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Teaching Professionalism: Theory, Principles, and Practices

Cruess, Richard, L

Clinical Orthopaedics and Related Research: August 2006 - Volume 449 - Issue - p 177-185
doi: 10.1097/01.blo.0000229274.28452.cb
SECTION I: SYMPOSIUM II: Professionalism
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Professionalism as a subject must be taught explicitly. This requires an institutionally accepted definition which then must be learned by both students and faculty. This directs what will be taught, expected, and evaluated. Of equal importance, and more difficult to achieve, is the incorporation of the values and attitudes of professionalism into the tacit knowledge base of physicians in training and in practice. This requires learning experiences which encourage self-reflection on professionalism throughout the continuum of medical education. Because of the great influence of role models and because most physicians do not fully understand professionalism and the obligations required to sustain it, faculty development is essential to the success of any program on professionalism. Also important are strong institutional support including adequate resources, the presence of a longitudinal program which ensures repeated exposure throughout the educational process, a supportive environment, and a system of evaluation which reinforces teaching.

From the Centre for Medical Education, McGill University, Montreal, Quebec, Canada.

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: Richard L. Cruess, MD, Centre for Medical Education, Lady Meredith House, McGill University, 1110 Pine Ave. W., Montreal, Quebec H3A 1A3, Canada. Phone: 514-398-7331; Fax: 514-398-7246; E-mail: richard.cruess@mcgill.ca.

Reciting the Hippocratic Oath or its modern equivalent is an important event in the life of all physicians. By voluntarily professing a commitment to a set of ideals, they join the medical profession, acquiring rights, privileges and a series of obligations linked to professional status.26 For generations these obligations-competence, caring, compassion, altruism, self regulation, and devotion to the collegial nature of the profession and to the public good-were understood clearly but were rarely taught explicitly at the undergraduate or graduate level.8 The attitudes and behaviors expected of physicians were passed from one generation to the next by respected role models. This system, though imperfect, appeared to work reasonably well until the latter part of the 20th century when the practice of medicine was changed dramatically by a variety of forces, many of which were beyond the control of the medical profession.26,44

Teaching by role models depended upon the presence of a fairly homogeneous physician population who shared common cultural values.47 This is no longer true as reflected by the wonderful diversity found in today's profession, and indeed in the society it serves. The environment in which physicians practiced also changed as alterations in healthcare systems throughout the developed world posed threats to the professionalism of individual physicians and their organizations.15 These threats varied depending on the nature of the healthcare system and the country involved, but are found in virtually every developed country.19 The increased complexity and cost of healthcare and the entry of the state and the corporate sector as payers altered the medical marketplace beyond recognition. A small cottage industry was transformed into a complicated sphere of economic activity consuming a substantial part of the gross domestic product of most developed countries.15 Physicians are now held to higher standards of accountability in economic and political terms10 as it is applied to the day-to-day practice of medicine.37 In addition, a better educated and better informed public, well served by modern technology, expects much more of their physicians.

These changes occurred against the backdrop of a society increasingly skeptical of all forms of authority, including those based on the special expertise and supposed devotion to altruism claimed by the professions.47,49 This skepticism was reinforced by the work of social scientists who questioned the altruism of the professions, claiming individual physicians and their associations had exploited their privileged position in society to advance their own needs.14,29,44,49 They recorded the many and serious failures in self-regulation and believed the medical profession used capriciously applied weak standards. They further accused the profession of not consistently addressing problems of concern to society.

Values traditionally associated with the healing professions have, in theory, been easier to reconcile with a healthcare system using the professions to deliver the complex health services required by society.15 The state and the corporate sector have their own less compatible intrinsic value systems. As the organizational model has shifted from the professional to the bureaucratic or market-oriented, values traditionally associated with the professions are at risk, and there is now general agreement that if professionalism is to survive, it must be taught explicitly,8,15,25,45 and role modeling, which remains a potent method of transmitting values, must be greatly improved.25,52,53

I will briefly use educational theory to underpin the teaching of professionalism and summarize current thinking on the most effective means of organizing and implementing a program of instruction.

