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Definitions of Professionalism: A Search For Meaning and Identity

Hafferty, Frederic, W

Clinical Orthopaedics and Related Research: August 2006 - Volume 449 - Issue - p 193-204
doi: 10.1097/01.blo.0000229273.20829.d0
SECTION I: SYMPOSIUM II: Professionalism
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This paper examines issues of medical professionalism using definitions and meanings as its analytic lens. It explores similarities, differences, and changes in meaning and interpretation over time and across three primary literatures of professionalism: sociology, medicine, and education. In compiling these literatures, three stages in the evolution of medical professionalism emerged: the first (1980s-early 1990s) was dominated by the polemics of professionalism and commercialism; a second (1900s) was dominated by calls to define medical professionalism as a concept and as a competency; the third (late 1990s-current) quickly superseded calls to define by highlighting the need to develop measures and metrics. Across these three stages, two sets of “authoritative voices” emerged in the medical literature with certain medical organizations and journal articles beginning to dominate, and in certain cases dictate, agendas and debates. The paper closes with an extended discussion of the largely US based and sociologically focused “new professionalism” literature, and contrasts this with a parallel UK medically based literature. The paper closes with a set of six conclusions covering the lessons learned in compiling this literature.

From the University of Minnesota Medical School, Duluth, MN. The author certifies that he has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Correspondence to: Frederic W. Hafferty, PhD, University of Minnesota Medical School-Duluth, 1035 University Drive, Duluth, MN 55812-2487. Phone: 218-726-7144; Fax: 218-726-7559; E-mail: fhaffert@d.umn.edu

“But, after all, what matters most is professional spirit. All activities may be prosecuted in the genuine professional spirit. In so far as accepted professions are prosecuted at a mercenary or selfish level, law and medicine are ethically no better than trades.”42

Abraham Flexner 1915

In this article I explore definitions of professionalism and how these definitions can take on different shades of meaning depending upon: (1) the academic orientation of the author and/or journal, (2) US versus UK approaches to professionalism, and (3) traditional representations of professionalism versus the “new professionalism” literature. I do not intend this review to be exhaustive. It is, however, intended to be authoritative (with the justification for this claim outlined below).

There are three primary academic literatures on professionalism today: sociology, medicine, and education. Sociological writings have an extensive theoretical and analytical tradition extending into the late 1800s.23,87,142 Although this literature covers a number of occupational groups, allopathic medicine is considered the prototype profession by sociologists and functions as a conceptual and analytical benchmark from which other occupations are assessed.

The medical literature on professions and professionalism has a similarly extensive history, but tends to be less analytically focused than sociology, with medical insiders often using key terms such as profession, professional, and professionalism as synonyms for good doctoring and good doctors. For most of the 20th century, these two literatures existed in parallel with little cross-fertilization. In the latter part of the 20th century, however, both literatures underwent a metamorphosis, coming first for sociology in the 1970s,46,73,83 followed by medicine in the 1980s.91,123,124 Sociologists, focusing on a wide variety of external environmental factors (eg, changing relations with the state, the runaway inflation of the 1970s) along with a number of internal forces (eg, increasing specialization/differentiation of workers) began to debate on whether medicine was becoming deprofessionalized, proletarianized, and/or corporatized.46,47,54-58,61,73,83,85,86,101,102,117 The surge of interest within organized medicine was tied largely to the arrival of managed care, corporate medicine, and “commercialism” (a favored pejorative term used by medical insiders) as physicians expressed concerns and fears about the loss of clinical autonomy and discretionary decision-making.10-12,17,74-80,91-95,100,107,119,122-130

Although the topics addressed and the terminologies used in sociology and medicine could be quite different, the substantive issues for these two disciplines actually were quite similar, namely the changing nature of medical work and the relative robustness of professionalism relative to market forces and bureaucratic organization.2,47,48,145 For sociology, the fundamental issue was the nature of social control in modern society. For medicine, the issues were much less academic and more about self-identity and social status.

