Professionalism comes from the word “profess” – meaning confess. The difficulty of defining professionalism, in my estimation, is the variation on how different groups of physicians profess their own values. Values foundational among those in the medical profession include humanism, altruism, compassion and respect. Beyond those, practices and health systems have emphasized and prioritized different values and use different language.

Two published articles report on using critical incidents as a way to identify and reaffirm an organization’s professional values. In Diagnosing culture in health-care organizations using critical incidentsby Larry Mallak et.al. (International Journal of Health Care Quality Assurance, 16/4 (2003) 180-190), the authors report on applying the critical incident technique (CIT) as a methodology to surface cultural information in a hospital. Employees who were trying to create a patient-centered healing environment were asked to think about the organization’s values and provide the values displayed in that incident. Analysis and categorizing of the CITs provide better insight and more detail concerning the values of the organization and highlight differences in how employees experience the organization’s culture. Mapped to stated values, the critical incident category reveals the relative strength of the values in the hospital (e.g., concerns for the patient was highest shared value while job “ownership” was the lowest).

The second article, Discovering professionalism through guided reflection by Patsy Stark et. al (Medical Teacher, Vol. 28, No. 1, 2006, pp.e25-e31) from Northern General Hospital, Sheffield, UK looks at the use of critical incidents as an assessment for first-year medical students' exposure to multi-professional health and social care experiences. Interestingly, one of the most frequent overall reflections was on doctor communication (both negative and positive), teamwork, social service resources and patient beliefs/autonomy/dignity resources. The authors state that “critical incidents encouraged students to understand and analyse professionalism in the context of the Duties of a Doctor.”

This critical incident reporting is similar to root cause analysis used for medical errors and improvement. There is some current experimentation to apply root cause analysis to professional lapses where clinicians are asked to reflect on the root causes of the lapse (at the individual behavioral level, the influences of the organization and broader policy level such as payment methods).

A long-debated issue is whether to use formative or summative assessment to advance professionalism. I would favor a formative process that would allow continuous growth and development to occur over a professional’s career while a summative assessment might have the unintended consequence of being seen as manipulative and could create cynical attitudes towards professionalism. It seems to me that there is real power in a guided self-reflection with a peer or mentor to provide feedback on behaviors and demonstration of shared values of an organization.

What do you think?

Professionalism is such an important yet difficult topic. No one can ever really know what's in another person's heart; we can only infer based upon their behavior, or perhaps more accurately, how we experience their behavior. So maybe that's the best way to assess professionalism - with a kind of 360 degree revew.

Lists of behaviors are helpful as teaching tools, and they also highlight some of the behaviors that seem to influence what people experience, so they have an important place. These behaviors are the vehicles for expressing values, so its helpful to be aware of them.

I think the most important thing for demonstrating, improving and assessing professionalsim is th capacity for reflection: to be able to notice, and to talk with each other, about what we are experiencing in each moment and how we are experiencing each other. We don't do this much currently, but it's a core discipline we must cultivate. This is how we become attuned to and self-regulating with regard to the values we are enacting, both at an individual and organizational level.

Anthony Suchman

When it comes to the issue of professionalism and its definitions [the plural is purposeful], I find myself caught between a rock and a hard place -- perhaps several rocks and several hard places. On the one hand, I applaud discussions of meaning (although I know "meaning" is different from "definition"). I think of profession as both an evolving concept and an ever-changing entity. Thus, it was fun to get the recent opportunity to read about what Flexner had to say about professions (not a great deal, but still interesting) and to compare and contrast those observations with our discourse of professionalism today. Then there are those cross-national differences etc. Great fun and great challenges. Similarly, I enjoy and find myself stimulated by the above posts. Pithy thinking is always to be admired.

On the other hand, I find myself cringing (I know it is a moral flaw on my part) when I read articles that open with what has become my least favorite professionalism first sentence -- that professionalism is difficult (impossible) to define. Ugh! It remind me (I don't know why) of that other "infamous" first sentence -- "It was a dark and stormy night."

What am I supposed to do with such a claim? Discount the rest of the article? Read it and conclude; "Yes, but..."? Or is somehow this -- and only this article -- going to solve the Sphinx-like riddle and provide us with the guidance that somehow has escaped all of the previous articles?

I get a similar rush of dismay when I go to a conference or meeting on professionalism and the same claim is made -- something to the effect that it (professionalism) is not definable, or that it is difficult to define, or that there is no consensus as to definition, or, the claim with the greatest cringe factor -- that professionalism is like pornography (impossible to define but you know it when you see it).

Again, what am I supposed to do with these claims?

