Talking About Professionalism Through the Lens of Professional Identity

Abstract

Professionalism is one of the Accreditation Council for Graduate Medical Education's (ACGME) Core Competencies, but the breadth of its content often makes this a difficult topic, both in remedial counseling and when presenting the topic to medical trainees and practicing clinicians. Physician professionalism encompasses both clinical competence and the virtues that comprise the physician's social contract. This difficult subject may best be approached tangentially, through the lens of professional identity. Professional identity describes clinicians’ affinity for, acculturation into, and identification with the practice of medicine. One method to highlight the benefits that individuals accrue by adopting professionalism's elements is to pose questions that optimize listeners’ self‐reflection about their lives and aspirations—in essence, their professional identity. Discussing professionalism this way often yields in‐depth discussions of how trainees believe their professional identity was formed and will impact their long‐term goals. Both in teaching and in counseling, educators can frame their discussions using professionalism and professional identity's overlapping and reinforcing elements to show listeners how to advance their personal and professional goals and avoid the short‐ and long‐term consequences of unprofessional behavior. To engage the audience, educators and supervisors can emphasize how adhering to the elements of professionalism may determine their career opportunities, the professional respect they receive, and their career fulfillment and, ultimately, longevity. In this way, educators can better guide trainees and clinicians to understand their personal reasons for acting professionally, that is, doing the right thing, at the right time, in the right way, and for the right reason.

Although professionalism is one of the Accreditation Council for Graduate Medical Education's (ACGME) Core Competencies,1 the breadth of its content (Table 1)2 and its many parallels with behavior expected of all working professionals often make it a difficult concept to fully grasp. That greatly complicates the task of discussing professionalism with clinicians at any training level (medical students, residents and fellows, practicing physicians, and other health care professionals), whether in remedial counseling or in group presentations. This paper presents a method (Table 2)3, 4, 5, 6, 7 for educators to help recipients understand how adhering to professionalism's basic elements will affect their career trajectory.

Table 1.

Elements of ACGME's “Professionalism” Core Content2

Maintaining emotional, physical, and mental health and pursuing continual personal and professional growth

Maintain a healthy lifestyle.a

Develop an approach to continuous lifelong learning (i.e., stay current in job requirements).a

Regularly attend conferences and CME activities (i.e., attend required meetings).a

Have a positive response to constructive criticism.a

Demonstrating humanism and cultural proficiency

Treat patients as humans, not subjects.

Treat patients and others respectfully (i.e., interactions with colleagues and clients should be respectful).a

Listen attentively, responding humanely.a

Maintain patient privacy and confidentiality.

Exhibit altruism and patient advocacy.

Advocate for the patient's welfare.

Display empathy.a

Demonstrating professional conduct and accountability

Be on time and arrive prepared for work.a

Dress appropriately and maintain good hygiene.a

Continue to see patients throughout the work period (i.e., put in a full day's work).a

Complete medical records thoroughly, honestly, and punctually (i.e., complete work accurately and in a timely manner).a

Consistently advocate for patients and their families.

Give and receive input and advice from colleagues.a

ACGME = Accreditation Council for Graduate Medical Education; CME = continuing medical education.

^aParallels with expectations of all working professionals.

Table 2.

Key Points for Professionalism Presentations or Remediation: Using Professional Identity to Discuss Professionalism

Presenters may want to use these questions and possible answers in a Socratic format, generating as much audience participation—and investment in the topic—as possible. During remediation, try to elicit appropriate responses from the individual, but be prepared to stimulate him or her, as required.

What do you want to accomplish during your medical career? What are your career goals?

Help others?

Clinical excellence?

Academic excellence?

Professional leadership?

Scientific advances/publications?

How about your personal goals?

Enjoy practicing medicine?

Fulfilling family life?

Minimizing stress and enjoying personal time?

Financial, personal and geographic stability?

What ideal physician characteristics (e.g., virtues, values, attitudes) do you possess or are working to achieve?3

Fairness

Honesty

Kindness

Teamwork

Judgmenta

Leadershipa

What factors that you control in your professional life could advance your opportunities to achieve or prevent you from achieving these goals?

Avoid or get treatment for substance abuse.b

Get prompt treatment for psychological issues

If suggested or suspected, get counseling for problematic personality traits such as narcissism, perfectionism, and selfishnessb

Learn to control anger, especially under heightened stressb

Leave personal problems out of the work environmentb

Be a reliable worker (e.g., no chronic lateness or absenteeism, come prepared to work)

Demonstrate positive team member behavior (e.g., do not cheat, falsify data, or disrespect or argue with other team or staff members)

Do not resist constructive advice (e.g., arrogance, defensiveness)

Work to improve relationships with patients and their families

Ask for help (clinically and emotionally) when you need it

Have a study plan and follow it

Read relevant professional literature

Identify a mentor and meet with him or her regularly

Know and follow the departmental, institutional, other relevant governing rules for your professional work. Accept supervisors’ directives

Actively participate in professional meetings, groups, and associations

Teach others, whenever possible

Ask for feedback on your clinical work and professional relations

Develop a career plan after investigating its feasibility for you

What are the professional consequences of persistent unprofessional behavior?c

Delay in educational progress

Diminished professional status

Required remedial interventions (short‐ or long‐term)

Limitations on specialty, fellowship or locations for graduate medical education

Probation at or expulsion from school, training program

Fewer patients and referrals

Limitations of clinical privileges

Diminished income

Negative media exposure

Altered working relationship with colleagues and staff

Loss of clinical privileges

Difficulty obtaining future positions

^aStudents and clinicians may feel that they do not themselves possess these qualities.