Education arrived somewhat late to the professionalism discussion/debate. Although I will not examine in depth definitions of profession in the educational literature, it is important we at least acknowledge education's presence in the overall professionalism debate because they represent an important case study of an outsider or nonprofessional looking in. Like many occupational groups during the 20th century, teachers were eager to stake their claim for inclusion into the professional pantheon. Furthermore, and similar to physicians, educators often chafed under what they saw as the intrusion of outsiders into their work space-the classroom for teachers and the examination room for doctors.59 At issue for both groups is the control of work. Finally, and even though they have not attained professional status, education is an important source of writings on the “new professionalism” and, thus, a source of claims about how professionalism might be changing in a postmodern world.60,112,113,153

The following pages will focus on definitions of professionalism across sociology and medicine with an emphasis on the latter. I will explore what sociology and medicine have to say about the nature of professions and professionalism with a particular eye toward how definitions can change over time. I then will explore what I label here as “authoritative definitions” of medical professionalism. I then will turn to the new professionalism literature, with a particular eye toward how this literature helps to link the American and British treatments of professionalism. I conclude by examining how we might reconcile differences across time, nationality, and discipline-with a particular focus on the special case of altruism.

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Voices and Stages Of Professionalism

There are two voices in the modern-day medical professionalism literature. The first, and most audible, belongs to those who argue for a more traditional and unvarying view of professionalism, with medicine becoming more or less professional over time depending on whether it lives up to core standards. The second voice argues that change in the institutional structure of medicine requires commensurate definitional adjustments, along with the caveat that different standards do not necessarily mean less professionalism.

These two voices, in turn, have pleaded their respective cases across three identifiable stages in the contemporary debate about the nature and meaning of professionalism in medicine. The first stage arose when corporate medicine and the medical marketplace began its assault on the city-gates of traditional medical practice, including its citadel, professional autonomy. Organized medicine responded to this encroachment with an efflux of conferences, journal articles, related publications, and sessions at national meetings, virtually all with a focus on identifying the enemy (commercialism) and with calls urging medicine to reestablish its traditional identity in this regard. Definitions of professionalism, even of a descriptive kind, were in short supply. As this literature grew, however, it became obvious the terms profession, professional, and professionalism were being used somewhat indiscriminately to cover a diverse number of qualities and characteristics.

The call to establish (or reestablish, as some would specify) an ethic of professionalism in medicine began to run into a definitional wall precisely because what could suffice at the level of rhetoric could not pass muster in the classroom or on the wards. Professionalism may well be synonymous with good doctoring, but exactly what were faculties to teach and/or clinicians to model? The cry for definitional specificity intensified. Several professional organizations, lead by the American Board of Internal Medicine (ABIM),3 began to rise to the challenge.

The ink was hardly dry on this call for core definitions when a third cry resounded throughout medical academia, this time to establish measures and metrics of professionalism.14,15,38,51,52,88,89,115,116,143,144 Similar calls could be heard within the Association of American Medical Colleges (AAMC), the Accreditation Council for Graduate Medical Education (ACGME), and the National Board of Medical Examiners (NBME).1,97,109

One particular cry was for professionalism to be identified as a “core competency” in medical school and residency training.4,5 Two organizations were pivotal in linking what had been in many respects separate movements within medical education: professionalism and competencies.38,62,84,160 These organizations were the ACGME7-9 and the Royal College of Physicians and Surgeons of Canada.43 For example, and focusing solely on the US, in 1995 the ACGME specified six core competencies for residency programs and their trainees. Professionalism was one of the six.7,8,18 This accreditational thunderclap set in motion a variety of efforts to link competencies and medical training within various medical specialty groups,29,82 around particular physician skills (eg, communication and interpersonal skills)35 and with respect to competency models for healthcare organizations in general.32 The push was on. Nevertheless, and with good reason, there also were calls by social scientists, such as Delese Wear, urging prudence and caution.158

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Authoritative Voices

Generally speaking, two sets of authoritative voices have risen within the modern medical professionalism movement. The first is tied to major medical groups and or associations and how they choose to define and operationalize professionalism. The second is linked to the academic literature and is reflected in those articles and related materials most cited within the academic community.