I realize the above list is populated with qualitatively different claims. I resonate most with the lack of consensus conclusion -- but I do not tie this to the quantitative claim that what we lack is definitions. There are definitions out there. And there are common threads across those definitions. We may lack satisfactory metrics -- but that is a different issue.

Medicine's modern-day professionalism movement is now over twenty-five years "old" -- and the ABIM and ABIM Foundation had a great deal to do with its development in those early (and continuing) years. One of the first claims made in this movement was that medicine lacked a clear idea/definition of professionalism -- and this claim (historically correct or not) launched a thousand Helenesque ships. These ships did not sink from sight upon launching. They are still around -- and I'd like (as a personal wish) to get over the "it can't be defined" claim -- if only because if one treats the claim as literally true -- then it (the claim) is a conversation stopper.

I realize this thread is not about this particular issue -- but this is what came to mind as I thought about issues of profession definition. Since it is too windy to row this morning, I'm off to the gym to pump iron -- which given my age is an experience awash with ironic challenges.

Confirming My Cheese Had Already Moved

Many individuals whose careers are focused in improving quality and safety have focused on measurement, quality improvement (QI) and re-engineering to improve processes and outcomes of health care. This has been a slow, stagnant progress and in many cases little progress has been made. Critics have spoken about the reductionistic nature of measurement and QI. What new thinking can get us out the quagmire?

Fred Hafferty, the educator who coined the phrase “hidden curriculum”, recently wrote about complex adaptive theory as the new frontier in understanding professional behaviors. Krasner, et. al had an article I wrote on this website about the effectiveness of mindfulness and discernment in combating clinician burnout.

Another landmark article from a prestigious research group that has studied primary care practices for more than 15 years, has recently published an article that applies complex adaptive systems to the development of new strategies for improving health care quality. The title tells all: How Improving Practice Relationships Among Clinicians and Non-Clinicians Can Improve Quality in Practice (by H. Lanham, R. McDaniel, B. Crabtree, W. Miller, K. Stange, A. Tallia, P. Nutting in the Joint Commission Journal on Quality and Patient Safety). Through four large-scale, federally funded research programs they developed a model of practice relationships that identifies seven characteristics of relationships to understand primary care practice changes. These relationship characteristics include trust, mindfulness, heedfulness, respectful interaction, cognitive diversity, social and task relatedness and rich and lean communication.

The article sets forth a radical shift in thinking about QI, rather than thinking about QI as “focusing on the parts and components of a process, complex adaptive system perspective enables a view of health care quality as an emergent property.” Seeing quality as an emergent property drives efforts to improve relationships among the parts and the people of the system. Interdependencies are valued when quality is seen as emergent over part or components. The authors state that quality arises through unfolding conversations rather than quality arising through well-designed initiatives.

This type of thinking also connects with the work on relationship centered care and community building (see Community: A Structure of Belonging by Peter Block). As thoughtful people in this area say -- it is all about small group conversations -- the building of respect and trust by reflections and learning.

Do we have the luxury of time for such anticipated slow change in health care? Given the urgency of the problems, in terms of quality and resource use, there is unsustainable growth in the health care industry. Things have to be done right now. This relationship orientation, some say, is not for everyone and sounds ‘too soft’ to make a real difference. Or, is this the best way to create substantive change that is aligned with professional values and deep seated needs of a healing profession?

What do you think?

Daniel Wolfson

Is Physician Self-Regulation Dead? What Medicine Can Learn from Journalism

During the discussion “Is Physician Self-Regulation Dead?,” at the College of Physicians of Philadelphia, the topic turned to the future of journalism. As I listened, I became struck by the parallels between journalism and medicine, and the lessons from journalism that can be applied to medicine:

Be aware of your press coverage, particularly your field’s scandals.

Gardiner Harris, public health reporter at the New York Times, acknowledged that journalists, including those at the New York Times, have had to contend with a number of their own scandals, such as the Jayson Blair fiasco, that have eroded public trust in their profession. Similarly, reports of egregious conflicts of interest, and popular press articles like Atul Gawande’s “The Cost Conundrum,” can have enormous impact on the public trust of physicians, and should be taken seriously by medical leaders.

Pay attention to your business model.

Both Harris and Christine Cassel, MD, President and CEO of ABIM and the ABIM Foundation, noted that journalism, like medicine, has struggled with balancing the provision of a public good with survival in a free market economy. As the decline of print journalism has illustrated, professions must continually adapt to changing markets to meet current demands. Similarly, as noted in this New York Times article, many health care organizations are operating on “century-old business models, for the general hospital and the physician’s practice, both of which are based on treating illness, not promoting wellness.”

Address disruptive innovations.

