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Parting the Clouds: Three Professionalism Frameworks in Medical Education

Irby, David M. MDiv, PhD; Hamstra, Stanley J. PhD

doi: 10.1097/ACM.0000000000001190
Perspectives

Current controversies in medical education associated with professionalism, including disagreements about curriculum, pedagogy, and assessment, are rooted in part in the differing frameworks that are used to address professionalism. Three dominant frameworks, which have evolved in the medical education community, are described. The oldest framework is virtue based and focuses on the inner habits of the heart, the development of moral character and reasoning, plus humanistic qualities of caring and compassion: The good physician is a person of character. The second framework is behavior based, which emphasizes milestones, competencies, and measurement of observable behaviors: The good physician is a person who consistently demonstrates competence in performing patient care tasks. The third framework is identity formation, with a focus on identity development and socialization into a community of practice: The good physician integrates into his or her identity a set of values and dispositions consonant with the physician community and aspires to a professional identity reflected in the very best physicians. Although each professionalism framework is useful and valid, the field of medical education is currently engaged in several different discourses resulting in misunderstanding and differing recommendations for strategies to facilitate professionalism. In this article, the assumptions and contributions of each framework are described to provide greater insight into the nature of professionalism. By examining each discourse in detail, underlying commonalities and differences can be highlighted to assist educators in more effectively creating professionalism curricula, pedagogy, and assessment.

D.M. Irby is professor of medicine and of research and development in medical education, University of California, San Francisco, San Francisco, California.

S.J. Hamstra is vice president, Milestones Research and Evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Previous presentations: Pieces of this work were presented at the AMS Phoenix Project Annual Meeting, Ottawa, Ontario, Canada, November 20, 2014; the Association for Medical Humanities, Dartington Hall, Devon, United Kingdom, June 24, 2015; and the Advances in Health Professions Education Research and Development Symposium, University Medical Center Utrecht, Utrecht, Netherlands, September 11, 2015.

Correspondence should be addressed to David M. Irby, UCSF School of Medicine, 533 Parnassus Ave., Suite U80, San Francisco, CA 94143-0710; telephone: (415) 502-1633; e-mail: irbyd@ucsf.edu.

When the topic of professionalism arises, the clouds of confusion descend, making it difficult to see the landscape: “There seems to be no agreement on what the term [i.e. professionalism] means.”1 For some, professionalism refers to virtues, aspirations, and humanism embodied in the good physician.2,3 Within this framework, virtuous physicians are able to apply ethical reasoning, restrain self-interest to their actions, and demonstrate compassion and respect as a humane person. Another perspective asserts that professionalism is a set of behaviors, a competency or a role that physicians perform.4,5 Professionalism within this definition is a domain of competence to be mastered, demonstrated, and assessed. Another framework defines professionalism as identity formation,6–8 which is a developmental process that describes how physicians in training take on increasing levels of professional identity. It involves being socialized into thinking, acting, and feeling like a professional. Unfortunately, much of the conversation and associated debates on professionalism fail to recognize the differing underlying frameworks, assumptions, and discourse communities, which results in misunderstanding and confusion.9

Historically, conceptions of profes sionalism have been modified or created anew to address the perceived shortcomings of the extant approaches to producing the good physician. For example, the virtues-based/ethics approach was used implicitly for generations but made more explicit in response to the increasingly complex ethical decisions created by new technologies and therapeutics, by the inability to imbue trainees with physician virtues through role models alone, and by patient complaints about uncommunicative and uncaring physicians. The behavior-based competency movement, with its focus on performance outcomes, arose out of frustrations with subjective measures of character and the apparent failure of trainees and physicians to apply moral reasoning to their subsequent actions. In turn, identity formation developed in reaction to the perceived reductionistic and prescriptive behavioral approach to competencies and milestones. Although advocates for these three frameworks often contest with one another over assumptions and recommendations, we feel that they are often talking past each other.

In this article, we describe three dominant frameworks that describe professionalism. Our approach is to examine professionalism from a variety of contrasting viewpoints to deepen our conceptual understanding of this complex construct. We examine the assumptions made by each framework and highlight both the historical and theoretical contexts that led to the crystallization of these assumptions. Our analysis suggests that no one framework is adequate for describing professionalism and that, in considering the features of each framework in turn, or as part of a whole, we gain a deeper understanding of the term.10 In this article, we seek to clarify the construct of professionalism and describe various strategies for curriculum, pedagogy, and assessment that are suggested by each framework and conclude by discussing their respective contributions. See Table 1 for a comparison of the three professionalism frameworks.

