If you wish to converse with me, define your terms.—VOLTAIRE
Every definition is dangerous.—ERASMUS
Much attention has been devoted in recent years to the question of professionalism in medical education and practice.1–9 While this attention has been salutary, there is no common understanding of what is meant by medical professionalism. Consequently, many of the discussions have been somewhat amorphous, because the word professionalism carries with it so many connotations, complexities, and nuances. It has virtually lost its meaning because it is so widely used. Different groups have used the word differently and for different purposes. Perhaps professionalism is like pornography: easy to recognize but difficult to define. Yet if professionalism is to remain integral to medical education and medical practice, and if the current, renewed focus on professionalism is to result in meaningful change that benefits both the profession of medicine and the society it serves, it is necessary to understand clearly what medical professionalism entails.
One needs a normative definition that is precise and inclusive, and that can be utilized by a wide variety of groups, including practicing physicians, medical educators, graduate medical education programs, professional organizations, licensing bodies, and regulatory agencies. Such a definition is necessary to enable and encourage dialog and eventually to achieve consensus about the meaning and importance of medical professionalism. In this article I propose such a normative definition. In doing so, I offer a new point of view and a new way to frame considerations of medical professionalism. I have attempted to create a persuasive definition based upon refined reflection about the nature of professions and the nature of physicians' work.
THE NATURE OF A PROFESSION
To understand professionalism, it is necessary to understand the nature of a profession. The medical community seems almost intuitively to grasp what the word profession means when applied to medicine, but it is important also to have a more structured understanding about what a profession is. To gain that understanding, it is neither necessary nor appropriate to craft a definition de novo. An extensive body of knowledge about professions exists in disciplines such as sociology and philosophy. In this article I make no attempt to review that body of knowledge. To understand the origins and meaning of professionalism, it is sufficient to recognize that certain common characteristics distinguish all professions, including medicine. A brief review of these characteristics is germane to understanding the origins and meaning of professionalism.
Eliot Freidson defined professions within a sociologic framework, using medicine as representative of all professions. In his seminal body of work, he argued that a profession is a specific type of occupation, one that performs work with special characteristics while competing for economic, social, and political rewards.10 Because a profession holds something of a monopoly over its work, it enjoys relative autonomy that derives from the nature of the work performed and from the relationship of the profession to institutions external to it, such as a sovereign state.10 That autonomy can be preserved only so long as the profession meets the responsibilities expected of it. From the sociologic perspective, professions exist without there being any necessary attention to whether the work has inherent ethical or moral value.
The concept of a profession has often transcended this rather narrow view to consider the moral or social value of the work performed. Justice Louis Brandeis alluded to a moral perspective when he noted that professional work was pursued primarily for others and not for oneself, and that success was measured by more than the amount of financial return.11 More recently, William Sullivan has emphasized the importance of the social value of professional work.12 There must be a balance between professional privileges and the public's perception that the profession is serving the public welfare: “Historically, the legitimacy, authority and the legal privileges of the most prestigious professions have depended heavily on their claims (and finally their demonstration) of civic performance, especially social leadership in the public interest.”13 Professions serve as guardians of social values,8 and professionals are expected to articulate and hold those values publicly. A profession, then, becomes a way of life with a moral value. It is in this sense that a profession becomes a calling, not simply an occupation.
Professions always reflect the particular social and cultural milieus in which they operate. Rapid advances of knowledge during the past 30–40 years have changed the natures of all professions, but none more dramatically than medicine. Professions have become more closely connected to the application of expert knowledge and less closely linked to functions central to the good of the public they serve. The rise of this “expert professionalism” has paralleled a decline in the older sense of “social-trustee professionalism.”14 The control and application of a specialized body of knowledge has come more and more to characterize a profession, as knowledge in all fields has grown and become more complex. But to rely solely on expertise is to diminish the special nature of a profession, especially insofar as it addresses societal needs. Steven Brint argues that “without a strong sense of the public and social purposes served by professional knowledge, professionals tend to lose their distinctive voice in public debate.”14 In many ways, that is the position in which the profession of medicine now finds itself: it has become distracted from its public and social purposes and thus lost its distinctive voice. In recent years, the debate about health care has been dominated not by physicians, individually or collectively, but by business, economic, and political interests. Strengthening medical professionalism becomes one way to restore medicine's distinctive voice.