There is good reason to listen to at least certain medical associations and groups with respect to organized medicine's identity as a profession. Over the past 25 years, organized medicine has devoted considerable resources to the problem of professionalism56 with large and internally influential medical groups such as the ABIM (and its Project Professionalism3-5) leading the charge. As a sociological and editorial aside, I have been both surprised and impressed by the broad commitment of organized medicine to issues of professionalism. Both reactions are linked to the strong commitment by various medical groups to work together on this issue, something that is at odds with one of the most dominant trends in medicine over the past 100 years, namely the rise of subspecialty medicine, and the concurrent fracturing of medical and occupational solidarity.142

The academic medical literature also is a potentially fertile source for authoritative definitions of professionalism. Here, the marker is citation counts, a well-established method in academia for establishing the influence of particular authors, journals, and/or disciplines around a particular topic or focus.13,24,108,118,135,154,155

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Authoritative Organizational Voices

Not all medical organizations should be considered equal when it comes to medicine's professionalism movement. The aforementioned ABIM, for example, began in the early 1980s with its Project Humanism, shifted its focus to a subsequent Professionalism Project3-5 in the early 1990s, and most recently helped to develop a Physician Charter6 in partnership with the American College of Physicians and American Society of Internal Medicine, and the European Federation of Internal Medicine.

While the ABIM's definition of professionalism has undergone some modifications over the past sixteen years, patient welfare and altruism have remained fundamental to its definition. For the ABIM, altruism is, “… based on the rule that the best interest of patients and not self-interest is the professional obligation.”3 Concurrently, the ABIM defines professionalism as “… those attitudes and behavior that serve to maintain patient interest above physician self interest…” and “… aspires to altruism, accountability, excellence, duty, service, honor, integrity, and respect for others…”3 (with all of these terms and phrases defined in the online text and with this present definition formally linked to the process of certification and/or recertification). In the context of faculty and residents as role models, the ABIM specifies that faculty and residents, “… must demonstrate humanistic qualities…” including“… integrity, respect, compassion, professional responsibility, courtesy, sensitivity to patient needs for comfort and encouragement, and professional attitude and behavior toward colleagues.”3 Finally (and still within the ABIM's Project Professionalism), the ABIM identifies seven issues that challenge or diminish professionalism (abuse of power, arrogance, greed, misrepresentation, impairment, lack of conscientiousness, and conflict of interest).3 The ABIM also identifies a number of personal and social-structural factors that challenge or threaten professionalism (ie, chronic fatigue, sleep deprivation, stress, and overwork; lack of confidence, self-esteem, and experience; difficult patients; chaotic, unstructured, unsupervised rotations; creative tension with other health professionals and lack of professionalism among housestaff; arrogant faculty; health risks to the professional; abuse of power; and family obligations).3

The ABIM's most current and widely recognized professionalism product is its “Physician Charter.”6 This two-page statement of professional principles has been endorsed by a number of medical organizations worldwide. The Charter is built around three fundamental principles (primary patient welfare, patient autonomy, and social justice), followed by 10 commitments (professional competence, honesty, patient confidentiality, appropriate relations with patients, improving quality of care and access to care, just distribution of finite resources, scientific knowledge, conflicts of interest [by invoking the concept of patient trust], and a generic commitment to professional responsibilities). The Charter highlights the concept of the social contract in its preamble (“Professionalism is the basis of medicine's contract with society”), and notes the assault of market forces on professionalism along with an “… explosion of technology, a changing health care delivery system, bioterrorism and globalization.” The Charter is the most complete statement of professional principles currently available. It is not, however, a definition.

A second organizational-authoritative voice is the aforementioned ACGME. The ACGME, with its accreditation-based model of change and its six core competencies (including professionalism), has secured professionalism's place in medical education, at least at the graduate level. The ACGME defines professionalism as “… respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development.”5

The ACGME also provides a minimum word definition of professionalism (professionalism is “manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population”) as well as listing the following positive aspects of professionalism: “respect, regard, integrity, and responsiveness to patient and society that supersede self interest.”7

Currently, the ACGME is engaged in defining best practices for each competency. Meanwhile, specialty organizations and residency programs have begun to apply (and assess) the six core competencies relative to their own discipline. Examples include emergency medicine,82 surgery,161 and neuropathology.29 The ACGME has compiled an online “Toolbox” of assessment methods to aid these and related efforts.9

The NBME, a private company, also has directed considerable resources toward defining and assessing professionalism. The NBME has formed a professionalism task force, with one goal being to develop professionalism metrics.109 In this effort, the NBME has identified sixty behaviors of professionalism109 and has created an intriguing pictorial representation of professionalism composed of a circular core of knowledge and skills surrounded by seven supporting qualities.109 Altruism occupies the 12 o'clock position, followed by (clockwise) responsibility and accountability, leadership, caring, compassion and communication, excellence and scholarship, respect, and honor and integrity. In this context, and as a model of succinctness, the NBME defines the behaviors of professionalism as: (1) altruism; (2) honor and integrity; (3) caring compassion and communication; (4) respect; and (5) excellence and scholarship.109