Table 1

Table 1

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Virtue-Based Professionalism

Construct

The virtue-based framework is the oldest, going back to Hippocrates, and continues to evolve and have strong advocates today.3,11,12 In the early 20th century, the physician was viewed as a man of character, whereas in the 21st century the physician is viewed as someone with characteristics, such as competence.13 In the virtue-based framework, physicians are viewed as moral agents who must put aside self-interest to act in the best interest of their patients. Virtuous physicians are expected to place the needs of patients before their own, keep information confidential, disclose and deal with conflicts of interest, and be altruistic, honest, reliable, and respectful. Virtue-based professionalism focuses on the internal habits of the heart, moral values, moral reasoning, and character development. Physicians are expected to apply ethical principles to their decisions and actions—ethical principles such as autonomy, beneficence, nonmaleficence, and justice. Many of these ethical principles have been codified into rules that must be learned and followed, such as informed consent, disclosing conflicts of interest, and ensuring confidentiality of patient information. From this perspective, professionalism requires compliance with these rules and expectations. This is often referred to as the medical profession’s social contract with society.14 In developing understanding of these rules and expectations, medical students progress or fail to progress through predictable stages in their moral development and moral reasoning.15–19 This stage model has been applied to remediation of medical students with arrested moral development as demonstrated by professionalism lapses.20

Humanism is often associated with this framework, being concerned with compassion, respect, and effective communication with patients. The intent of virtue-based professionalism and humanism is to internalize values and ethical reasoning to develop a self-giving disposition toward patients and colleagues. In this framework, professionalism is the application of virtue to practice.3

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Strategies

Writers who use a virtue-based framework make recommendations for curricular, pedagogical, and assessment strategies to facilitate learning. Professionalism is often a theme that runs throughout the curriculum, and includes medical ethics, moral reasoning, humanism, patient communication, and often the use of honor codes. One example of such an honor code comes from the University of Texas Medical Branch (UTMB) at Galveston, where all employees and learners must pledge: “On my honor, as a member of the UTMB community, I pledge to act with integrity, compassion, and respect in all my academic and professional endeavors.”21 Rituals such as the white coat ceremony are also used to instill professional values. Pedagogical strategies include the use of direct instruction, the Hippocratic Oath, role models, case studies, reflective writing, appreciative inquiry, and white coat ceremonies.22 Assessment is typically carried out through written exams, reflec tive writing exercises, self-assessment, observations and feedback, and, sometimes, moral reasoning assessment.

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Remediation

Professionalism lapses are viewed as a failure of character and virtue.3 Lapses can also be seen as a failure to move through the predictable stages of moral development, which involves incorporating professional values and the practical wisdom to discern how to respond to given situations. When professionalism lapses occur, they should be dealt with by seeking to understand what prompted the behavior, encouraging the learner to reflect on the aspirational goals of professionalism and their own behavior, and developing their moral reasoning abilities.20

The virtue-based approach to profes sionalism focuses on inner habits of the heart, the development of moral character, and acting in a self-giving, ethical, caring, and humanistic manner. Because this framework promotes adoption of aspirations and inner dispositions, learners often report feeling less coerced and more inspired than when confronted with the behavioral approach.3 The dominant assumption of this framework is that professionalism involves altruism and self-sacrifice, where the good doctor is a person of character.12,23

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Behavior-Based Professionalism

Construct

The dominant framework for profes sionalism today is behavior or outcome based, which focuses on competencies and emerged out of frustrations associated with attempting to measure and evaluate character as described by the virtue-based framework. Behaviors can be defined, observed, and assessed—thus allowing complex and integrated sets of competencies to be demonstrated and certified. For almost two decades, the Accreditation Council for Graduate Medical Education (ACGME), the American Board of Internal Medicine, the Royal College of Physicians and Surgeons of Canada, and the General Medical Council in the United Kingdom have all subscribed to an outcomes-oriented learning model that is anchored in competencies.24–26 As an example, the ACGME refers to professionalism as one of six domains of competence; in the ACGME’s framework, professionalism includes demonstrating compassion, integrity, and respect; being responsive to patient needs; and being accountable to patients, society, and the profession. More recently, the Carnegie Foundation for the Advancement of Teaching en dorsed this framework by calling for standardization of learning outcomes and individualization of the learning process.6

Milestones are the developmental steps toward full competence, which can be clearly defined and monitored to assess resident and fellow progression. Professionalism milestones make explicit reference to an increasingly sophisticated set of behaviors that include caring, honesty, and a commitment to patients and their families, all the way up to managing ethical conflicts and demonstrating leadership regarding the principles of bioethics.

