is small but one is too many. Yet, deans of student affairs and curriculum allow the one or two or more of such students in each class to graduate when such students are known to be inadequate or inappropriate candidates for graduation. Several barriers and challenges exist to make such a tough decision, including compassion and desire to help the troubled student, concerns about being backed up by the higher leadership of the institution, concerns about raising red flags with accreditation bodies and legal liability. Nevertheless, when students clearly should not become doctors moving them through to graduation has consequences for medicine and society.
Professionalism: Graduate medical education & practice
Beyond medical school, major efforts have been made to promote professionalism in graduate medical education and medical practice (Kirk). Professionalism is now one of the six core competencies of the Accreditation Council for Graduate Medical Education (ACGME). Internal medicine organisations have developed a professionalism charter based on three fundamental principles of professionalism: the primacy of patient welfare, patient autonomy, and social justice. This charter has been adopted by many major professional organisations.
Imprinting medical professionalism on trainees requires more than theoretical discussion and a general espousal of professionalism. An institution-wide action plan is needed to move from values to behaviours (Kirk). The knowledge trainees need to learn includes cognitive and non-cognitive categories. An approach has been developed to link the non-cognitive skills, or values, to specific observable behaviours. Behaviours linked to the value of responsibility include following through on tasks, arriving on time and acceptance of blame for failure. Manifestations of maturity including listening well, avoidance of making inappropriate demands and avoidance of being abusive and critical in times of stress. Communication skills include maintenance of patient confidentiality and avoidance of loud, disruptive, hostile, derogatory or sarcastic comments. Manifestations of respect include patience, sensitivity to physical and emotional needs of patients and peers and non-discriminatory inclusivity.
Several steps have been identified for effective teaching of professionalism (Kirk). These are: setting expectations, performing assessments, remediating inappropriate behaviours, preventing inappropriate behaviours, and implementing cultural change. The first step involves defining the characteristics of expected behaviour for all members of the institution. This involves developing policy statements that are linked to processes including reporting channels, due process, absence of retaliation for those who report behaviour, remediation processes, and follow-up. On joining the institution, students, residents, staff and faculty receive the list of expected behaviours for which they will be evaluated and held responsible. The consequences of acting inappropriately also are stated. The initial orientation and written documentation are reinforced by teaching and role modelling of professionalism.
The second step is assessment, including the incorporation of expected behaviours into formative and summative evaluations. Also, 360-degree evaluations – evaluations by peers, nurses, patients, direct supervisors and a wide variety of colleagues – are important for the evaluation of professionalism. The third step of remediation requires early identification of unacceptable behaviours followed by the development of an explicit remediation plan. The consequence of serious issues and non-compliance with remediation up to and including dismissal is enforced. A student or resident who shows a pattern of irresponsibility by consistently being late or not following through on assignments needs to be held accountable.
The responsibilities of medical educators
Professionalism is an essential component of medicine’s contract with society. Medical educators have a major responsibility for inculcating professional identity formation in medical students, residents, and fellows. Medical educators also have a major responsibility to remove recidivist trainees from advancement in the profession. Developing a supportive institutional culture is an overarching element for effective teaching of professionalism. Implementation of an institution-wide professional charter is recommended as an effective mechanism toward the advancement of professionalism.
Always be guided by the question: do you want this person to be the physician that cares for your love ones? If not, take action.
Blyyny RL. Medical professionalism in the modern era. The Pharos. Winter 2018, pp, 2-11.
Buja, LM. Medical education today: all that glitters is not gold. BMC Med Educ. 2019 Apr 16;19(1):110. doi: 10.1186/s12909-019-1535-9.
Kirk, LM, Blank LL. Professional behavior—a learner’s permit for licensure. N Engl J Med. 2005 Dec 22.;353(25):2709-11. doi: 10.1056/NEJMe058275. P.
Kirk, LM. Professionalism in medicine: definitions and considerations for teaching. Proc (Bayl Univ Med Cent). 2007 Jan;20(1):13-6. doi: 10.1080/08998280.2007.11928225.
Papadakis MA, Teherani A, Banach MA, Knettler TR, Rattner SL, Stern DT, Veloski JJ, Hodgson CS. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med. 2005 Dec 22;353(25):2673-82. doi: 10.1056/NEJMsa052596.
Santen SA, Christner J, Mejicano G, Hemphill RR. Kicking the Can Down the Road – When Medical Schools Fail to Self-Regulate. N Engl J Med. 2019 Dec 12;381(24):2287-2289. doi: 10.1056/NEJMp1908940.
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