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Educational Theory

Of the educational theories available, situated learning theory best describes the most effective design model to transform students from members of the lay public (or non experts) to expert members of a profession possessing skills and a commitment to a common set of values.33 Situated learning theory developed after observations of instances where learning had taken place successfully.2,4,20,30 It attempts to bridge the gap between “know what” and “know how” by embedding learning in authentic activities, helping to transform knowledge from the abstract and theoretical to the useable and useful. Its proponents suggest there should be a balance between explicit teaching of a subject and activities in which the knowledge learned is used in an authentic context.4 While the theory is felt to be applicable to all forms of learning, it is particularly appropriate to educating the professions that are communities or cultures joined by “intricate, socially constructed webs of belief.”4 An individual's desire to learn is engaged and linked to their intention to join the community of medical professionals. This does seem to describe the situation found in medicine where students voluntarily choose to become members of a profession.27

There are those who have emphasized professionalism needs to be taught explicitly using definitions or outlining professionalism as a list of traits or characteristics.7,8,50 The objective is to ensure every physician understands the nature of professionalism, the reasons for its existence, its characteristics, and the obligations necessary to sustain it. This can be termed the cognitive base of professionalism; in terms of the theory, the subject to be learned is articulated, hopefully in a way that ensures that it is clear to all. Others have stated the teaching of professionalism should be approached as a moral endeavor, emphasizing altruism and service and stressing the importance of role modeling, efforts to promote self-awareness, community service, and other forms of acquiring experiential knowledge.6,22 They seek to embed the learning in an authentic activity, emphasizing the usefulness of the knowledge. While it would be wrong to overemphasize the differences between these two approaches, they do exist. In this instance, everyone appears to be correct.4,32 Professionalism must be taught explicitly, since physicians have shown by their well-documented failures in self-regulation that they do not understand contemporary professionalism.15,29,44,47,49 This, combined with a general perception that physicians are less altruistic than they were in the past, has led to a loss of trust in the profession.34,41 If physicians as rational human beings are to incorporate a set of values into their day-to-day life, they must be able to articulate and understand them together with the reasons for their existence.

However, if the teaching of professionalism is limited to one or more formal didactic sessions outlining the cognitive base, the impact will be minimal. Professionalism is a fundamental aspect of the process of socialization, during which individuals acquire the values, attitudes, interests, skills, and knowledge-the culture-of the groups they seek to join.13,17,36 As situated learning theory suggests, a balance must be struck between teaching the cognitive base explicitly and providing opportunities where learning can occur in an authentic context.4,32,33

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Principles of Educating for Professionalism

Teaching the cognitive base of professionalism is not difficult. Establishing an environment where the process of socialization in its most positive sense can take place is much harder. The incoming student must be transformed into a professional who understands professionalism and incorporates the attitudes and behaviors of the profession into his or her practice. How this is best accomplished constitutes the main challenge to medical educators at the present time. There is general agreement there are several important factors to be considered.

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Institutional Support

Establishing a major program of instruction requires the support of those directing the institution, be it a medical school, a hospital, or a postgraduate program.24 The active participation of the dean and associate deans, the department chairs, and program directors will be required to send the message the subject is important and the institution's reward system will recognize those who participate. This support must be manifested by decisions regarding the allocation of space, teaching time, and financial resources.16,18

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The Cognitive Base

Students and residents must be made aware of the nature of professionalism, its historical base, the reasons society uses the professions, the obligations necessary to sustain professional status, and its relationship to medicine's social contract with society.8 There is little disagreement on these issues24 and there is now a rich literature available to physicians on the subject. It can be taught using a variety of educational techniques including lectures, small groups, or as a part of problem-based learning modules. However, it must be made explicit, and it must be clear professional status is granted by society and it can be changed if society wishes. Professional status is a privilege.26,47,49