THE NATURE OF PHYSICIANS' WORK
Medical professionalism is exemplified through what physicians actually do—how they meet their responsibilities to individual patients and to communities. Any definition must therefore be clearly grounded in the nature of the physician's work. The values and behaviors that individual physicians demonstrate in their daily interactions with patients and their families, and with physicians and other professional colleagues, become the foundation on which medical professionalism rests.
In this article, I do not attempt to provide a comprehensive account of the range of professional activities that can constitute physicians' work; the breadth of possibilities is too great, even for an individual physician. However, certain elements that characterize the nature of medical practice are key to providing a contextual understanding of medical professionalism. At the core of medical practice is the need to create and nurture a healing dyadic relationship between physician and patient. Other elements of medical professionalism reflect broader responsibilities that the physician has to society and the profession, to family and self.
The practice of medicine traditionally has embodied a set of values that limn the nature of medical work.6 Those values include, among others, a commitment to service, advocacy, and altruism. Physicians have long recognized a duty to individual patients and to larger groups, such as their communities. That duty now often extends to health plans or employers. The nature of the physician's work is active and, to a large extent, self-directed. It involves the application of a specialized body of knowledge and the need constantly to enlarge that knowledge. The work has inherent moral value and provides a societal good. It recognizes the worth of all human individuals. For example, the Association of American Medical Colleges (AAMC), in the first report of its Medical School Objectives Project (MSOP),15 identified four major attributes that medical students should have demonstrated by the time of graduation and that physicians should possess for the practice of medicine. The report stated that physicians should be altruistic, knowledgeable, skillful, and dutiful. Since 1994 the American Board of Internal Medicine (ABIM) has required that those seeking board certification demonstrate that they have acquired the values of professionalism, which “aspires to altruism, accountability, excellence, duty, service, honor, integrity and respect for others.”16 While aspires connotes an important sense of striving, it is incorrect to assume that the goals to which one aspires cannot be reached or that aspirations cannot be grounded in specific actions. Indeed, both the MSOP objectives and the ABIM requirements speak to the nature of physicians' work. The explication of these attributes—particularly those relating to altruism, service, and duty—addresses essential elements of medical professionalism.
A DEFINITION OF MEDICAL PROFESSIONALISM
From the arguments in the preceding sections, one can appreciate that the key to understanding medical professionalism is not to be found in a simple dictionary definition. Rather, the concept of medical professionalism must account for the nature of the medical profession and must be grounded in what physicians actually do and how they act, individually and collectively. Bearing this in mind, I assert that medical professionalism consists of those behaviors by which we—as physicians—demonstrate that we are worthy of the trust bestowed upon us by our patients and the public, because we are working for the patients' and the public's good. Failure to demonstrate that we deserve that trust will result in its loss, and, hence, loss of medicine's status as a profession.
Medical professionalism, then, comprises the following set of behaviors:
- ▪ Physicians subordinate their own interests to the interests of others. Medical professionalism reflects the physician's open willingness to subordinate his or her interests to best meet the needs of patients. It manifests the physician's fiduciary relationship with patients and the physician's duty to serve as the patient's advocate. The expectation that a professional will subordinate self-interest has long been a hallmark of professions, and hence is the sine qua non of professionalism. Because physicians have responsibilities to many others as well, they will not infrequently confront conflicts of interest, such as those arising between the health system that employs them and the individual patient seeking care. When such conflicts arise, the patient's legitimate interests and needs must remain paramount. The MSOP objectives state that physicians must demonstrate “a commitment to advocate at all times the interests of one's patients over one's own interests,” as well as “an understanding of the threats to medical professionalism posed by the conflicts of interest inherent in various financial and organizational arrangements for the practice of medicine.”15
- ▪ Physicians adhere to high ethical and moral standards. The concept that professional work has a moral value compels the physician to behave ethically in his or her personal and professional life. Long embedded in the ethos of medicine are principles of beneficence and nonmaleficence. Physicians have a duty to do right and to avoid doing wrong. Patients have a right to expect no less.
