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Academic Medicine and Medical Professionalism: A Legacy and a Portal Into an Evolving Field of Educational Scholarship

Hafferty, Frederic W., PhD

doi: 10.1097/ACM.0000000000001899
Invited Commentaries
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In this Invited Commentary, the author examines two curated Academic Medicine volumes showcasing foundational research and key writings on professionalism in medicine and medical education, collectively spanning from 1994 to 2016. The author reviews the beginnings of the medical professionalism movement and examines how the trends and themes reflected in the first volume—specifically the work to define, assess, and institutionalize professionalism—capture key elements in this movement. He then examines how the trends and themes in the second volume align with and build on those from the first, noting two themes that extend across a number of second volume articles: a unit-of-analysis issue and the challenge of context. The author identifies several topics that have yet to be adequately mined and calls attention to two bridge-spanning articles in the second volume that, respectively, take us into the future (around the topic of identify formation) and back to the past (on the hidden curriculum). Finally, the author reflects on “directions home” in medicine’s noble search for its moral core and collective identity.

F.W. Hafferty is professor of medical education, Division of General Internal Medicine and Program in Professionalism and Values, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0002-5604-7268.

Editor’s Note: This is an Invited Commentary on Academic Medicine’s e-book, Professionalism in Medicine and Medical Education, Volume II: Foundational Research and Key Writings, 2010–2016, a collection of articles, reports, and perspectives, published from 2010 through 2016 in Academic Medicine that focus on professionalism. The e-book is available at http://journals.lww.com/academicmedicine/Pages/eBooks.aspx.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Frederic W. Hafferty, Mayo Clinic, 200 First St. SW, Rochester, MN 55901; telephone: (507) 284-8343; e-mail: fredhafferty@mac.com; Twitter: @FHafferty.

This autumn, Academic Medicine releases the second volume in its series of e-books on medical professionalism. The first, Professionalism in Medicine and Medical Education: Foundational Research and Key Writings 1994–2010 (PMME I), is a collection of perspectives, original articles, and research reports highlighting some of the most important topics and writings on the practice and pedagogy of professional preparation published in Academic Medicine from 1994 to 2010.1 The second volume, Professionalism in Medicine and Medical Education, Volume II: Foundational Research and Key Writings, 2010–2016 (PMME II), continues in this tradition.2

Although the articles across these two volumes are arranged by date, there is no underlying intimation that they should be consumed serially. Nonetheless, the overall time period covered (1994–present), and the broad range of themes and issues included, captures, with remarkable fidelity, a good part of what we now refer to as “medicine’s modern day professionalism movement.”3,4 This movement was preceded by an earlier (1970s) and quite vigorous debate within sociology about how large-scale social, economic, political, and technological change within U.S. society might be having substantial—and deleterious—effects on medicine’s status as a profession and on the identity of physicians as professionals.5–7 These sociological concerns and conclusions, although widely shared within the medical sociology community, had little discernible impact within organized medicine. Rather, as viewed by medical leaders, all was well within the House of Medicine. By the time medicine began to acknowledge these sociopolitical tremors and fault lines, the analytic fervor within sociology had ironically begun to abate.8 This concomitant movement of awakening and abdication, however, did mark an important shift in the principal object of analytic concern—from sociology’s long-standing focus on the profession as a collective entity to organized medicine’s emergent preoccupation with issues of professionalism, particularly at the level of individual practitioners and trainees.9 An iconic article in these respects is Arnold Relman’s “The New Medical-Industrial Complex,” published in the New England Journal of Medicine in 1980.10 Relman’s concerns with corporate threats to traditional medical practice were deliciously sociological in their framings, and very much about issues of profession and professionalism. Nonetheless, the article contains no direct references to sociology (including the aforementioned sociological debate), nor did Relman deploy either the term “professionalism” or “profession” in his analysis. A scant two years later, and in a similarly focused article published in Health Affairs (“The Future of Medical Practice”), Relman marshals sociological framings and the language of professionalism to warn colleagues about medicine’s threatened status as a profession.11 What intervened was the Pulitzer Prize–winning publication by Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry12—a book Relman13 would admiringly review for his (as editor) journal.