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Experiential Learning

A professional identity arises “… from a long term combination of experience and reflection on experience…”21 Therefore, a major objective of medical education should be to provide stage-appropriate opportunities for gaining experience and reflecting upon it. There must be structured opportunities allowing students, residents, and practitioners to discuss professional issues in a safe environment, personalize them, and hopefully internalize them over the course of education and training.1,24,33,51 In this way they develop their professional identity as novices develop into skilled professionals. The insight gained becomes part of a larger body of knowledge described as tacit, which one knows but cannot tell.39 It has been pointed out while tacit knowledge is difficult to teach, it can be learned.42 It is best learned not in the lecture hall, but by situated learning encouraging self-reflection42 and promoting reflective practice43 or mindfulness.11

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Continuity

It has also become evident professionalism must be taught throughout the curriculum at the undergraduate and postgraduate levels.21,24,40 As the objective is to teach the cognitive base and to internalize the values of the profession, instruction and opportunities for self-reflection appropriate to the stage of training must be provided in all major teaching units. Only in this way can the growth of tacit and explicit knowledge of professionalism take place in parallel with growth of knowledge in other areas. Professionalism is not a first year or a fourth year course. Professionalism must be seen as a part of all of medicine and so must be taught in a longitudinal fashion throughout the curriculum.

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Role Modeling

Role models remain the most potent means of transmitting those intangibles called the art of medicine.25,52,53 Professions use collegiality as a means of agreeing upon common goals and encouraging compliance with them.23 Thus, the peer-pressure of respected role models remains an enormously powerful tool.12,13,24,36 Conversely, the destructive effects of role models who fail to meet acceptable professional standards can be equally strong. Students quite rightfully state we ask them to do what we say, not what we actually do. Negative role modeling is pervasive and must be addressed.

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Faculty Development

For role models to be effective, it seems axiomatic they must understand the role which they are modeling. This must start with institutionally agreed upon definitions of professionalism and its characteristics and acceptable standards of behavior. To achieve consensus and to ensure faculty have the necessary knowledge and skills to teach and role model professionalism, faculty development is essential to the success of any teaching program on professionalism.45 As a result, a role that for centuries has been taught implicitly must be made explicit to the student and the role model.

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Evaluation

What has been learned (as opposed to what has been taught) must be evaluated to meet medicine's obligations to its students, to teachers and mentors, and to society.5 Students must know the objectives of the teaching program and be informed if they are meeting them. Formative evaluations with feedback on a regular basis are powerful and essential tools designed to assist students and residents in achieving their goals as they progress through the system.46

In more mundane but no less important terms, evaluation drives learning.46 If students know they are to be tested on a given subject they are more likely to attempt to learn it. Formative and summative evaluations of students and residents also provide feedback to the teaching programs as to whether its goals are understood and met.

Professionalism is so fundamental to medicine's relationship to society, evidence that its cognitive base has been learned and its values internalized and reflected by behaviors must be recorded. Medicine as a profession is granted the privilege of self-regulation, which requires that it set and maintain standards.7,44,47,49,50 The public must be assured of the competence and the character of the graduates of undergraduate and postgraduate programs. Regular and rigorous evaluation is essential to meeting this obligation, with summative evaluation providing evidence of the profession's accountability in this domain.

In addition, the program for teaching professionalism should be subject to systematic evaluation to be certain it is meeting its objectives. Program evaluation is a Liaison Committee on Medical Education requirement.31

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The Environment

The final point upon which there is general agreement is that the institutional culture can support professional behavior or subvert it. Medical education is carried out in an environment heavily influenced by economic, cultural, and organizational forces in the institutions themselves and in the healthcare system.17,24 It has been pointed out there is a formal curriculum containing the official material as outlined in the mission statement of the institution and in course objectives16-18 This states what the faculty believe they are teaching. There is also an extremely powerful informal curriculum consisting of unscripted, unplanned, and highly interpersonal forms of teaching and learning taking place among and between faculty and students. Role models at several levels, from peers to senior attending physicians, function at this level and can have a profound effect for good or ill on the attitudes of students and residents. In addition, there is a set of largely hidden influences functioning at the level of the organizational structure and culture. The influence of this hidden curriculum can, like role models, be extremely positive or negative. The message sent by decisions which, for instance, favor research or profit over teaching or ignore patient or community needs sends a message very difficult to counteract. The informal and hidden curricula are partly responsible for the difference between what students are taught and what they actually learn.17 A broadly based faculty development program can help to change the environment and affect the informal curriculum.45 However, the hidden curriculum also requires attention.48 The incentives and disincentives built into any institutional culture require change, along with a host of other factors including economic and structural policies established at the institutional level.24

These principles apply to undergraduate and postgraduate training. It is axiomatic there is a single cognitive base applied with increasing moral force as students enter medical school, progress to residency training, and enter practice. While parts of this body of knowledge are easier to teach and learn at different stages of an individual's career, it remains a definable whole at all times and should be taught as such.