The AAMC and the American Medical Association (AMA) also have played important roles in the professionalism movement, but in a more indirect fashion. Over the past twenty years, their respective journals, Academic Medicine and the Journal of the American Medical Association, have been pivotal sites for academic work on professionalism. The sheer volume of the material on professionalism published in these two journals precludes (short of a formal content analysis) any identification of a core definition. Nonetheless, these journals contain a wealth of information on or about professionalism including articles on measuring professionalism,15,156 teaching and/or instilling professionalism in medical education,90,151 self-reflection and/or mindfulness and professionalism,37,38 charity care and professionalism,96 quality of care and professionalism,22 humanism connoisseurs,106 deprofessionalization,121 the distinction between narrative and rule-based professionalism,27 a presidential address,132 and a normative definition of professionalism.150

Before returning (for obvious reasons) to this last reference, there is one additional aspect of professionalism to grapple with as we move through the professionalism literature: the use of the word “professional” as an adjective. When an article refers to professional competence, as does Epstein and Hundert,38 or professional integrity, as does Miller et al,104 it is important to ascertain whether the authors are talking about the integrity or competence of professionals qua professionals (eg, where our focus is on the competence or integrity as practiced by professionals), or whether they are using professional to indicate a special type or elevated level of competence or integrity and thus are tacitly drawing a distinction between regular integrity and professional integrity or everyday competence and professional competence. As I will point out below, a focus on professional competence can have everything to do with competence but very little to do with professionalism.

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Authoritative Voices: Most Referenced Journal Articles

The second type of authoritative voice is formed by journal article citation counts (Table 1). Abstracting core definition(s) of professionalism from within a Top Ten list of medical professionalism journal articles is more difficult than one might imagine. While the highest ranked (n citations = 168) article is the previously summarized, and definitionally impoverished, Physician Charter,6 the second (n = 125) and third (n = 91) most frequently cited articles (“Defining and assessing professional competence”38 and “Mindful Practice”37) are less about professionalism than they are about establishing a definition of“professional competence” (with professional and professionalism being used as adjectives-thus signifying a type of competence, not a type of professionalism) in the first case, and about developing a particular aspect of professionalism (eg, mindfulness or critical self-reflection) in the latter. Epstein's mindfulness article comes closest in noting professionalism “… informs all types of professionally relevant knowledge, including propositional facts, personal experiences, processes, and know-how, each of which may be tacit or explicit.”33

TABLE 1

TABLE 1

It is not until we come to the fourth (n = 81) and fifth (n = 60) most frequently cited articles (Wynia et al's “Medical professionalism in society”163 and Swick et al's “Teaching professionalism in undergraduate medical education”151) that we begin to encounter some degree of definitional specificity. Wynia et al's model of professionalism is heavily sociological in nature. The model is built around three core elements (devotion, profession, and negotiation). The authors consider devotion to medical services to be a moral commitment by physicians and organized medicine in which devotion is operationalized by “… placing the goals of individual and public health ahead of other goals …” (eg, altruism).163 Wynia et al ' s second core element, professing, also warrants attention. Here, the authors literally call upon medicine to make public (to profess) its ethic. Professing facilitates two outcomes. It helps the physician maintain commitment to their devotion, and it informs the public about medicine's service orientation. The authors also consider the mandate to profess as an expression of “civic engagement” (see below). Finally, they identify negotiation as, “… a political process of negotiation, in which professionals advocate for health care values in the context of other important, perhaps competing, societal values.”163 Professionalism thus functions within a social arena of competing values, an important sociological observation.

The article by Swick et al151 appears in the same issue of JAMA as the Epstein article on mindful practice.37 This material is based on a survey of how US medical schools teach professionalism. The author-researchers categorized their data using “… four attributes commonly recognized as essential to professionalism …” (“subordinating one's self-interest to the interest of patients; adhering to high ethical and moral standards; responding to societal needs; and evincing core humanistic values [eg, empathy, integrity, altruism, trustworthiness]”).163 Of particular interest here is the fact Swick and colleagues locate altruism in two of their four essential attributes; once by definition (attribute #1) and once by using the term to define another attribute (attribute #4).