- ▪ Physicians respond to societal needs, and their behaviors reflect a social contract with the communities served. Any profession—not just the medical profession—best meets its obligations when it attends actively to its duty to address community and societal needs. Sullivan's concept of civic professionalism stresses the importance of social leadership by the professions.12 The MSOP objectives state that a physician will demonstrate “knowledge of the important non-biological determinants of poor health and of the economic, psychological, social, and cultural factors that contribute to the development and/or continuation of maladies,” as well as “a commitment to provide care to patients who are unable to pay and to be advocates for access to health care for members of traditionally underserved populations.”15
- ▪ Physicians evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others, and trustworthiness. Some might argue that humanistic values are not requisite to professional behavior, that a physician can exemplify professionalism without humanism. Yet values such as compassion, altruism, integrity, and trustworthiness are so central to the nature of the physician's work, no matter what form that work takes, that no physician can truly be effective without holding deeply such values. The practice of medicine is a human endeavor. To address the needs of their patients, physicians must ensure that humanistic values remain central to their professional work. Wynia and colleagues argue that respect for human worth and trustworthiness are “particular obligations.”8 Physicians must demonstrate “compassionate treatment of patients” as well as “honesty and integrity in all interactions with patients' families, colleagues and others.”15 To evince humanistic values speaks directly to the ABIM's expectation that physicians will aspire to altruism, honor, and integrity, among other attributes.16
- ▪ Physicians exercise accountability for themselves and for their colleagues. Implicit in the relative autonomy granted to a profession is that its members will set and enforce standards of practice. Demonstrating true accountability is key to maintaining the privilege of autonomy that medicine has long enjoyed but which many now feel has been eroded. That erosion is due, in part, to a perception by many that physicians have not always been willing to exercise accountability for themselves or their colleagues. The loss of autonomy relates directly to Freidson's observation that autonomy is a privilege granted by external authorities.10 Professional work has always been, at its best, a collegial endeavor rather than an entrepreneurial enterprise. Collegial interactions have traditionally typified a profession, but such collegiality should be used neither to mask ineffective or inappropriate practice nor to protect incompetent physicians. Meaningful peer evaluation becomes one mechanism to enforce standards of practice and hence to exercise accountability.
- ▪ Physicians demonstrate a continuing commitment to excellence. Competency is an important professional quality. Professions are based upon intellectual work, a specialized body of knowledge, and expertise. The demands of intellectual work require that physicians maintain the highest standards of excellence through the continuing acquisition of knowledge and the development of new skills. The exponential growth in biomedical knowledge makes it imperative that physicians be able to retrieve and use information efficiently, whether to make clinical decisions about individual patients or to address questions of a community's health. Excellence is internally focused. It is the individual physician's commitment to expand his or her knowledge and to keep abreast of the rapid changes in biomedical science and clinical practice. A commitment to excellence makes life-long learning fundamental to professionalism. The MSOP objectives ask that physicians demonstrate “the capacity to recognize and accept limitations in one's knowledge and clinical skills, and a commitment to continuously improve one's knowledge and ability.”15
- ▪ Physicians exhibit a commitment to scholarship and to advancing their field. If commitment to excellence has an internal focus, then a commitment to scholarship has an external focus. It is the desire to share one's knowledge for the benefit of others, whether patients, other physicians, or the community. The nature and the goals of medicine should commit physicians to advance the body of knowledge in their discipline, whether from cutting-edge research or from assuring that a practice setting is most conductive to cost-effective and efficient patient care. Physicians should support the efforts of their colleagues and the profession to improve the health not only of individual patients but also of communities.
- ▪ Physicians deal with high levels of complexity and uncertainty. Uncertainty and ambiguity have long characterized the practice of medicine, and they will continue to do so despite advances in technology and in biomedical knowledge. Work that is simple and repetitive, or that does not involve a great deal of judgement, does not require the independent decision making that is a hallmark of professions.17 The physician must be able to exercise independent judgement in order to make appropriate decisions in the face of complex, often unstable circumstances, and usually with incomplete information.
- ▪ Physicians reflect upon their actions and decisions. Professionals must be able to reflect dispassionately upon decisions made and actions taken, not only to improve their knowledge and skills, but also to bring balance to their professional and personal lives. Reflection becomes one mechanism to stimulate a commitment to excellence and enable accountability, but it goes beyond that. The ability to think reflectively and critically is important to deductive reasoning, and physicians must demonstrate “the ability to reason deductively in solving clinical problems.”15 Reflection and deductive reasoning are thus central to clinical decision making.