In addition, while the principle that self-reflection on real and theoretical situations encountered in the life of a student, resident, or practitioner is essential to the acquisition of experiential learning and the incorporation of the values and behaviors of the professional, the opportunities to provide situations where this can take place will change as an individual progresses through the system, as will the sophistication of the level of learning.17,24,33,40

Teaching the cognitive base of professionalism and providing opportunities for the internalization of its values and behaviors are the guiding principles of organizing the teaching of professionalism at all levels. How this can best be done will vary with the type of curriculum used, the institutional culture, and the resources available.

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Implementing a Teaching Program on Professionalism

It is neither desirable nor possible to establish a standard curriculum on how to teach professionalism at the undergraduate or postgraduate level. Each institution, be it a faculty of medicine or a postgraduate training program, must determine how best to do this in their own environment as there are wide variations in the overall structure of the medical curriculum, the culture of the institution, the environment, and the resources available. As an example, the opportunities for establishing a formal program will vary depending upon whether the curriculum is traditional, organized around organ systems, or problem-based. However, the principles outlined above should not change.

The following is a description of how one institution (McGill University) has organized teaching professionalism over the past decade, and is offered as a brief example.

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Faculty Development

Faculty development is essential to the successful launch of any major program at the undergraduate or postgraduate level. Four separate workshops on teaching or evaluating professionalism were held over a 3-year period with the first two hosted by the dean. Over 150 individual faculty members participated. This allowed for institutional agreement on definitions and characteristics, methods of teaching and evaluation, and the thrust of curricular change.45 Most importantly, it assured the presence of skilled teachers, group leaders, and hopefully role models. Finally, it promoted faculty buy-in.

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Undergraduate Program

McGill uses an organ-based curriculum with no departmental courses being taught in the first 16 months. There are 13 units (gas, fluid, and electrolytes, musculoskeletal and blood, nervous system and special senses, etc). This is followed by a 7-month block called Introduction to Clinical Medicine. Finally, there are 16 months of traditional clinical clerkships followed by a final 4 months titled Back to Basics, which includes a resume and update of the most clinically relevant basic sciences, public health, and a block devoted to the study of the social sciences in medicine.

An integrated course on physicianship has been established, running in a longitudinal fashion throughout all 4 years of undergraduate medical education. Separate blocks are devoted to the teaching of the role of the healer and of the professional. It is understood in most institutions both roles are included in the institutional definition of professionalism. Preexisting activities addressing the roles of the healer and the professional have been incorporated in the new program. In addition, new learning experiences have been developed. There are Flagship Activities on a regular basis, involving the entire class. They serve to highlight the importance of the subject and provide the cognitive base. Attendance is taken during the small group sessions, which follow a didactic presentation.

The Flagship Activities start with an introduction to the roles of the healer and the professional, given to medical students during the first organized lecture on the first day of instruction. Definitions are provided (Appendix 1)9,38 as are the characteristics of the healer and the professional (Appendix 2). In addition, the International Charter on Medical Professionalism is distributed.35 This formal presentation is followed by 2 hours of small group discussion led by trained faculty group leaders. Discussion of vignettes illustrating professional or unprofessional behaviors has been shown to be an effective means of promoting self-reflection3 and they are used extensively. Situations appropriate to the level of instruction are used and discussion is specifically aimed at elucidating the attributes of professionalism (both good and bad) demonstrated by the vignettes. We channel discussion using a structured grid (Appendix 3).