In summary, these Top Ten articles, as a group, do not offer us tremendous insights into definitions of professionalism, even when a given article focuses on professionalism as opposed to competence, reflection, or some other aspect of medical work. In fact, there are only two articles identified in this review of the medical professionalism literature that intentionally seek to provide a clear and cogent definition of professionalism, and neither of them is ranked high enough to appear in our table. One is solo authored by Herbert Swick (“Toward a normative definition of medical professionalism”)150 (citation count n = 41), which would have made a Top Twenty list. The other is an article by Cruess et al (“Profession: A working definition for medical educators”)31 (citation count n = 2). To be fair, the Cruess et al article is a recent publication (2004) as of this writing with relatively little time to make its mark.

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Toward a Formal Definition

The Cruess et al article opens by asserting that the literature on professionalism lacks a succinct and adequate definition on professions and professionalism, a conclusion I have come to embrace as I did the background work for this paper. By way of definitional background, the article then specifies a profession is an occupation and a vocation, with professionalism defined in the context of a social contract between medicine and society. In this contract, medicine operates from a core of knowledge and skills used in the service of others. Members are governed by a code of ethics and members profess a commitment to “… competence, integrity and morality, altruism, and the promotion of the public good within their domain.”31 In return, society accords medicine “… status, privileges, and financial rewards . . .”31 with a mutually shared understanding medicine “… will be devoted to service, will guarantee competence, be moral in their endeavors, and address society's concerns.”31 In offering this definition, the authors explicitly reject the idea an adequate understanding of professionalism can be based on a “… list of attributes, characteristics, or behavioral patterns …”31-a rather clear indictment of the general medical literature on professionalism.

Although not a part of their formal definition, Cruess, Johnston, and Cruess make three additional points worth highlighting. First, they consider professionalism to be a dynamic entity, and thus something that evolves within the ever changing relationship between medicine and society. The notion of a dynamic versus static conception of professionalism is key to understanding the nature of (more than the definition of) professionalism, and is an issue infrequently addressed in most treatments of professionalism. Second, and related, medicine's social contract with society is under constant renegotiation. Finally, the ability and willingness of medicine to profess core values and orientations to the public and peers alike is a crucial element of professionalism.31 The importance of publicly affirming one's knowledge, skills, and core values is another aspect of professionalism not often found in the academic medical literature.

Swick, meanwhile, seeks to establish a “… normative definition of professionalism.”150 For Swick, professionalism consists of nine behaviors by which 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.”150 Physician-professionals: (1) subordinate their own interests to the interests of others, (2) adhere to high ethical and moral standards, (3) respond to societal needs (drawing upon the concept of a social contract), (4) evince core humanistic values (eg, compassion, altruism, integrity, and trustworthiness), (5) exercise accountability (for self and peers),(6) demonstrate a continuing commitment to excellence,(7) exhibit a commitment to scholarship (eg, advancing the field), (8) deal with high levels of complexity and uncertainty, and (9) reflect upon their actions and decisions.150

While Swick ' s nine behaviors cover a broad range of definitional elements, they do not highlight the changing nature of professionalism, nor do they identify “professing” as a core professional attribute. Finally, medical students often find Swick's definition of altruism (“Physicians subordinate their own interests to the interests of others”) to be particularly onerous. Medical students want to do good, but they do not feel compelled to subordinate themselves in the process.

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The New Professionalism

Most of the post 1980s writings reviewed for this paper promote a traditional view and definition of professionalism. The prevailing call is for physicians to rediscover, return to, or recommit themselves to the core nature or essential principles of professionalism. There are, however, exceptions to this normative bent where authors argue for a “new professionalism.” While I cannot provide a detailed review of these arguments here, I do want to explore whether they provide us with an extended definition and understanding of professionalism. As was the case in the traditional professionalism literature, calls for a new professionalism are found across the literatures of medicine, sociology, and education. In keeping with our earlier standard, I will once again focus almost entirely on the medical literature, with sociology as a backdrop, and bringing in education only when it takes us in a substantively different direction.