THE IMPORTANCE OF HAVING A NORMATIVE DEFINITION
Many individuals and groups have become keenly interested in the state of medical professionalism. Individual physicians have become alarmed about what is happening to their practices in the face of the corporate transformation of the U.S. health care system. Professional associations such as the American Medical Association have been concerned about the changes this transformation has wrought in physicians' time-honored responsibilities toward patients. Medical educators have been concerned for years about the impact that physicians' behaviors have on the professional development of medical students and residents. Hence the recent calls for a renewed focus on professionalism. Dialog among these many individuals and groups must continue, but it is imperative to heed Voltaire's plea: “If you wish to converse with me, define your terms.” The normative definition presented in this article is meant to encourage a dialog grounded in a common understanding of professionalism, with a goal of eventually achieving a degree of consensus sufficient to enable the medical community to strengthen professionalism in medical education and medical practice.
Professionalism must be considered on two levels: individual and collective. The nine elements in my normative definition represent a spectrum of behaviors that individual physicians should demonstrate if they are to successfully meet their obligations to their patients and to their communities. Together, they encompass the essentials of professionalism as it is demonstrated by individual physicians. But many of these elements apply equally well to the profession of medicine as a collective body. The profession—through its academic and practice leadership, as well as its organized bodies—must sustain the covenant of trust that has long characterized the relationship between medicine and those it serves. As a profession, medicine has been criticized by the public and by payers for resisting change and for a perceived unwillingness to address such important social goals as access or cost-effective medical care. Such reluctance can be considered a breach of social-trustee, or civic, professionalism. Relman has noted that “medical professionalism… is being seriously challenged by the industrialization of medicine.”4 In an industrial model of health care, adhering to professional values and behaviors—practicing professionalism—can help maintain the distinction between medicine as a profession and medicine as a commodity. If that distinction is to remain sharp, it will be important that physicians, individually and collectively, understand what professionalism means, not only in the abstract but also in the very real “humdrum, day-in, day-out, everyday work that is the real satisfaction of the practice of medicine.”18
While definitions can be dangerous, as Erasmus noted, it is nonetheless important that physicians comprehend fully what medical professionalism entails, both for an individual practice and for the profession. Serious negative consequences will ensue if physicians cease to exemplify the behaviors that constitute medical professionalism and hence abrogate their responsibilities both to their patients and to their chosen calling.
1. Blumenthal D. The vital role of professionalism in health care reform. Health Aff. 1994;13(Part I):252–6.
2. Cruess SR, Cruess RL. Professionalism must be taught. BMJ. 1997;315:1674–7.
3. Hensel WA, Dickey NW. Teaching professionalism: passing the torch. Acad Med. 1998;73:865–70.
4. Relman AS. Education to defend professional values in the new corporate age. Acad Med. 1998;73:1229–33.
5. Reynolds PP. Reaffirming professionalism through the education community. Ann Intern Med. 1996;120:609–14.
6. Swick HM. Academic medicine must deal with the clash of business and professional values. Acad Med.1998;73:751–5.
7. Swick HM, Simpson DE, Van Susteren TJ. Fostering the professional development of medical students. Teach Learn Med. 1995;7:55–60.
8. Wynia MK, Latham SR, Kao AC, Berg JW, Emanuel LL. Medical professionalism in society. N Engl J Med. 1999;341:1612–6.
9. Association of American Medical Colleges. Professionalism in Contemporary Medical Education: An Invitational Colloquium. Washington, DC: Association of American Medical Colleges, 1998.
10. Freidson E. Profession of Medicine: A Study of the Sociology of Applied Knowledge. Chicago, IL: University of Chicago Press, 1988.
11. Brandeis LD. Business—A Profession. Boston, MA: Small, Maynard, 1914.
12. Sullivan WM. Work and Integrity: The Crisis and Promise of Professionalism in America. New York: Harper Collins, 1995.
13. Sullivan WM. Professionalism after managed care? In: Professionalism in Contemporary Medical Education: An Invitational Colloquium. Washington, DC: Association of American Medical Colleges, 1998.
14. Brint S. In an Age of Experts: The Changing Role of Professionals in Politics and Public Life. Princeton, NJ: Princeton University Press, 1994.
15. The Medical School Objectives Writing Group. Learning objectives for medical student education—guidelines for medical students: report I of the Medical School Objectives Project. Acad Med. 1999;74:13–8.
16. American Board of Internal Medicine. Project Professionalism. Philadelphia, PA: American Board of Internal Medicine, 1995.
17. Southon G, Braithwaite J. The end of professionalism? Soc Sci Med. 1998;46:23–8.
18. Williams WC. The practice. In: Coles R: William Carlos Williams: The Doctor Stories. New York: New Directions Books, 1984.