What Does Professionalism Mean to the Physician?

Abstract

Professionalism, which is a core competency for physicians, can be described as a spectrum of behaviors and may have a significant impact on the problems in today’s changing health care climate. In this article, we discuss the meaning of professionalism and its role in the Southern California Permanente Medical Group (SCPMG) and consider how it may be applied to integrated care delivery systems such as Kaiser Permanente. To understand professionalism, one must consider Stern’s definition, which consists of four principles: excellence, humanism, accountability, and altruism. SCPMG has taken three of these principles—excellence, accountability, and altruism—and divided the fourth, humanism, into another three principles similar to those identified by the University of California Los Angeles Task Force on Professionalism: humanitarianism, respect for others, and honor and integrity. SCPMG has a rich history and culture of promoting clinical excellence and professionalism, as evidenced by the programs and initiatives described throughout this article. Indeed, the SCPMG experience validates professionalism as a core physician competency comprising a set of behaviors that are continually refined.

Introduction

Medicine is undergoing rapid changes. Health care reform will undoubtedly have a huge impact on the profession and will result in more patients with insurance coverage and less reimbursement per patient. Even without health care reform, pressures to control the cost of care will increase, because the US currently spends more on health care than other developed countries yet has generally poorer outcomes. In addition, consumer groups have been questioning the quality of medical care since the 1999 Institute of Medicine Report that estimated that about 98,000 Americans die per year because of medical errors.¹ The pay-for-performance model is now embedded within Medicare’s payment system, with as much as 5% of gross revenue dependent on star rating and another sizable amount of money allocated for meaningful use of information technology. There will likely be shortages of nurses, physicians, and other health care providers at the same time we face the challenge of providing coverage for more patients.² Costs will continue to increase because of new technology, new and expensive medications, and the aging of our population.³

So, where in all of this change and tumult does the concept of professionalism fit? Why was it necessary for legislators to create programs funded with large sums of money to get the medical profession to deploy health information technology systems, improve quality and service, and make health care affordable? Have we as a profession failed?

Southern California Permanente Medical Group (SCPMG) leadership decided to address these questions by reinvigorating the concept and practice of professionalism as an integral part of how we practice medicine. Although professionalism can trace its roots to Hippocrates, we must consider how professionalism may have a significant impact on the problems of health care in today’s changing climate. The purpose of this article is to review the meaning of professionalism, describe how the concept of professionalism has been used in SCPMG and various medical settings, and consider how professionalism may be applied to integrated delivery systems such as Kaiser Permanente (KP) in a unique and valuable way.

Professionalism Defined

There are many published definitions of professionalism. Traditionally, professionalism was considered an attitude.⁴ More recently, many have challenged this view and characterized professionalism as a set of behaviors. It is one thing to know what professional behavior is, but another to consistently demonstrate professional behavior under the pressures of a busy practice with conflicting demands and multiple priorities.⁵ As such, professionalism is a skill that can be practiced and learned over time.^6,7 Important in this concept is that professionalism is a spectrum of behaviors and not an all-or-none set of attributes. To characterize some physicians as unprofessional and others as professional is to diverge from this concept. It is specific behaviors that are either professional or not. The most professional physician may have lapses in behavior.

Professionalism is about accountability and the need for physicians to work in teams and systems that may override physician autonomy for the greater good of the patient or society.

Professionalism requires one to continually improve, regardless of where one starts. It is not a state of being but rather a journey to improve and refine one’s skills over time. Professionalism has been viewed as an individual physician competency.⁸ Recently, however, it has been recognized that the environment interacts in a strong way with professionalism and that professionalism is applied in a context. The individual physician’s professional behavior influences his/her environment and the latter, in turn, influences the physician.^4,9 This has been noted particularly in medical education.¹⁰ Lastly, professionalism may require the physician to put himself/herself in harm’s way (eg, treating a patient with a contagious disease), as the physician puts the patient first. At the same time, a physician’s family and personal life are important, and a balance must be reached.

