Ellsbury, Kathleen E.; Carline, Jan D.; Wenrich, Marjorie D.
In the last decade, considerable attention in both lay and medical publications has focused on physicians’ professionalism. Researchers and professional organizations have proposed several similar definitions of professionalism. Swick’s normative definition encompasses nine categories of behaviors that, taken together, comprise professionalism.1 Several national organizations have developed and widely disseminated guidelines, charters, and definitions of professionalism. One of the most widely cited is the Physician Charter, a collaborative effort by the American Board of Internal Medicine, the American College of Physicians, and the European Federation of Internal Medicine.2 This charter, published in 2002, specifies three fundamental principles and 10 professional responsibilities that represent a contract between the physician and society.
Medical schools have recently placed considerable emphasis on professionalism. In a survey of 125 U.S. medical schools by the American Medical Association Ethics Standards Group, 110 reported that their schools “provide curriculum content relating to professionalism and professionalism values.”3 However, most of the research on professionalism has focused largely on graduate and predoctoral medical education, not on practice settings outside of academic settings in which most learners will eventually work.
Few studies have explored the perceptions of professionalism in community-based practices. One study used interviews with physicians in diverse specialties to elicit information about their practice structure, philosophy, goals, and views of the medical profession.4 The authors identified the need to create a new grounded theory of professionalism applicable to medical practice as a whole, from students and residents to physicians in practice. Another study described physician-reported “deceptive” tactics that physicians employed in their dealings with third-party payers when trying to obtain care that they deemed medically necessary for their patients.5 Others have discussed tensions between business and professional medical values.1,6
The importance of professionalism in practice is underscored by a joint statement of the American College of Physicians and the Harvard Pilgrim Health Care Ethics Program working group that explored the impact of a changing health care environment on patient-physician relationships.7 The paucity of research on professionalism in community-based medical practice may be based both on an assumption that a practitioner’s attitude toward and display of professionalism are established in the training setting and on a tendency for the academic setting to be the center of debates and discussions about difficult and complex concepts such as professionalism. The logistics of studying practicing physicians are also challenging.
In addition to the relative lack of studies about perceptions of professionalism in community settings, it is apparent that broad and often abstract concepts prevail in discussions about professionalism.8 Words like respect, integrity, and compassion tend to predominate. Although these words are broadly meaningful, they may provide an incomplete picture regarding community-based physicians’ perspectives on professionalism. Aspects of and forces influencing professionalism as described in academic settings may not encompass the range of forces influencing physician behavior in practice. Rothman has suggested that much of the writing about professionalism has overlooked some important aspects.9
The purpose of this study was to determine whether prevailing definitions of and guidelines for professionalism in the literature accurately reflect the perspectives of practicing, community-based family physicians. This specialty group represents the largest single specialty group in the United States10 and family practitioners serve as the point of first medical contact for many patients. We chose a qualitative method in hopes of exploring issues and facets of professionalism that may not have been described elsewhere in the literature.
Using focus groups with community-based family physicians, we tested our hypothesis that community-based family physicians would hold views of professionalism that differ from views of professionalism held in academic settings.
Based on prior work with professionalism and a review of the literature, we constructed a moderator’s guide that pursued two lines of inquiry, each employing several different questions. The first line explored the meaning of professionalism in the family physician participants’ day-to-day practice, in terms of both their own perceptions and what they observed in other physicians. The second asked the participants to describe what they thought patients were most concerned about or valued most in a physician’s professional behavior. One investigator (a nonclinical medical educator) facilitated the focus groups, while the other two investigators (another nonclinical medical educator and an academic family physician) observed. We asked very concrete questions and probed for examples based in the physicians’ practice experiences. When participants identified abstractions, such as respect and integrity, we inquired about specific behaviors that defined or described these abstractions. Each focus-group lasted 90 minutes, and each was conducted using the same discussion guide and directions. The group discussions were audiotaped and later transcribed. Participants completed a brief demographic questionnaire that asked about gender, practice structure, and focus, and whether or not they had been involved in continuing education or other activities related to professionalism.
Invitations were mailed to 329 randomly selected members of the King County Academy of Family Physicians in Seattle, eliciting their participation in a focus-group on professionalism. We invited these individuals for two dates on which investigators were available. Sixty physicians indicated their willingness and availability to participate. Because we were most interested in the views of community-based practicing physicians, we excluded 27 faculty physicians in local residency programs and full-time university-based faculty physicians. Of the remaining 33 physicians who were eligible to participate, 18 came to one of the two focus groups. Participants received a light meal, parking, and an honorarium of $50. The study was approved by the University of Washington Human Subjects Committee.