A second formal session is held during the introduction to the patient block. The format is similar, with a formal lecture attempting to reinforce the first by repeating the definitions and summarizing the characteristics. Stress is laid on the obligations expected of the medical profession, indicating meeting these obligations is necessary for maintaining professional status. In addition, the concept of the social contract is introduced for the first time. Once more, this is followed by small group discussions with more sophisticated vignettes using situations relevant to the experiences of a second-year medical student.

During the third year, a program (which has been piloted) will be introduced. The students will be asked to write a 1000 to 1500 word description of an example of professional or unprofessional conduct they have seen during their medical school experience. These personal vignettes will be discussed by the group directed by a trained group leader.

The fourth-year program is one I regard as extremely important. An 8 hour seminar series is given during the Back to Basics program. It is titled Professionalism, Medicine's Social Contract and You. Approximately 15 articles from the social sciences and medical literature are distributed before the course, which begins with a formal presentation on the social contract. There then are three 2-hour seminars organized around the subjects of Self-Regulation, Conflicts of Interest, and The Social Contract and You. Students present the literature to each other, again with a trained group leader. In our experience, students just before graduating from medical school are in a receptive and self-reflective mood, and this is the richest part of the entire program.

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Communication Skills

An expanded course in communication skills has been established using the Calgary-Cambridge model.28 In addition, McGill's clinical method-the means students use to obtain a history, perform a physical examination, arrive at a diagnosis, plan a course of therapy, and relate to the patient-has been redesigned so the values of the healer and the professional are emphasized during the process.

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White Coat Ceremony

The white coat ceremony is a whole class flagship activity occurring as the students enter their full time clinical experience. It stresses professionalism in its most positive aspects.

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Other Flagship Activities

Introductions to the cadaver and the body-donor service, which have been in existence for some time, have been brought into the physicianship program, stressing the roles of the healer and the professional. The teaching of biomedical ethics has been incorporated into the physician-ship program as an extremely important flagship component. It is also taught using a combination of formal lectures to impart the cognitive base and small group discussions. There are activities during clinical rotations designed to promote self-reflection and the incorporation of the principles of biomedical ethics into the day-to-day lives of the students.

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Additional Programs

Narrative medicine, spirituality, and community service have been brought under the umbrella of the physicianship program, again stressing the roles of the healer and the professional.

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Mentorship

We established a mentorship program. Students and faculty were asked to nominate individuals they believe to be the most effective teachers and role models. From a large list, a group of mentors were chosen and named Osler Fellows. Salary support has been provided and each fellow has been assigned a group of six students. They will follow the same students throughout their 4 years of medical education and have a series of prescribed activities but, of course, may go beyond them.

A mandatory activity is the supervision of a student-led portfolio on physicianship. The portfolios are expected to assist the student in reflecting on their goals and document progress toward meeting these goals. The International Charter is included in the portfolio. Properly used, portfolios can be a powerful aid to self-reflection.

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Evaluation

A longitudinal evaluation system has been developed using traditional global assessment tools and newly developed methods. All students must successfully pass the physicianship course each year. A plan for evaluating the program itself was instituted coincidently with the first year of the teaching program.

The formal lectures provide an extensive cognitive base for each medical student. The small group discussions, the mentorship program, the programs in narrative medicine and spirituality, and others are designed to create the reflective practitioner, or one who demonstrates mindfulness. The faculty development program and the Osler Fellows Mentorship Program have provided skilled group leaders and have, I believe, helped to change the environment and make it more supportive of professional values. Finally, the evaluation system is designed to highlight the importance of the subject, reinforce teaching, provide formative feedback, and attempt to meet the faculty's obligations to society in a summative fashion. McGill has created an integrated program on professionalism that has elements throughout all 4 years of medical education.

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Postgraduate Education

The program uses the same overall approach. There are activities designed to ensure the cognitive base is understood by all residents. In addition, an attempt is made to ensure the issue is addressed throughout postgraduate training and opportunities for self-reflection are present.

A mandatory half day for all residents in McGill programs has been instituted at the PGY2 level. As is true of the undergraduate program, it begins with a formal lecture, during which the definition is provided, the attributes of professionalism are reviewed, and the social contract is discussed in detail. The role of professional associations and licensing bodies is also addressed.