Our definition of professionalism uses three of Stern’s four core principles: excellence, accountability, and altruism. We divide the fourth principle, humanism, into three principles similar to those noted by Ian Cook, MD, from the University of California Los Angeles Task Force on Professionalism: humanitarianism, respect for others, and honor and integrity.¹¹ Multiple definitions of professionalism describe similar principles, behaviors, and concepts.^12–14

Excellence

Excellence refers to physicians learning throughout their career and understanding that their skills and knowledge constantly need improvement. This requires some self-reflection to assess where improvement is needed. Excellence also refers to continual improvement in quality of care. This improvement may be at an individual level, a system level, or a public health level. It can be adherence to evidence-based guidelines, such as the US Preventive Services Task Force guidelines or those issued by medical groups, such as the SCPMG Clinical Practice Guidelines. It may also include better communication with patients or cultural competence. Excellence also requires physicians to be aware of new scientific knowledge and technology, to evaluate it critically, and to deploy it as indicated. This latter function has become more difficult in recent years because of the proliferation of randomized trials and publications that makes it difficult for individual physicians to stay current. Fortunately there are reliable means of assessing new technology and science, including published meta-analyses, Cochran Reviews, and published guidelines. Professionalism should require physicians to participate in the development of practice guidelines and deployment of new technology in their own practices. For example, in SCPMG there is a robust process for evaluating new technology with the Medical Technology Assessment Team and Medical Technology Deployment Strategy Team. Various pharmacy and therapeutics committees require physician participation. Excellence also requires physicians to continually improve in resource utilization and patient safety.

Accountability

Accountability is another aspect of professionalism that requires the physician to avoid letting self-interest override the patient’s interest. This includes the concept of ownership of patient outcomes and follow-up. There is additional accountability to one’s colleagues with regard to working well in teams and covering each others’ practices. In an integrated delivery system like KP, this can mean making sure that the delivery system is thriving and doing the right thing. There is also accountability to the profession’s ideals and precepts as well as society at large. Physicians are often viewed as leaders both inside and outside of health care. Recent literature suggests that the skills and behaviors that characterize professionalism are similar to those that characterize physician leadership.¹⁵

Altruism

Altruism is part of professionalism and signifies advocating the interests of one’s patients over one’s own interest. It requires one to honor patients’ wishes, including wishes for end-of-life care. This is difficult and often not done.^16,17 Excellent communication with patients and respect for patients’ cultural needs are part of this aspect of professionalism. Finally, altruism may require disclosing medical errors to the patient, and the hospital, as well as medical care systems, despite any personal embarrassment. Medical literature would suggest that these errors and incidents are grossly underreported.^16,17

Humanitarianism

Humanitarianism refers to the physician’s commitment to service, which is particularly relevant for those in need. Physicians demonstrate commitment to service when they care for those who are uninsured or underinsured with the same compassion and attention they give to fully insured patients. Although members of a prepaid system of care, such as KP, are mostly insured, the mission of physicians in this context is still to improve the health of their communities, reduce health disparities within their own system, and take care of nonmembers who may appear in their system. Medical groups are encouraged to promote volunteerism as a component of professional duties.¹⁸ In SCPMG, sabbatical time and other educational time is available for those interested in volunteer work.

Respect for Others

Respect for others is an important principle of professionalism, because it really speaks to collaboration with the entire health care team. The health care team must be patient focused. Disrespect for staff or colleagues may interfere with the delivery of high-quality care to the patient. Lack of collaboration may lead to medical errors, particularly when members of the health care team are afraid to speak out regarding safety. In SCPMG we have promoted a number of initiatives in surgery to promote teamwork and communication and to reduce errors.

Honor and Integrity

The final set of principles of professionalism is honor and integrity. Physicians are expected to exhibit the highest standards of behavior. Physicians are faced with choices that may lead them astray on a daily basis. Misrepresentation of events when coding patient diagnoses and treatments for the purpose of financial gain is one of a multitude of potentially tempting opportunities for physicians to be less than honest. In a prepaid health care system with salaried physicians, reporting of time worked is often based on the honor system, which is a test of physicians’ integrity. Integrity also means obeying laws and complying with regulations.

How Has Professionalism Been Exercised at the Southern California Permanente Medical Group?

SCPMG has a long history of promoting professionalism. Sidney Garfield, MD, the founder of the Permanente Medical Groups, clearly recognized excellence as a component of professionalism and identified the need for continual education and development of physicians. He articulated the need for preventive care and a proactive role for physicians in the workplace and society to accomplish this aim. He identified the need for physicians to work in teams and use computerized medical records well before these systems were commercially available. One important aspect of professionalism that deployed early in the history of SCPMG was the creation of a weekly educational half-day, when physicians could have dedicated time to learn new medical knowledge and skills with easily accessible continuing medical education programs located nearby. Physician symposia were created so that physicians could attend conferences with their peers to both network and learn new information.