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The New Medical Professionalism

The new medical professionalism literature is comprised of one “camp” and one person. The camp is composed largely of an emerging US-based literature on mindfulness and medical practice. This literature, in turn, is anchored in a broader academic literature on personal reflection or reflexiveness.137,138 Ronald Epstein's previously noted article “Mindful Practice”37 is the most widely cited reference (citation count n = 91, Table 1) on mindfulness in the professionalism literature, but there are a number of other scholars who frame self-reflection and/or mindfulness as a precursor to, and necessary component of, peer review.16,20,21,26,28,98,111,139,146 Furthermore, this literature identifies self-reflection/mindfulness as an ingredient in the development of a professional self-identity, thus linking this body of work to the medical socialization literature. Epstein considers self-reflection to be the, “… sine qua non of the successful professional and essential to the expression of core values in medicine such as empathy, compassion, and altruism.”37 Furthermore, Epstein believes an ongoing practice of critical self-reflection “… enables physicians to listen attentively to patients' distress, recognize their own errors, refine their technical skills, make evidence-based decisions, and clarify their values so they can act with compassion, technical competence, presence, and insight.”37 Related terms used by Epstein include self-monitoring, tacit-personal knowledge (thus linking self-reflection to the hidden curriculum literature),57 peripheral vision, and subsidiary awareness. Parallel terms in the medical literature include self appraisal93 and reflection-in-learning.141 Self-evaluation is also part of the ABIM's continuous professional development (recertification) program.5 The concepts of reflection and mindfulness are avenues into topics such as narrative medicine,25 service learning,110 medical humanism,105,120 and the use of portfolios in evaluation.38 Medical education programs have built learning programs around self and group reflection experiences.99

The second half of the new medical professionalism literature is tied to the professional career and work of Sir Donald Irvine.63-72 Unlike the more social-psychologically focused literature on reflection and mindfulness, Irvine grounds his vision of a patient-centered professionalism in the structural and normative context of medicine in the UK. Sir Donald links his new professionalism to several formal medical-governmental calls for action (eg, “Tomorrow's Doctors”49 and “Good Medical Practice”50 and most specifically to recertification (eg, relicensure). These mandates have no direct parallel (at least formally) to the medical professionalism movement in the US.

Sir Donald considers professionalism to be the “… essential characteristics of a good doctor…”,134 which he goes on to define as doctors who are medically knowledgeable, skillful, up-to-date, empathic, honest, good listeners and communicators, and effective team players.134 More globally, Irvine views professionalism as resting on three pillars, expert knowledge and skill, ethicality, and service to patient.134 He also links professionalism to public and patient trust, which are grounded in a social and political consensus between the public and the profession about what constitutes good medical practice, including what it means to be a good doctor.134 For Irvine, this means the public must be a full participant in all essential committees and oversight bodies including recertification, yet one more call that has no direct parallel in the US.134 Finally, Sir Donald, the very ideal of a medical insider, has been quite pointed and public in his criticisms of organized medicine in the UK, viewing medicine ' s precarious professional status as something of its own doing. While US medicine certainly has had its own internal critics, there has been no one who parallels Irvine's particular institutional status and willingness (over an extended period of time) to attack old structures and policies and recommend new courses of action. He is a unique figure in the international professionalism movement.

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US and UK Views on Professionalism

There are differences between the US and UK professionalism movements other than those captured in our discussion of Sir Donald Irvine. British definitions of professionalism (including but not limited to Sir Donald's) appear to be more patient-centered or patient-centric than what is found in the US professionalism literature. Although there is an extensive US-based literature on patient-centered care, this literature, by and large, does not link patient-centered care with issues of professionalism. A second difference involves the concept of altruism. British definitions, for reasons not entirely clear to this writer, do not highlight altruism as a core concept or an organizing principle. The closest Sir Donald comes is in identifying “service” as one of his three pillars. A third difference arises from Sir Donald himself. According to Irvine, British physicians locate their understandings of professionalism within doctors' attitudes and behaviors while excluding scientific knowledge and clinical performance from the equation.134 US physicians, according to Sir Donald, place more definitional weight on scientific knowledge and technical competence, leaving attitudes and behaviors to a category more akin to deportment or etiquette than professionalism.68

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The New Sociological Professionalism

Sir Donald's emphasis on creating strong structural and normative linkages between the public and the profession has conceptual ties, interestingly enough, to the new professionalism literature in sociology. There are three major orientations or literatures in academic sociology addressing the new professionalism: responsive medical professionalism lead by the writings of Frankford et al;44,45 civic professionalism as espoused in the writings of Sullivan147-149 and others;159 and, finally, a close conceptual cousin of civic professionalism, democratic professionalism.36,114,136 Although he does not advocate any organizing concept, sociologist David Mechanic has an influential article (citation count n = 26) on managed care and the imperative for a new professionalism.103

