Wynia, Matthew K. MD, MPH; Papadakis, Maxine A. MD; Sullivan, William M. PhD; Hafferty, Frederic W. PhD
Dr. Wynia is director of patient and physician engagement, Improving Health Outcomes Team, American Medical Association, and clinical assistant professor, Department of Medicine, University of Chicago, Chicago, Illinois.
Dr. Papadakis is professor of medicine, Department of Medicine, University of California, San Francisco, and staff physician, San Francisco Veterans Association Medical Center, San Francisco, California.
Dr. Sullivan is founding director, Educating Tomorrow’s Lawyers, University of Denver, Denver, Colorado.
Dr. Hafferty is professor of medical education and associate director, Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota.
Editor’s Note: A commentary by D.C. Leach appears on pages 699–701.
Please see the end of this article for information about the authors.
Funding/Support: None reported.
Other disclosures: None reported.
Ethical approval: Reported as not applicable.
Supplemental digital content is available for this article at http://links.lww.com/ACADMED/A191.
Correspondence should be directed to Dr. Wynia, 515 N. State St., Chicago, IL 60654; telephone: (312) 464-4980; fax: (312) 464-4613; e-mail: Matthew.firstname.lastname@example.org.
A perennial challenge for every profession is to collectively establish and enforce professional standards.1 This challenge came to the fore during a 2012 initiative of the American Board of Medical Specialties (ABMS) to develop a working definition of “professionalism.”2 The ABMS is the umbrella group for 24 U.S. specialty and subspecialty boards that certify individual medical and surgical specialists. The authors worked with ABMS leadership to create an operational definition that could serve as a foundation for member boards in their wide array of certification and maintenance of certification activities. In doing so, the ABMS definition ended up approaching professionalism from a different vantage point than many other contemporary definitions, which generated some foundational insights about the nature of professionalism that might prove useful for organizations and individuals seeking to better understand and strengthen professionalism in health care.
Our initial approach was functional. The member boards are the assessment arm for lifelong learning among physicians, and the definition needed to be well suited to this responsibility and to the diversity of the member boards. But we also sought to address several broader questions: What is the purpose of professionalism, how does it work, and what does it entail?
In a literature search and by surveying the member boards of the ABMS, we found more than 20 different definitions of professions or professionalism (some prominent examples are included in Supplemental Digital Appendix 1, http://links.lww.com/ACADMED/A191). In reviewing these, we noted that a few others have also sought to frame the social functions of professionalism within a definition. Jordan Cohen and others have described medical professionalism as a tool, the “basis”3 or the “means [to] fulfill the profession’s contract with society,”4 and Eliot Freidson called it “a set of institutions which permit members of an occupation to make a living while controlling their own work.”5 Still, many recent definitions do not address the foundational purpose of professionalism explicitly; instead, they focus on articulating a list of attributes, behaviors, commitments, obligations, principles, values, virtues, or other desirable traits of professionals.
Some definitions display both descriptive and normative components. These generally acknowledge some important descriptive characteristics of professional knowledge (extensive and complex), training (lifelong), and practice (difficult to assess). They then propose a set of shared values that the writers assert professionals ought to exemplify, such as compassion, justice, honesty, respect, altruism, and service. For purposes of assessment, the best of these definitions go on to articulate lists of measurable behavioral expectations derived from each proposed value.6
Problems With Definitions Based Primarily on Lists
These “list-based” definitions of professionalism are quite functional for teaching, measurement, and certification, yet in several ways they also risk obscuring the foundational purpose, functions, and demands of professionalism.
First, reducing professionalism to a list of desired professional principles, traits, or behaviors is akin to reducing the entire experience of cooking to checking off the grocery list while shopping. Professionalism requires behaviors, so a list of measurable professional behaviors is necessary, but the list, in and of itself, is not sufficient to define professionalism. Second, professionalism defined simply by a list of desired behaviors risks being misconstrued as a state that individuals can attain by checking off the elements of the list. Finally, defining professionalism as a list of personal attributes suggests that professionalism primarily is operationalized at the individual level, deflecting attention from the essential group activities that underlie professionalism, including the ongoing development and enforcement of professional standards that self-regulatory organizations like the ABMS must do.
A Better Way to Define Professionalism
Rather than comprising a list of desirable values and behaviors, we argue that professionalism transcends these; it is the reason for creating such lists and acting in accordance with them. In this light, professional behaviors should be recognized as derivative of the belief system of professionalism. Professionalism is not merely an accounting of what physicians promise to patients and society. At root, it is the motivational force—the belief system—that leads clinicians to come together, in groups and often across occupational divides, to create and keep shared promises.
The ABMS definition of professionalism, adopted in both long and short versions by a unanimous vote of the ABMS Board in January 2012, asserts that:
Medical professionalism is a belief system about how best to organize and deliver health care, which calls on group members to jointly declare (“profess”) what the public and individual patients can expect regarding shared competency standards and ethical values and to implement trustworthy means to ensure that all medical professionals live up to these promises.2
(The long version of the definition7 and the background framing for the definition8 are also available.)