An emerging elaboration on the behavioral framework is the addition of a systems perspective. Advocates of this persuasion make the argument that many professionalism issues arise out of conflicting expectations and clashes that inevitably follow boundary-spanning interactions in complex organizations. Conflicts can occur when performing a handoff, seeking a consult, admitting a patient to an inpatient service, and discharging a patient. Systems can precipitate or mitigate professionalism lapses. To act in a professional manner, learners require knowledge, skill, and judgment to deal with specific situations and to negotiate conflicts.27

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Strategies

Curriculum strategies involving this framework include teaching learners the expected behaviors and competencies as well as systems thinking, root cause analysis, diplomacy, and communication, especially in crisis situations. Pedagogical strategies include direct instruction, role modeling, case studies, simulations, peer and instructor coaching, as well as written examinations and reflections on self-awareness and self-control in conflict-prone settings. Assessment often involves the use of written exams, rating forms, self-assessment, observations and multisource feedback, critical incident reports on lapses, and professionalism mini observations.27,28

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Remediation

Professionalism lapses are viewed as acts of inappropriate behavior and reflect a lack of skill in negotiating conflict-prone situations. The most common professionalism lapses are (1) lapses in responsibility (e.g., late or absent, unreliable), (2) lapses related to the health care environment (e.g., cheating, falsifying data, disrespecting other members of the team), (3) lapses related to diminished capacity for self-improvement (e.g., arrogance, defensiveness), and (4) lapses around impaired relationships with patients (e.g., poor rapport).29 Remediation strategies often involve a system to identify lapses, meeting with the student when a lapse is observed, developing a remediation plan, and monitoring compliance with the plan.30 Other frequently used strategies for remediation include mandated mental health evaluation/treatment, completion of a professionalism assignment, mandated professionalism mentor, and counseling for stress or anger management.31 Lucey32 makes the case for continuous formative evaluation of professionalism by using root cause analysis to identify and debrief professionalism lapses. All students should be taught the skills to skillfully manage even the most challenging professionalism situations.27,32

This framework also asserts that professionalism issues arise at three levels: with the individual physician and patients, with colleagues, and with society. In addition to physician–patient interactions, professionalism issues arise during interactions with other members of a practice, clinic, or hospital, and with the external environment. The latter include payers, policy makers, and systems that perpetuate inequities in health care. Each of these levels of professionalism interacts with the others and requires different lenses for determining appropriate forms of professional action.5,9

The behavior-based competency framework emphasizes the importance of clarifying learning outcomes and of teaching to and examining observable behaviors. The focus is on doing rather than being. The systems perspective adds clarity to the context within which professionalism is lived out. The dominant assumption in this framework is that professionalism involves measurable behaviors, and that the good doctor is one who is competent in performing various patient care tasks.

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Professional Identity Formation

Construct

The third framework is professional identity formation, which has received considerable attention in recent years as medical educators responded to the limitations of the behavior-based framework.8,33–35 Identity addresses who we are and who we want to become. This involves the evolution of one’s identity with an increasingly integrated commitment to the values, dispositions, and aspirations of the physician community. Identity formation is viewed as an adaptive, developmental process occurring at individual (psychological)8,36 and collective (sociological)37 levels that socialize learners into thinking, feeling, and acting like a physician.8 Learning evolves through participation in a community of practice, through observation of role models and their interactions with others, as well as direct instruction, coaching, assessment, and feedback.6,7

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Strategies

Identity formation can be addressed as a curricular theme within doctoring and ethics courses. These curricular themes tend to be learner focused and developmental in nature. Examples of developmental challenges in identity formation include the early transition from being a graduate student to a physician in training, from being a student in the classroom to a member of a health care team in a clinical setting, and from being a learner with minimal responsibility to a resident with major responsibility for patient care. Questions that arise for students and residents include How do I fit into this team and/or profession? How do I see myself in this context? Do I identify with members of this community of practice? Do I aspire to be like them? 38–40

Pedagogical strategies include direct instruction, role models, case studies, guided discussion of emerging and often conflicting identities, use of self-assessment, reflective writing, and appreciative inquiry.14,22 Assessment is usually multidimensional and multisource and uses aspirational orientations toward assessment and, sometimes, moral reasoning assignments and assessment.7,8,16

