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It Depends: Results of a Qualitative Study Investigating How Practicing Internists Approach Professional Dilemmas

Ginsburg, Shiphra MD, MEd; Bernabeo, Elizabeth MPH; Ross, Kathryn M. MBE; Holmboe, Eric S. MD

Academic Medicine:
doi: 10.1097/ACM.0b013e3182736dfc

Purpose: Context has a critical influence on individuals’ behaviors and is essential to understanding lapses in professionalism, yet little is known about contextual factors relevant to practicing physicians. This study used standardized professionalism dilemmas, or challenges, to explore practicing internists’ reasoning in their handling of typical challenges.

Method: In spring 2011, the authors created several professional challenges relevant to physicians in practice and conducted five focus groups with practicing internists (n = 40). Each group discussed five or six of the challenges, and the facilitators specifically asked what the participants would do and why. The authors used constructivist grounded theory to analyze the transcripts.

Results: The scenarios were effective in eliciting discussion and debate. Analysis revealed many guiding principles (e.g., patient welfare, keeping patients happy) that influenced physicians in their approach to professionalism challenges, but these principles were highly context-dependent. The authors found individuals’ responses to be malleable and subject to much modification depending on input from peers. Responses often shifted in an iterative and complex manner, depending on factors such as the “type” of patients (including the physician’s personal feelings toward them), the nature of the illness or diagnosis, and the physician’s relationships with others.

Conclusions: Despite recognizing and articulating basic guiding principles of professionalism, physicians’ approaches to professional challenges were subject to multiple, interdependent, idiosyncratic forces unique to each situation. A deeper understanding of these factors and how they interact is critical for the development of strategies to teach and evaluate professionalism in practice.

Author Information

Dr. Ginsburg is associate professor of internal medicine, University of Toronto, and scientist, Wilson Centre for Research in Education, University Health Network, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

Ms. Bernabeo is research associate, American Board of Internal Medicine, and PhD candidate, Bryn Mawr College Graduate School of Social Work and Social Research, Bryn Mawr, Pennsylvania.

Ms. Ross is research associate, American Board of Internal Medicine, Philadelphia, Pennsylvania.

Dr. Holmboe is chief medical officer and senior vice president, American Board of Internal Medicine, Philadelphia, Pennsylvania.

Correspondence should be addressed to Dr. Ginsburg, Internal Medicine (Respirology), Mount Sinai Hospital, 600 University Ave., Suite 433, Toronto, Ontario, Canada M5G 1X5; telephone: (416) 586-8671; fax: (416) 586-8864; e-mail:

© 2012 Association of American Medical Colleges