During the 1990s the Medical Directors of SCPMG recognized that professionalism required patient communication skills in addition to the ability to communicate technical, scientific knowledge well. They recognized there was a need to measure, to improve, and to develop physicians’ patient communication skills. A system of patient surveys was developed (Member Appraisal of Physician/Provider Services, [MAPPS]), and various courses and programs were created to assist physicians in improving their communication skills.¹⁹

Later in the 1990s, a need was identified to teach physicians about cultural aspects of care that are important in a diverse population, and a program was created to teach about culturally responsive care. Expanding on this idea of better communication with patients, a language concordance program was created in 2007 in which physicians could be tested for foreign language competence, and venues for teaching and improving foreign language skills were implemented along with systems to better match physicians and patients with limited English skills.^20,21 Cultural sensitivity and patient communication continue to be relevant today, and health disparities are another issue to be addressed.

In 2005, SCPMG recognized that our physicians needed a clearer code of conduct that would highlight the importance of integrity, collaboration with the health care team, and other behaviors characterizing professionalism. The SCPMG Board of Directors passed the Physician Performance Management Process, with clear definitions of behaviors expected of physicians based on the KP values: accountability, flexibility, innovation, partnership, diversity, integrity and quality, service, and results. Consequences of good performance and below-standard performance were described.

In 2007, Jeffrey Weisz, MD, former Medical Director of SCPMG, recognized the need for promoting professionalism via promotion of excellence and challenged the Medical Group with the statement, “I’d like to throw a challenge to all of you … choose a goal for an area where you’d like to see us lead the country.”²² This was a paradigm shift. The previous thinking had been to create targets that would position us in the 75th or 90th percentile.

In 2007, SCPMG recognized the need to develop physician leaders. SCPMG University School of Foundations was created and began providing new physicians with multiple-day learning sessions covering a wide variety of topics relevant to performance and professionalism. Another program is tailored to new physician-leaders and teaches them the elements of successful management and leadership.

How To Improve Professionalism

Medical curricula need to include professionalism as a skill for continual refinement consisting of a set of behaviors rather than attitudes. This process needs to continue during graduate medical education and in the health care delivery system. At an integrated delivery system such as KP, this becomes easier to accomplish because there is already an alignment of team-based care, practice guidelines, sharing of information via a comprehensive electronic medical records system, and a single multispecialty Medical Group. As accountable care organizations proliferate, they will likely be able to accomplish a similar structure capable of promoting professionalism.

It is said that one cannot manage what one cannot measure. When we consider professionalism as a set of behaviors rather than an attitude, we can measure and improve it.^7,23 This is accomplished at SCPMG with a number of tools, including patient satisfaction scores, clinical strategic goals, board recertification courses and other educational programs that meet the Maintenance of Certification requirements for recertification, annual self-assessments reviewed with the chief of service, the National Surgical Quality Improvement Program (for surgeons), a rigorous peer-review process, and formal peer appraisals.

SCPMG is taking a further step to make professionalism part of other processes that are already in place. The intent is to make the concepts of professionalism more widely known so that it will be a living and breathing part of all we do. To that end, the specific principles of professionalism will be incorporated into the annual physician self-assessment process, the physician leader peer survey process, and the evaluation of new physicians during their first few years to determine readiness for partnership with the Medical Group. Other medical groups such as the Mayo Clinic have a long history of promoting professionalism. At the Mayo Clinic, this starts during medical school training and continues; professionalism training is provided for faculty physicians.²⁴ Other medical groups may wish to consider these efforts when promoting professionalism in their organizations.

How Professionalism Can Be Used to Improve Care in an Integrated Delivery System Like Kaiser Permanente

As we enter a new era of health care reform with various and complicated payment systems, issues of transparency, pay-for-performance programs, and increased numbers of insured patients with limited resources, professionalism should help us create a roadmap for navigating through these changes. Professionalism can be part of the collective culture of an institution that can create an environment where innovation and improvement are the norm. It can create a collective identity in the organization, as it is doing in SCPMG. By focusing on accountability in teams, we can foster higher levels of integration and collaboration. A focus on excellence will be required to find new methods of improving quality, service, access, and affordability. Ed Ellison, MD, the current Executive Medical Director of SCPMG, has challenged us to increase the use of scientific performance improvement tools in our quest for continual improvement.²⁵ This will require us to use the behaviors of professionalism—excellence, accountability, altruism, humanitarianism, respect for others, and honor and integrity.

As Medical Groups invest in a culture of professionalism, it is comforting to know that despite increased regulations and health care legislation, professionalism, which is values based, is one thing that remains constant for physicians.