Disruptive innovations, a term coined by Clayton Christenson, allow “a whole new population of consumers access to a product or service that was historically only accessible to consumers with a lot of money or a lot of skill.” Gardiner Harris reflected that the internet was a major disruptive innovation for print newspapers, in that consumers now had access to free information that they would previously have paid for. The print newspaper field was caught unprepared to deal with this innovation.

In addition to the internet, a whole wave of disruptive innovations can turn health care on its head. These innovations include smartphones, electronic medical records, and retail medical clinics. Physicians should seize the opportunity to learn about and adopt beneficial innovations – such as electronic medical records – that will become increasingly entrenched in everyday practice.

What do you think of this comparison? What lessons can physicians learn from other profession, particularly regarding disruptive innovations?

- Amy Cunningham

“Respect Yourself” and Your Community

On the final week of the year, I pondered how health care reform will really turn out. Can we as a country go beyond legislation primarily focused on insurance reform and design a better system that can be sustainable overtime? At this rate of spending we are pulling resources away from our communities’ education, public transit and arts programs, and from a social safety net.

The ABIM Foundation has convened a task force of fifteen wise and accomplished physicians and patient/consumer leaders to develop recommendations on how individual physicians can manage the just distribution of finite resources – one of ten commitments in the Physician Charter. This commitment has proven to be most controversial because it appears to conflict with the Charter’s principle of patient welfare – doing what is best interest of the patient.

In his 1968 article “Tragedy of the Commons”, Garrett Hardin imagines a pasture held in common by a community. Once the commons is built, sheep farmers working in their self-interest overgraze the commons to its ruin. In 1975, Howard Hiatt reflecting on Hardin wrote, “Surely nobody would quarrel that there is limit to resources any society can devote to medical care…The dilemma confronting us is how we can place additional stress on the medical commons without bring ourselves closer to the ruin.” Hardin was also cited by Christine Cassel at the 2006 ABIM Foundation Forum on efficiency and an article in JAMA, Managing Medical Resources: Return to the Commons?

Foundation task force member Don Berwick’s recent address to the 2009 IHI National Forum (an audio-visual production of the speech can be obtained at www.ihi.org) evokes Hardin’s article “Tragedy of the Commons” through the introduction of the findings of Elinor Ostrom, the first women to win the Nobel Prize for economics who studied the problems of collective action.

In a recent interview with NPR’s “Planet Money,” Ostrom disagrees with Hardin’s inevitable tragedy and ruin of the commons. She describes farmers in the Swiss Alps whose community has established some simple rules of using the commons such as boundaries of who uses the commons and limits of the use, self-governing and monitoring of those rules. This past summer, Berwick et al. interviewed high-quality and low-cost areas like Cedar Rapids and find they share similarities to Ostrom’s Common Pool Resources principles; for instance, how these communities understand the limits and boundaries of their health care commons. In my opinion, these examples highlight respect and understanding of the community and those who reside in it.

In his address, Berwick also relates the story of Hajia Mary Issaka, a nurse-midwife working in a clinic in Ghana whose efforts are getting incredible results regarding child/infant mortality rates. Issaka says the secret of her success lies in respect for her patients. Respect of both community and patients are important lessons for the health care system in 2010 and beyond and, in my view, values that lie at the core of professionalism.

One of the Physician Charter’s major contributions is extending the respect and integrity of relationships with patients to relationships with organizations and our communities. Preserving communities’ resources is not in conflict with the putting the interest of the patient first -- it’s in service of the patient welfare and their communities. We need to give respect for the proper use of each resource and fully understand the impact of their misuse. Providing what medical enterprises need to survive in a fee-for-service environment will be the ruin of American society, and subsequently our standard of living and public civility. Each of us in the medical system has a professional commitment and obligation to get this right.

Do Ostrom and Issaka have the beginning of a solution to our many problems in the current health care system?


Daniel Wolfson

A recent article by Earnest and Federico, titled Perspective: Physician advocacy: what is it and how do we do it? (Acad Med. 2010;85(1):63-67) defines and describes a spectrum of physician advocacy activities and calls on medical schools and GME programs to train physicians and accrediting bodies to define advocacy competencies requirements.

Although I thank the authors for highlighting the importance physician advocacy, I question if competency training, although necessary, is totally sufficient. A better teacher of physician advocacy is what is actually done by medical schools and institutions that house residency programs to advance their social missions. Institutions like Leigh Valley Hospital teach civic professionalism by example – through the operation of clinics in underserved communities and the millions of dollars of free care they are providing during a period of high unemployment. An organization’s conflict of interest policy, its commitment to disclosure of errors and its dedication to removing unnecessary care send important messages to physicians about their institutions’ social contract with society. As far as training in advocacy is concerned, actions speak louder than curriculum.