Frankford ' s call for a more responsive professionalism is grounded in the concept of personal reflection (and thus in the concepts of reflective practice or reflective social action). However, while much of the remedial professionalism literature in medicine focuses on the social psychology of recommitment, Frankford's emphasis is on a self-defined ethical system embedded in an appropriate institutional infrastructure (which supports the attainment of key work orientations). To this end, Frankford identifies four “major ideals” and three “necessary characteristics” of this supportive institutional structure.45 Most importantly, at least with respect to traditional medical definitions of professionalism, Frankford rejects medicine's traditional claims for autonomy.45 Instead, he calls for a new normative identity, which emphasizes a responsiveness to lay values and community needs, and thus a vision of change distinct from markets or autonomy in structuring the relationship of medicine and society.45 At the same time, Frankford's definition of professionalism (a “…sacrifice [of] economic self interest in the service of patients …”) has strong traditional overtones, particularly with its clear reference to altruism.44

Sullivan's call for civic professionalism presents a similar theme of civic engagement.148 For Sullivan, a civic understanding of professionalism involves a new moral framework of civic equality, including social engagement and mutual obligation via an emergent social solidarity. In this respect, medicine ' s traditional cognitive and technical experience acquires an important moral and ethical component. Sullivan's civic understanding also involves practitioners becoming more self-aware and reflexive.147,149 Like Frankford, Sullivan's civic professionalism, with its orientation towards civic equality, points to new partnerships and normative relations between physician and patient, physician and other healthcare workers, as well as medicine and society.

Mechanic, much like Frankford, calls for a new professionalism in the face of new healthcare structures. In particular, Mechanic calls for a more responsible practice of medicine grounded in an ethic of fairness and social justice. Mechanic's new professionalism is grounded in four elements: new forms of patient advocacy, an ethic of responsibility for population health, new types of patient partnerships built around relationships that are truly collaborative and oriented to better health outcomes, and the development of an evidence-based culture in medicine.103

Finally, and moving our focus from sociology to medicine, there are a growing number of medically situated articles that stress medical and sociological elements in their calls for a new professionalism. Three examples are Whitcomb's 2005 Academic Medicine editorial on civic professionalism,153 Brennan's call for a professional responsibility and quality of care grounded in what he con-jointly labels civic professionalism and activist professionalism,22 and Gruen et al's 2004 JAMA article53 on physician-citizens and physicians' public roles, including advocacy and community participation, all in the service of quality of care.

In summary, sociologic writings on a new professionalism, whether they are labeled civic, responsive, democratic, or otherwise, stress the theme of social reengagement with the public and communities. In this respect, the new professionalism literature has strong thematic links to the patient-centered professionalism advocated by Irvine. While there are instances where sociological arguments for a new professionalism draw upon the concept of the social contract,145,148 this concept is much more likely to be encountered in medical writings on a new professionalism, sometimes accompanied by a corresponding emphasis on quality of care and patient safety. Similarly, while the concept of reflexiveness does make an appearance in sociological tomes, it is clear the mindfulness side of professionalism is more a medical than a sociological phenomenon.

Although I have not specifically addressed British sociological writings on professionalism, it is important to note the establishment of the European Union (EU) has changed the economic, political, and social dynamics in the UK and on the continent, altering the professionalism playing field. The question here is how professional organizations, with their traditional links to nation states and/or geographically situated organizations, can move in concert with what Evetts39,40 refers to as the “… expanding sovereignty of regional and supranational public bodies.”41

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DISCUSSION

There are three social movements at work in medicine today: evidence-based medicine; patient safety; and professionalism. All are related and all can be subsumed under the broader marquee of quality-of-care. Nonetheless, the evidence-based and patient safety literatures often fail to highlight their natural ties to professionalism. This, in turn, marginalizes the professionalism movement from its perceived-to-be more scientific brethren.

In this review of professionalism definitions, one core finding is context matters. There are differences between traditional and new professionalism views of professionalism, between US and UK descriptions, and between medically and sociologically grounded depictions. Even something as fundamental as identifying a core dimension (is it knowledge and skills, or attitudes and values?) was presented by Sir Donald Irvine68 as contingent upon the normative and structural differences between US and UK healthcare systems.