All three investigators independently reviewed transcripts, and developed codes using a modified grounded theory approach. This involved an initial thorough independent review of focus-group transcript content by each of the three investigators, with subsequent multiple discussions among investigators to arrive at a consensus on the themes emerging from the focus groups. Using an iterative process, two domains of themes were identified for coding. The first domain incorporated categories commonly described in the literature, such as altruism, respect for patient autonomy, and integrity. The second domain related to tensions or conflicts in day-to-day practice experience when more traditional values of professionalism (e.g., altruism, integrity) were applied to actual practice. Consensus was achieved among the three investigators for all focus-group comments.
Description of participants
The two focus groups took place in August and September 2003. Among the 18 participants, 7 were female and 11 were male, distributed equally across the two focus groups. Additional demographic information was obtained for 15 participants, as three participants did not provide demographic information. Thirteen participants were board certified in family medicine; all participants declared family medicine as their specialty. On average, participants had completed their training in 1983. Participants reported spending a mean of 88% (range 30–100) of their time in patient care. Nearly half spent 100 percent of their time doing patient care.
Three participants were self employed, three were in group practices of fewer than 20 physicians, five were in large group practices, five were in a variety of other practice types, and three did not report their practice type. None had been involved in continuing education on professionalism. One participant chaired an ethics committee and three others participated in quality assurance/ professionalism committees. Further analyses used combined data from the two focus groups.
Identification of value sets
Focus-group transcripts revealed patterns similar in some respects to existing studies of professionalism, but different in other respects. Although we were able to categorize many of the comments under abstract terms proposed in previous taxonomies of professionalism qualities (compassion, communication, integrity/honor, responsibility, respect, competence, and excellence/scholarship), many other comments were unique, reflecting what appear to be sets of values. These sets of values appeared to be in a state of dynamic tension, creating what some participants experienced as stress, contradiction, or a balancing process. Investigators labeled the values sets with which individual physicians tended to compare their own values, as follows:
* patient values
* professional values
* medical organization and/or employer values
Specific examples of these values balanced against individual physicians’ values sets, with illustrative quotes, are shown in List 1. Although each observation and example appears in only one category, some could be appropriately placed in other categories as well.
Some participants described situations that demanded balancing multiple sets of values at once. In addition to the balancing multiple forces described in List 1, participants’ internal dialogue around their decision making reflected a tension among different aspects of the four sets of values. As one physician said, “[In many situations] nobody checks our work…” Participants described the need for “intellectual honesty,” “not taking the easy way out,” adhering to an internal set of standards or compass, “knowing one’s own limits,” “going the extra mile,” or “giving patients more than they expect.” One participant spoke of integrity as “doing what is right, even when no one will notice… I also think that there’s something beyond my patient and I in the exam room… it’s our community and our society at large.” Another said, “There’s always some point when something is murky and you’re tired and it would be easy and probably okay to let it slide or forget about it, and I think the honesty comes in saying, you know, ‘No,’ it doesn’t matter when it is; this question has to get answered, you know, whatever the question may be.” Another referred to “cleaning up one’s own messes”—a global concept of taking responsibility in the face of complications, mistakes, and difficulties.
Participants described the need to resist potential conflicts of interest in their practices. These included temptations to accept rewards from pharmaceutical companies and to perform unnecessary procedures to increase their income. One discussant referred to this phenomenon as “saving myself from myself.” Physicians seemed acutely aware of their level of autonomy and the need to self-regulate, with all the stresses this responsibility implies.
Most participants seemed to have come to terms with their self-perceived fallibilities. Participants frequently referred to insights and wisdom acquired through experience, not necessarily learned during formal medical training. They described a need to appear competent and confident, while admitting their limitations and errors, and seeking help when needed. One participant described with some irony this perception of the unwary patient: “[My] best preceptor said to me one day, you know, be really careful because once you’ve mastered [knowing what’s going on in a patient’s life], they will love you and trust you no matter what, and they’ll have no idea if you’re totally wrong.”
The results from this exploratory focus group–based study provide new insights into the meaning of professionalism for family physicians in practice settings outside of academic settings, and the tensions that the quest for professionalism evokes for them among multiple values sets.