It is also interesting to note what examples of physician advocacy were described in the article and what was not used as an example. Earnest and Federico cite access to care, lack of universal coverage, public health initiatives, injury prevention and liaison to the media as a good spectrum of physician advocacy activities. What bothers me is what is missing. Perhaps the most crucial issue for the national, post-health care reform (or post-lack of health care reform) discussion is the affordability and sustainability of health care.

Will physicians assume leadership here or feel like this is someone else's responsibility? Can physicians advocate and be leaders in building a different framework for managing resources consistent with professional values? The time for physician advocacy is needed now and in this critical area.

Is physician advocacy for just distribution of finite health care resources an appropriate role for physicians?

Daniel Wolfson

Going West to Go East

I was fortunate to be asked to speak at a Portland, Oregon city-wide summit, sponsored by the Foundation for Medical Excellence and led by Medical Director Barry Egener, titled "Organizational Strategies to Promote Professionalism." Dr. Egener is also the Chair of the Professional Task Force of the ABIM Foundation and American Board of Internal Medicine; charged with steering the ABIM enterprise toward advancing professional values and behaviors.

At the summit, John Christensen's "Value of Physician Well-Being to Organizations" addressed improving physicians' well-being using a framework of positive psychology that is rooted outside of medicine but quite applicable to physicians trying to operate in what sometimes can be hostile environments. He argued that maintaining the resiliency of the workforce is an important asset needed by organizations aspiring to be high-performing delivery systems. My impression of John's talk was that by focusing on the well-being of all physicians and clinicians, we improve the health of those we treat and improve the safety, quality and cost of the process. We could thereby begin to measure this resiliency as a quality worth measuring for an organization.

Christensen pointed to his published paper in the Journal of General Internal Medicine detailing an experience at Legacy Clinic (another Portland connection) that fashions this "intervention" to enhance control over work environments, enhance order by designing efficient offices and assembling high-quality staff, and give meaning and a sense of fulfillment in work. The goal was to improve physician satisfaction, organizational health and decrease burnout. Results showed emotional and work-related exhaustion decreased significantly and Quality Work Competence (QWC) survey results showed significant improvement initially and remained stable over time.

Why is this author who usually discusses the meaning of professionalism interested in the well-being of clinicians? Because the less satisfied the clinician, the more acts of unprofessional behavior, error, low-quality, patient disrespect and higher cost will occur.

John also pointed me to some interesting articles on virtuousness in organizations related to the field of positive psychology as well as well-being. An article, by Kim Cameron at the University of Michigan et al. titled, Exploring the Relationships Between Organizational Virtuousness and Performance, is worth a read by interested followers. The study of 18 diverse companies -- mostly for-profit and only one from medicine -- found that positive relationships exist between perceptions of organizational virtuousness and the perceived and objective measures of organizational performance. Per Cameron's definition, virtuousness is "a connection with meaningful life purpose, the ennoblement of human beings, personal flourishing… and resilience in suffering."

If there is a correlation of individual well-being with organizational performance, why aren't more organizations focused on well-being? Surely most organizations say they focus on the well-being of their workforce but does it measure up to the examples cited in the two referenced articles?

What do you think?


Daniel Wolfson

Should We Be Outraged?

A recent JAMA article by Catherine DesRoches et al, Physicians’ Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues reports that 64% of the physicians surveyed “completely agreed” with the professional commitment to report significantly impaired or otherwise incompetent physicians. 36% of the surveyed physicians responded "somewhat agree," "somewhat disagree," or "completely disagree." Should we be outraged by these findings?

The biggest reason given for failing to report someone was the belief that someone was already handling the situation. I would suggest that a limited number of centers to remediate incompetent and impaired physicians might be a cause as well. Turning someone in will only punish -- not rehabilitate -- the impaired physician.

Matthew Wynia of the AMA's editorial in the same issue suggests a "glass half-full" interpretation of these data: A solid majority of physicians (64%) “completely agreed" that they are obliged to report impaired or incompetent colleagues. And a number of those who did not agree "completely" agreed "somewhat.”

Physicians should not report "some" of the time; they must always report. Specialty societies should join together in denouncing this 64% outcome. We must set the standard for reporting impaired and incompetent physicians at 100% of the time.

This mentality threatens the very basis of professionalism and the social contract that grants autonomy through self-regulation. If the profession is unable to work with delivery systems, licensing and certifying bodies to identify physicians that can potentially harm or kill patients, it cannot maintain its self-regulatory status.

- Daniel Wolfson