PMME I is a testimony to the turmoil and excitement of this time. This volume accurately captures the array of concerns about how best to define, assess, and ultimately institutionalize professionalism within the arenas of medical education and medical practice, and thus, it captures the movement as a whole. If nothing else (and this volume is a great deal more), PMME I is a portal into the collective thinking about professionalism of that era. While no one journal can claim to be the conceptual fulcrum of emergent medical thinking on professionalism, it also is true that there was a collective commitment within Academic Medicine to scholarship on this topic during the 1990s and early 2000s under the editorial stewardships of Addeane Caelleigh and Michael Whitcomb. When I wanted to bathe in cutting-edge work on medical professionalism during this time period, I turned to Academic Medicine—a choice I now find confirmed within PubMed and ISI Web of Science (as I conduct an informal search for indicators such as “most highly cited” professionalism articles—or just observe the sheer volume of work published on this topic during these two decades). These really were exciting times. Medical professionalism was a field of scholarship in search of its identity.

The portal into our historical journey opens to Volume I’s first article on ethics training and the hidden curriculum.14 In what today might be viewed as an existential disaster waiting to happen, much of medicine’s formal efforts to define, assess, and institutionalize professionalism would generate a staggering array of unanticipated and unintended consequences; disjunctures in messaging arose between the “formal new” and the variety of informal, tacit, and indeed hidden ways in which medical trainees and practitioners traditionally had come to learn about what it meant to be a professional. In short order, and as a direct result of organized medicine’s remedial frenzy, trainees found themselves enmeshed within learning environments in which formal curricula intersected in a variety of confounding and countervailing ways with other-than-formal curricula—generically labeled the “hidden curriculum” (but without everything being literally hidden or therefore negative). Students quickly found themselves betwixt and between as they began to wrestle with a bedeviling array of messaging about what it meant to be a good doctor. In turn, medical educators, ever so slowly, began to realize that creating definitions, crafting assessment tools, and generating new curricula was a lot easier (and more productively seductive) than painstakingly effecting changes in the culture of medical practice.

Insightful windows into this bedlam of learning appear in PMME I under a variety of framings, including “hidden,” “informal,” “humanism,” and “role modeling.” For example, a heightened awareness of how role models functioned as important vehicles of tacit learning opened pedagogical eyes to the variety of messaging (both positive and negative) that these cultural standard bearers were in fact delivering. Likewise, the identification of professionalism by the Accreditation Council for Graduate Medical Education (ACGME) as one of its six core competencies set a bar not only for how residents should be taught and assessed regarding (among other things) their professionalism but also for how other types of providers, including faculty, might be assessed (even informally). Although not substantively reflected in this volume, concerns about issues of professionalism, humanism, and the hidden curriculum also raised parallel questions about the development and socialization of faculty.15 In short, the development of formal definitions, assessment tools, and the variety of formal efforts to institutionalize professionalism (via the creation of codes, charters, competencies, and curricula) began to raise parallel questions about how this bubble of enthusiasm for professionalism might unintentionally contribute to a hardening of medical student hearts16 and the vanquishing of their virtue.17

The excellence of these Volume I chapters notwithstanding (and every one has been seminal in shaping my own thinking on professionalism), there is a piece missing from our discussion: a “so what.” So what if we define professionalism? So what if we teach and assess it? So what if we develop curricula and competencies regarding professionalism? How do we link what happens in medical schools to the more proximal and seminal issues of quality, outcomes, and patient safety? These questions deliver us to a linchpin article in the first collection, “Unprofessional Behavior in Medical School Is Associated With Subsequent Disciplinary Action by a State Medical Board,” by Papadakis and colleagues.18 By empirically linking the unprofessional behavior of practitioners (via state medical board actions) with behaviors by students during their undergraduate medical training, we now had evidence of something long suspected: How students behave during medical school relates to how they might turn out as future physicians. From this point forward, not acting to address issues of professionalism within the halls of medical schools and clinical training sites could be viewed as not acting in the best interest of patients, and thus, not working to preserve the public’s trust. As the opening decade of the 21st century drew to a close, all of these efforts at foundation building were beginning to support an emergent recognition as to “the complexities of” professionalism.19–22

Issues of context and complexity bring us to PMME II, which covers a shorter time frame but has no less thematic richness or contemporary relevance. Given Volume I’s focus on issues of definition, assessment, and institutionalization, how does Volume II build on this infrastructure?