A second finding focuses on altruism. Although altruism appears to have a ubiquitous (if sometimes tacit) presence in definitions of professionalism, it is a face with many profiles. While US-based definitions appear smitten by the notion of selflessness, UK-based depictions prefer to emphasize service. However, altruism and service are not sociologically equivalent concepts. Moreover, altruism-laced definitions of professionalism also may be running afoul of a new generation of medical students and residents who appear more attuned to an ethic of lifestyle and balance over altruism in guiding work orientations.33,157,162 In fact, many medical students today appear genuinely skeptical of calls to altruism, viewing them as just another way for faculty to exploit students as workers or for patients to take advantage of a physician's giving nature.55 Even students inclined to endorse altruism as a core professional value will balk at certain definitions. Swick's144 first normative principle “…physicians subordinate their own interests to the interest of others …” is a case in point. The culprit is the verb subordinate. Many US medical students fervently wish to do “good work,” but not if they have to “subordinate” themselves to do so.55 Then there is the “lifestyle movement” which is neither limited to US medical students152 nor to medicine.81,140 In fact, the ability to “strike an appropriate balance” between patient care and personal responsibilities is beginning to crop up as a new and positive aspect of professionalism.34

Third, definitions of professionalism come in all kinds of shapes and sizes. As a result of work on this paper, I have come to prefer succinctness over inclusiveness (and thus a longer string of key qualities and characteristics). My preferred medical definition of professionalism is built around a tripartite framework of (1) core knowledge and skills, (2) ethical principles, and (3) a selflessness and/or service orientation. The key here is to differentiate between ethics and service versus altruism. My preferred core sociological definition is grounded in Sullivan's147 tripartite of: (1) expert knowledge, (2) self-regulation, and (3) a fiduciary responsibility to altruism. Finally, and with its emphasis on civic engagement, is Wynia et al's(1) devotion to service, (2) a profession of values, and(3) negotiation within society (to balance medical values with other societal values).

Fourth, issues of civic engagement and the need for medicine to profess and to establish meaningful operational linkages with the public are key elements in the new, postmodern19 professionalism literature. Nonetheless, the US medical professionalism literature has paid far too little attention to how any recommitment to professionalism at the organizational level will become apparent to the public. How is the public to know, after all, whether medicine is sincere or disingenuous in its claims that it is recommitted to an ethic of professionalism? One possibility is to link (à la Sir Donald Irvine) professionalism and the practices of certification and licensing. After all, assertions can appear more rhetoric than real unless they are tied to the assessment of medical competence and medical work.

Fifth, self-reflection and/or mindfulness is a critical component of professionalism. It is the personal equivalent of peer review. In turn, self-review and peer review are necessary conditions for professionalism.

Finally, any future work on issues of definition and professionalism would do well to consider a formal content analysis of authoritative voices and British sociological views on professionalism (neither of which were covered in this review). In this latter respect, work by Julia Evetts37 on professionalism and the evolving European Union would be a wonderful place to start.

There is no panacea as organized medicine seeks to renew its identity as a profession. The major hurdle right now (especially for the US) is for organized medicine to discover how best to translate all of its internally generated and directed programmatic efforts into structures that will be applied to the public ' s welfare. The particular form, (eg, civic, postmodern, democratic, relational) or vehicle (eg, social contract) is less important at this time than medicine's acknowledgement that professionalism cannot be established by shear willpower or good intentions.30 Profession is an attributed status requiring considerable and ongoing social legitimization from society. How medicine makes its case to the public, then, is far more important than the steps it takes to convince itself of good motives and intentions.

Finally, it is important remember the market and bureaucratic organization will not go away. Nor will they step aside and leave the healthcare playing field to medicine as its sole province. Medicine needs to establish professionalism as a way of organizing work so it can deliver a better quality of healthcare than its two ‘competitors.’ If it is unwilling or unable to so, then medicine needs to step aside and allow the chimera of professionalism to slide off into the historical backwaters of the 20th century.

Acknowledgments

The author wishes to thank Richard and Sylvia Cruess for the opportunity to stretch his sociological imagination; and to Tracy & Eli Kemp who were instrumental in the birth of this project.

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