This is followed by small group discussion using sophisticated vignettes. In addition, the groups are instructed to answer specific questions regarding the social contract. The International Charter is distributed to all residents and discussed.

An attempt is made to provide unit-specific activities on a regular basis. Rounds are devoted to discussing professionalism and workshops are occasionally given for faculty and residents. An attempt has been made to have issues discussed during bedside rounds, with varying degrees of success.

It is obvious the complexity of postgraduate education makes it more difficult to ensure regular exposure to the issue and continuity is harder to maintain.

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DISCUSSION

There appears to be little controversy over the general principles which have been outlined. It is obvious that any teaching program must begin with a definition of professionalism and that this definition should dictate what is taught, expected and evaluated. While there are a variety of definitions available in the literature, there is little disagreement as to what constitutes professionalism in contemporary society. Different individuals arrange the words in a somewhat different fashion, but the key elements are found in all definitions. In addition, there is wide agreement that teaching professionalism as a theoretical subject will have very little influence upon the behavior of future physicians. The substance of professionalism must be incorporated into the day-to-day lives of practicing physicians and must be reflected in observable behaviors. “Self-reflection” or “mindfulness” is felt to be the most appropriate means of achieving this essential step.

The barriers to establishing teaching programs are also recognized. Chief among these is the influence of the informal and hidden curriculum and of negative role models. Only now are faculties of medicine beginning to address these issues in a constructive fashion.

Finally, there is also agreement that because adequate tools to assess professional behavior are only now beginning to appear, it is difficult to evaluate the impact of those programs already in place.

It seems safe to predict that the future will see more vigorous attempts to establish longitudinal programs of instruction on professionalism as well as the development of more effective means of providing a supportive environment which encourages professional behavior.

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References

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APPENDIX 1

Definitions:

Heal: To make whole or sound in bodily condition; to restore to health or soundness; to free from disease or ailment; to cure (of a disease or wound).38

Profession: An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.9

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APPENDIX 2

Attributes of the Healer:

Caring and Compassion: a sympathetic consciousness of another's distress together with a desire to alleviate it.

Insight: self-awareness; the ability to recognize and understand one's actions, motivations and emotions.

Openness: willingness to hear, accept and deal with the views of others without reserve or pretense.

Respect for the Healing Function: the ability to recognize, elicit and foster the power to heal inherent in each patient.

Respects Patient Dignity and Autonomy: the commitment to respect and ensure subjective well being and sense of worth in others and recognize the patient's personal freedom of choice and right to participate fully in his/her care.

Presence: to be fully present for a patient without distraction and to fully support and accompany the patient throughout care.

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Attributes of Both the Healer and the Professional:

Competence: to master and keep current the knowledge and skills relevant to medical practice.

Commitment: being obligated or emotionally impelled to act in the best interest of the patient; a pledge given by way of the Hippocratic Oath or its modern equivalent.

Confidentiality: to not divulge patient information without just cause.

Autonomy: the physician's freedom to make independent decisions in the best interest of the patients and for the good of society.

Altruism: the unselfish regard for, or devotion to, the welfare of others; placing the needs of the patient before one's self-interest.

Integrity and Honesty: firm adherence to a code of moral values; incorruptibility.

Morality and Ethics: to act for the public good; conformity to the ideals of right human conduct in dealings with patients, colleagues, and society.

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Attributes of the Professional:

Responsibility to the Profession: the commitment to maintain the integrity of the moral and collegial nature of the profession and to be accountable for one's conduct to the profession.

Self-regulation: the privilege of setting standards; being accountable for one's actions and conduct in medical practice and for the conduct of one's colleagues.

Responsibility to Society: the obligation to use one's expertise for, and to be accountable to, society for those actions, both personal and of the profession, which relate to the public good.

Teamwork: the ability to recognize and respect the expertise of others and work with them in the patient's best interest.

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APPENDIX 3

Worksheet

TABLE

TABLE

TABLE

TABLE

© 2006 Lippincott Williams & Wilkins, Inc.