Quite well, actually. In fact, this volume provides 25 distinct and provocative quite-wells. Granularities aside, I want to highlight two themes that extend across most of the included articles. The first is a unit-of-analysis issue. The second targets the challenging issue of context. The unit-of-analysis theme seems a natural extension of the themes and topics covered in PMME I. As noted, much of the early work on professionalism focused its definitional, assessment, and institutionalization efforts on individual motives and behaviors. Social scientists, however, know that how a community defines or frames an issue (in this case, professionalism) exerts considerable influence on how members view what constitutes a legitimate response to those problems.23 In short, definition shapes evaluation and resolution—or at least how the community is willing to approach analysis and what it is willing to consider as a resolution. If professionalism is defined as residing in the behaviors and motives of individual physicians and trainees, then solutions to that problem are similarly constrained. But, what if the problem is not one of motives? What if the answers to issues of professionalism are not to be found (exclusively) in more course work, more frequent assessment, or more strictly enforced codes? What if the issue is not so much individual people but, rather, context, the settings in which they operate? As we move into PMME II, we encounter a broad array of efforts to wrestle more aggressively with both this unit-of-analysis issue and with that of context.

Issues of context appear in a variety of places and manifestations across Volume II—particularly within the orienting framework of culture. A recognition that “our” (and yes, there is intentional irony here) understandings of professionalism have a decidedly Western and Eurocentric underpinning make an important appearance—both as a general critique and with specific references to alternative framings (e.g., Japan; Taiwan). Here too, we explore differences between how medical schools define and remediate professionalism in the United States and how they do so in Canada. Volume II also begins to delve into issues of race/ethnicity through a professionalism lens. These multinational, cross-national, and racial/ethnic broadenings also push us to imagine what is missing and how potential future volumes might showcase perspectives from the Middle East, South America, and Africa.

Volume II also begins to move us toward a more aspirational framing of professionalism and away from a rules-based and command-and-control approach. In addition, writings on the hidden curriculum become more granular and contextual, including more explicit efforts to link this conceptual tool to topics such as professionalism and, as a somewhat separate issue, humanism.

Notable in this volume is the connection of professionalism to a variety of important themes in medical education and medical practice such as the techniques of appreciative inquiry and reflective ability, along with the concept of emotional intelligence. Evoking Robert K. Merton’s sociological framing of unintended consequences,24 we also begin to encounter a more refined recognition that what we intend (be it with curricula, assessment, or codification) is not necessarily what we reap. From a student perspective, we witness how explicit efforts to inculcate professionalism in one formal teaching setting (anatomy) can easily be undercut or negated when subsequent educational venues either teach alternative framings or, worse yet, ignore issues of professionalism altogether (and thus convey “important” messages about professionalism via the null curriculum).25 Meanwhile, the somewhat marginalized “magic bullets” (to use the sociologist Renee Fox’s framing26) of medical ethics and the humanities are given a fresh reexamination via the lens of professionalism. Here too, newer topics are accorded their moment in the professionalism sun, including issues of wellness, work–life balance/integration, burnout, and social media. These topics, while expanding our understanding of the contextual dimensions of professionalism, also, for the most part, reinforce an individual rather than a collective framing of professionalism issues.

It also is worth mentioning what we do not see, if only as a beacon for potential future volumes. While definitional and assessment issues have a much lower profile in Volume II, when they do appear, it is with important reframings. For example, Wynia and colleagues’ contribution27 deliberately highlights professionalism as a collective enterprise and thus seeks to shift the definitional conversation away from its more traditional and individualistic roots. Alternatively, issues of assessment are noticeable in their absence and thus appear enigmatic. Perhaps Academic Medicine needs to more aggressively move toward extending the boundaries of contemporary professionalism assessment28–32 and thus push the community beyond those earlier and groundbreaking works by scholars such as Louise Arnold,33 David Stern,34 and Shiphra Ginsburg and colleagues?35 Perhaps we need to explore the interplay of formative versus summative assessment in the context of professional formation? We also need a more empirical work on organizational professionalism, not only in terms of how organizational context comes to shape the presence and practice of professionalism at the individual level but also in terms of how organizations themselves can meaningfully be viewed and assessed as professional entities in their own right.36 This means, among many other concerns, thinking about organizations as something other than a collection of individuals whom we happen to consider “professionals.” And per our discussion above, organizational context is also a unit-of-analysis issue.

We should extend this call for more empirical and conceptual attention not only to assessment but also to issues of diversity and inclusion, interprofessional education, maintenance of certification, and further global framings (including whether we should be moving to a singular global idea of “professionalism” or to more contextually/regionally based understandings).

Also yet-to-be adequately mined are the more clinical issues of patient safety and quality of care. Definitional framings of professionalism in places such as the United Kingdom are much more inclusive in these respects than what we encounter in the United States, perhaps influenced by the ACGME’s identification of professionalism as a distinct competency.