Although behaviors are important for accountability, regulatory, and enforcement purposes, recognizing that professionalism is fundamentally a belief system about how groups ensure that their members are worthy of trust will enhance commitment, resilience, and adaptability as health practitioners navigate the ongoing challenges of publicly declaring and exhibiting professional behaviors, especially because we cannot anticipate all the behaviors the evolving health system might require.6 This definition also leaves room for broader forms of professionalism as the health system encompasses more and different roles for a variety of health practitioners.
Perhaps most important, this definition draws attention to the primary function of professionalism in health care: ensuring that health professionals are worthy of patient and public trust. Achieving this purpose requires living up to the belief that professionalism is a realistic and desirable means of organizing and delivering health care; hence, this definition goes behind the veil created by lists of professional expectations and suggests why professional groups must both generate these lists and enforce them.
Implications of Defining Professionalism as a Belief System
Identifying professionalism as a belief system about how best to organize and deliver health care is not entirely new. The sociologist Eliot Freidson5 called professionalism “the third logic” and compared it to alternative logics of markets and bureaucracies as ways to organize and deliver goods and services. The greater importance of this new formulation lies in several specific implications that it carries for individual practitioners and professional organizations.
First, defining professionalism as a belief system identifies foundational scientific and technical competency standards and shared ethical values as equally important and recognizes that both are within the purview of professionalism. Earlier definitions that focused on lists of values and character traits tended to conceive of professionalism as being only about ethical standards, so much so that “ethics” and “professionalism” often have been used interchangeably. There are hazards in conceptualizing professionalism as a separate area of competence, equal to ethics and distinct from practitioners’ responsibilities to attain and maintain the technical and other skills necessary to provide quality care. The more professional groups recognize that technical, interpersonal, and values-based competencies make up interlocking sets of promises, all of which are required by professionalism, the more effective our training and assessment programs will be.
Second, because this new definition requires practitioners jointly to develop and declare collective public promises and ways to hold each other accountable, it calls explicit attention to shared accountability, to the legitimacy and effectiveness of existing self-regulatory mechanisms, to the public’s key role in setting expectations for health professionals, and to the roles of professionals in the public sphere. In short, the unwillingness or inability of groups of professionals to govern their work effectively poses a fundamental challenge to societal belief in professionalism. The inability of individual practitioners to see professional mechanisms for establishing and enforcing shared standards as legitimate also poses an existential threat to professionalism. For example, the 24 U.S. member boards are operationalizing self-regulation to ensure the lifelong competency of physician diplomates through “maintenance of certification” programs.9 Yet, a majority of respondents to a 2010 Web poll, and even some experts, did not endorse this self-regulatory mechanism.10 Jointly developed professional standards require broad participation in the process, and public declaration (“professing”) is bound to generate contentious discussions about policy and practice. Novel means of engaging more physicians, other health professionals, and the public in this process, including through social media, might prove fruitful and, by the ABMS definition, would also buttress belief in professionalism as a legitimate means of organizing and delivering health care.
Finally, recognizing that professionalism is a normative belief system, and that its legitimacy is dependent on living up to its promise of ensuring that practitioners are trustworthy, forces serious consideration of what happens if professionals and their organizations fail to establish credible means of ensuring that practitioners are worthy of trust. Believing in professionalism means holding the conviction that medical professionals can come together to establish and enforce standards for competence and ethics, and that society is best served when health care is entrusted to these professionals. But not everyone believes in professionalism. In fact, there are prominent alternative belief systems about how best to organize and deliver medical care, including consumerism and other “isms.”11 This new definition calls attention to the fact that if professionalism fails to ensure trustworthiness, if the public no longer believes in professionalism, it can be revoked in favor of substitute belief systems that rely less on patient and public trust in health practitioners.
Believing in Professionalism Demands Collective Action
In sum, this new definition of professionalism, though created for the ABMS, offers guidance on questions facing all health practitioners and professional organizations that come together for the purpose of strengthening professional bonds. We opened this essay with three questions: What is the purpose of professionalism, how does it work, and what does it entail? We conclude that medical professionalism is a normative belief system about how best to organize and deliver health care. As such, professionalism should serve to ensure that practitioners are worthy of the trust bestowed on them by patients and the public. Most fundamentally, therefore, professionalism requires that health professionals, as a group, be ready, willing, and able to come together to define, debate, declare, distribute, and enforce the shared competency standards and ethical values that must govern medical work.
Acknowledgments: The authors gratefully acknowledge the members of the Ethics and Professionalism Committee of the American Boards of Medical Specialties (ABMS) for multiple robust discussions of the issues addressed in this paper. Except where expressly noted, the opinions expressed herein are those of the authors and should not be construed as policies of the ABMS or any of its member boards.
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