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Remediation

Professionalism lapses are viewed as a failure to progress through the developmental stages of identity formation and internalize the values of the medical profession. This requires stage-appropriate strategies to monitor and intervene when lapses occur. Remediation programs need to be tailored to the developmental stage of the learner and assist the learner to understand the nature of professional identity, the process of formation, and the obligations inherent in becoming a physician.7 Measures of moral reasoning, use of a professionalism identity essay, along with self-assessment and reflection have been successfully used to remediate professionalism lapses.20

Professional identity formation focuses on both the individual and the group and, like the virtue-based framework, explores internal developmental processes of being and becoming versus doing. The dominant assumption in this framework is that professionalism involves becoming a good doctor by aspiring to attain a certain professional identity, as depicted by positive role models. This perspective goes beyond the virtue- and behavior-based frameworks by acknowledging the powerful social forces implicit in becoming part of a community of practice.29

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Reflections

Each framework has strengths and limitations and contributes to the larger whole. The strength of the virtue-based framework is its emphasis on character—the inner life of the physician, aspirations, moral reasoning, and habits of the heart. This perspective helps to motivate and inspire learners and removes much of the perceived bludgeoning effect of the behavioral framework. The challenge with this framework is that it is difficult to assess character and moral reasoning, although Bebeau and Lewis’s16 work on assessing moral reasoning suggests that this is possible.

The strength of the behavior-based framework is its clarity of expectations and connection to assessment.27,28,41,42 Articulators of this framework have thought the most deeply about issues of assessment and remediation.27,28,41–43 This framework also goes beyond the level of the individual professional and the patient to include interactions with colleagues, the profession, and health policy. However, this framework is often criticized for its reductionistic approach, which tends to separate different components of integrated actions into discrete behaviors, which, in turn, creates unrealistic demands on assessment and feedback. This is partially being addressed through the use of entrustable professional activities, which aggregate competencies into larger and more integrated tasks/activities.44,45 Finally, the behavior approach assumes that behaviors accurately reflect inner mental models and, as such, can be meaningfully assessed.

Professional identity formation calls attention to both the person and the group and explores developmental processes of being and becoming. This framework is more difficult to describe, interpret, and assess, although recent work within this framework is beginning to flesh this out. More research on the implementation and effectiveness of recommendations arising from this framework, as well as the other two, is needed and will help guide future practice.

While proponents of these three frame works base their recommendations for curriculum, pedagogy, and assessment on differing assumptions, their recom mendations both diverge and converge. See Table 2 for practical applications of the three frameworks on curriculum, pedagogy, and assessment.

Table 2

Table 2

Professionalism lapses are viewed differently by the three frameworks (i.e., lapse of character, lapse of behavior, lapse of identity formation), yet they share common remediation strategies: Feedback needs to be formative rather than punitive, individuals and systems need to be held accountable, interventions should involve self-reflection and skill development, remediation plans and future actions should be monitored, and consequences should escalate in a stepwise fashion that is appropriate to the specific lapse.46

By contrasting these frameworks, the distinction between professionalism as a trait (character or behavior) and professionalization as a process (identity formation and development) becomes more sharply visible. We can see that professionalism involves attributes of the individual, such as behaviors, skills, or attitudes that lead to decisions that reflect distinguishing features of the profession. In the case of medicine, these would include putting patients’ needs above the self and exhibiting responsibility for the patient in terms of confidentiality, conflicts of interest, honesty, reliability, and respect. Professionalization, on the other hand, is concerned with the process of becoming a member of a profession. This includes processes of socialization and identity formation—in other words, taking on the features of a professional who defines that specific community. This includes the process of taking on professional values, which might then result in a demonstration of professionalism.

Becoming a good doctor is consonant with each framework. Although we have represented these three frameworks as pure types, the edges are often fuzzy, and some authors have moved among them. For example, the works of Bebeau et al and the Cruesses and colleagues have addressed professionalism from the perspective of virtues/ethics14,15 as well as identity formation.7,8,16,20

From our perspective, current conflicts in medical education over curriculum, pedagogy, and assessment of professionalism are rooted in the differing assumptions underlying each framework. By better understanding them, we hope that the conversations and dialogue around professionalism can be clarified and made more transparent to teachers and learners alike.

Acknowledgments: The authors wish to thank the following for commenting on the manuscript: DeWitt Baldwin, Eric Holmboe, Catherine Lucey, Brian Hodges, Bridget O’Brien, Patricia O’Sullivan, Maxine Papadakis, Joanne Schwartzberg, and Paul Rockey.

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