Also lacking is how we better understand professionalism from within the politics of inclusion and exclusion. The issue of race-conscious professionalism highlighted in this volume needs to be extended to the related issues of ethnicity, gender, social class, sexual identity, disability, and religion, among others. For example, the exploration of how formal and other-than-formal educational practices within medicine and medical education produce heteronormativity, although quite visible in scholarship outside of medicine,37,38 has yet to make an appearance within the medical education literature. Issues of marginality also bring us back to the hidden curriculum, since the composition of our training milieus—which includes our provider and patient populations—have an important impact on how we conceptualize what it means to be a professional.

This—the idea of what it means to be a professional—brings me to the topic of professional identity formation, a hot topic of late, and one that purposefully has been excluded from this volume with the possibility that it will receive its own focused treatment at a later date. Still, how identity, as a conceptual lens, furthers conversations about professionalism, and does so at both the level of individuals and organizations, remains an important challenge to issues of professionalism. Meanwhile (not to connect professionalism to every hot topic), other concerns, implicit bias being one, need to be aggressively explored through a professionalism lens.

Before ending, I want to direct special attention to the two concluding articles in PMME II. Both are bridge spanning in that they take us into the future (around the topic of identify formation) and back to the past via the opening article of PMME I (on the hidden curriculum14). In these respects, the articles by Irby and Hamstra39 and by Jha and colleagues40 function as lenses through which we can examine the rich legacy of themes and articles that appear across these two volumes. By differentiating among virtues, behaviors, and identity, Irby and Hamstra cover the waterfront of definitional, assessment, and institutionalization practices, while also providing us with a stepping-stone to an emerging (identity formation) literature. In turn, the use by Jha and colleagues of a planned behavior to fitness (PBF) approach to professionalism asks us to revisit a number of what will be familiar themes within the two volumes: behavior versus identity, remediation, and what the authors characterize as their desire to examine the more “hidden dimensions of professionalism,” including context, social norms, interpersonal relations, and local cultures. The authors’ focus on relationships is of particular interest to me because it points to the potentially exciting ways in which we might explore professionalism from a relational perspective,41–43 be that relationships among individuals, among organizations, or among the complex array of ways we have begun to think about professionalism.

Endings should contain some mixture of optimistic and cautionary flavorings. Not to belay the obvious, but however unique their execution, PMME I and PMME II represent a singular, albeit important, portal into the evolution of medicine’s modern-day professionalism movement. Over the years, a number of medical journals, educationally focused and otherwise, have marqueed critically important work in this evolving field. Nonetheless, as I look across this extended waterfront of publications, I am left with a disquieting sense of unease. In something akin to a phrasing (“no direction home”) made famous by this year’s Nobel Prize–winning liturgist, Bob Dylan, I harbor reservations as to where this whole “professionalism thing” is going. In spite of the vast literature that has been generated, professionalism continues to occupy an enigmatic presence within the medical community. It has an underdeveloped presence in maintenance of certification and continuing professional development frameworks. Similarly, the Liaison Committee on Medical Education has embedded relatively few specifics about professionalism in its compendium of standards. Professionalism does have a higher profile within the ACGME’s milestones project and in its Clinical Learning Environment Review initiative44,45—although both projects are evolving and remain relatively separate undertakings. Perhaps even after two decades of conceptual and empirical excitement, now is too soon to expect inklings of closure?

But perhaps this desire for closure is its own no direction home. Perhaps professionalism is more of a journey than a destination. Perhaps professionalism is best captured not in a definition or metric but in the willingness of a community to engage with itself in an ongoing and reflective search for a soul defined by the core values of selflessness and service? Perhaps the true promise of medical professionalism lies not in professional dominance or in the metrics of accountability46 but in the willingness of a community to do its best, patient by patient, and to do so even in the face of the increasing social divisiveness that today seems to dominate so many specters of social life? Perhaps the true promise of professionalism lies in medicine’s collective ability to function as a beacon of hope where the relentless pounding of market and bureaucratic forces are continuously and conscientiously opposed by another, socially vital way—of organizing work and valuing agency.

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Acknowledgments:

The author wishes to thank the present and previous editors and editorial staff of Academic Medicine for their considerable gifts to the field of medical professionalism scholarship, and in particular to Anne Farmakidis and Elizabeth “Liza” Karlin, who curated Volume I; to Liza and Heather Grimm, who curated Volume II; and with particular gratitude to Liza and Heather for their time and insights as the three of us waded through the multitude of issues that would become this Invited Commentary.

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References

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