Our findings suggest that overlapping and competing value sets create tensions that community-based physicians experience in their day-to-day interactions with patients, colleagues, employers, and professional organizations. For example, a recurrent theme among participants related to the tensions of having to be “on time” with regard to the practice’s expectations (values) concerning physician productivity. This tension seemed to create a sense among physicians of compromising their own values (such as serving and listening to their patients and adhering to professional values such as altruism and good patient-doctor communication). Our findings substantiate that these tensions are strongly present in the minds of the physicians we studied, and pose frustrations and concerns to them as they deliver care.
Conflicts among the values of medical organizations, physicians, and patients that fall under the category of “challenges to medical professionalism,” such as “scarcity of resources,” “consumerism,” “commercialism,” and “industrialization,” appear to detract from “excellence of health care.”11 Conflicts between the values of patients and those of physicians have been the subject of considerable reflection. Some have called for more dialogue between society and the medical profession on this issue.12 Bloom6 more pointedly addresses the current state of professionalism in today’s health care system:
In medicine today [maintaining ethical standards] has been overwhelmed by the demands of managed care. The leaders of medical education, in turn, proceed as though the practice of medicine has not changed. They turn their graduates loose after formal training that offers virtually no preparation for the current realities of medical practice, as though scientific and clinical expertise will be enough. In this process, I do not see how the ethical standards of professionalism as we define them here can survive.
Mechanic has proposed a “new professionalism” that addresses the growth of managed care and its constraining effects on treatment autonomy and medical professionalism, incorporating such concepts as procedural justice, population-based health, and evidence-based medicine.13 Frankford and colleagues call for closer links between medical education and practice to teach the “value of professionalism both within and without more by action than by exhortation” reformulated around a democratic ideal through such activities as “community assessments; community polling; direct democracy; focus groups; rotating lay leadership and participation in committees of educational and practice institutions; regularized contacts with neighborhood associations”; “good clinical practices and high ethical standards”; and “collegial, experiential, reflective, lifelong learning.”14
The tensions between values of organizations (including payers) and those of physicians reflect similar tensions more prevalent in the 1990s when managed care wielded considerable influence in medical reimbursement. Rosenbaum proposes that “much of the managed care backlash the nation has witnessed over the past several years … is testament to the law’s great concern that it do no harm to the moral and ethical base on which the very practice of medicine rests.”15 At a minimum, our findings support the continued importance of these issues in the minds of practicing physicians as they think about issues of professional behavior and values, even as managed care evolves. The findings also exemplify the level of tension or stress that these issues engender among practicing family physicians as they try to cope with multiple, competing, and often conflicting demands and perspectives.
These insights provide some guidance into the design of professionalism curricula at several levels of training. The issues that physicians face, including health care funding and access to care, mold the professional concerns and dilemmas that continue to trouble the profession. Instruction in professionalism and ethics needs to deal with the realities of current practice, and with the more fundamental principles and values of professionalism. At the undergraduate level and graduate levels, discussions and instruction about professionalism should focus on the issues facing learners, such as maintaining confidentiality and integrity in dealing with patients, and developing and maintaining appropriate relationships with other members of the health care teams. Residency training needs to move trainees toward an understanding of the tensions that will confront them in practice. Continuing medical education for physicians should focus more strongly on such topics as balancing the demands of payers while assuring high quality care for patients, improving access to care while maintaining the economic viability of health care systems, and understanding modern perspectives of the role of physicians in society.
This study has several limitations. First, the participants were from a single specialty (family medicine) in one western city, and the findings are therefore limited in generalizability. However, the study provides strong rationale for a larger, multispecialty, and multisite study. Second, the number of discussants was relatively small, but the study utilized two focus groups to serve as a cross check confirmation of themes and concerns, an approach consistent with the literature on focus-group methodology. Third, there is always the danger in focus groups that more vocal participants may have influenced the comments of the more reticent ones. Investigators were careful to elicit comments from all participants and limit the comments of those with sustained dialog. Finally, the ability to interpret intent, nuance, and meaning from short statements and phrases is limited. This is an inherent shortcoming of focus groups, yet a remarkable amount of depth came out of the discussions in this study.
Most of the literature on professionalism explores opinions and curricula in academic settings, or statements from professional organizations. The literature on professionalism provides little information on views of community-based physicians in particular. Our study brings to light some of the issues at play in contemporary primary care practice, especially among family physicians situated outside of academic centers, in roles that many of our trainees will eventually assume. The results should be considered carefully for further validation in other specialties and across other geographic locations.
We would like to acknowledge the King County Academy of Family Physicians for their cooperation. A small grant from the Center for Medical Education Research of the University of Washington made this work possible.