^bCharacteristics shown to be associated with unprofessional and disruptive behavior.4, 5, 6, 7

^cIndividuals also nearly always experience significant consequences in their non‐professional lives.

When I was asked to present the topic of professionalism to residents who, their faculty felt, had not been behaving professionally, I was initially at a loss on how to make a topic viewed as abstract both relevant and interesting. My approach was to discuss professionalism through the lens of professional identity (Table 3)—a personal issue for every clinician. This strategy yielded an in‐depth discussion of how the trainees believed their professional identity was formed and would affect their long‐term goals and aspirations. Encouraging self‐reflection on professional identity is a way to introduce ideal professional norms and how they align with trainees’ own personal attitudes, values, and goals. This reflection can include role model and mentor behavior they hope to emulate and unprofessional or disruptive behavior they should avoid in the pursuit of their professional goals.

Table 3.

Professional Identity Questions

Self

1. How would you describe yourself? (e.g., medical student/resident, physician, researcher, spouse, parent, citizen)

2. Why did you go into medicine?

a. Did a role model influence you?

b. Do/did you have a picture of the ideal physician you wanted to be?

3. Why did you choose/are you planning to go into the specialty of ______?

a. What clinical and nonclinical traits does an excellent physician in that field need to have?

b. Do you have/are you working on acquiring those traits? How?

4. Who are your role models/mentors?

a. What desirable traits do they have that you don't have?

b. Are you working to acquire those traits? How?

c. Are you trying to behave as they do?

5. Where do you see yourself in 10 years?

a. What current behavior will help or prevent you from achieving those goals?

b. How will achieve those goals?

Others

6. How do others see you?

a. Colleagues and supervisors (e.g., capable/incompetent, compulsive/laid back, hard worker/lazy, friendly/off‐putting, experienced/novice, helpful/self‐serving, caring/uncaring, truthful/liar)

b. Family and friends (e.g., medical professional/trainee, humble/arrogant, supportive/discouraging)

Work

7. Do you treat medical school/residency/clinical practice as your job or as a calling?

8. What traits does a good employee have? (e.g., honesty, helpfulness, arrives on time, completes tasks, takes initiative)

a. Do you treat colleagues well? (e.g., cooperative, respectful, gives criticism gently, takes criticism well)

b. Do you present/treat yourself well? (e.g., clean and neat appearance, admits what they don't know, stays fit and well rested, takes time for self‐reflection)

What is Professionalism?

Physician professionalism encompasses both clinical competence and the virtues that comprise the physician's social contract. Aside from the knowledge and skills needed to proficiently practice medicine, the ideal medical professional demonstrates “compassion, integrity, and respect; [is] responsive to patient needs; and [is] accountable to patients, society, and the profession,” and uses generally accepted ethical principles to identify and reason through ethical dilemmas.8, 9, 10 The sources of ideal virtuous physician behavior stem from ancient and modern medical ethical oaths and codes that flowed naturally from Aristotle and subsequent philosophers’ writings that urged individuals to act consistently in an ethical manner. The goal of virtue‐based medical professionalism is for clinicians to internalize such values and ethical reasoning so that they can develop an unselfish disposition toward patients and colleagues. Within this framework, professionalism is the application of virtue to practice.10

Defining the attributes of professionalism helps trainees understand the accepted rules that they must follow to successfully acculturate in their chosen career path. But educators need to do more than define these important attributes. As the Royal College of Physicians and Surgeons of Canada stated, ‘‘To ensure that clinicians have the desired values and behaviors, we cannot rely on trainees to passively absorb them. Rather, we must formally teach and reinforce these values and behaviors among trainees and practitioners.”11 In explicit recognition of this, the ACGME has long included professionalism in its six Core Competencies.2

Over the past decades, major organizations governing postgraduate physician education in the United States, Canada, and the United Kingdom have reorganized teaching and evaluation, moving from what has been characterized as a virtue‐based to an outcomes‐oriented (metric‐based) learning model.9, 12, 13, 14 The ACGME now requires trainees to reach “Milestones,” increasingly complex behaviors at each level of a specialty's training, which are assessed using the Core Competencies. However, measuring and evaluating professionalism has traditionally been both difficult and subjective, reliant on observation, coworker reports, sentinel events, and patient surveys. The ACGME's suggested assessment methods for evaluating professional competency, “multi‐source feedback (MSF), patient surveys (can be part of MSF), and direct observation,” appear comparable to traditional methods of assessing virtue‐based professionalism.15 By making professionalism a Core Competency with associated Milestones, the ACGME signals both that they consider it an integral part of the medical school curriculum and that they recognize Aristotle's admonition that the study of ethical principles is not the goal but rather a tool to help individuals act in an ethical manner.16

What is professional identity?

Professional identity describes clinicians’ affinity for, acculturation into, and identification with the practice of medicine.17 Personal identity develops from the multiple relationships and experiences throughout life. It likely begins to develop as individuals are gradually exposed to real doctors and the media's interpretation of them. They then form their own image about who physicians are, what they do, and how they ought to behave. Beginning with acceptance into medical school, trainees’ professional identities slowly form through experience, role modeling, and the assumption of clinical responsibilities.18 This transformation from layman to skilled physician requires them to assume the medical profession's accepted roles, responsibilities, values, and ethical standards.19

Medical educators generally accept Kegan's framework for the development of professional identity.20 As Bebeau21 described the stages most applicable to medical trainees, “Individuals move from self‐centered conceptions of identity [Stage 2] through a number of transitions, to a moral identity characterized by the expectations of a profession—to put the interests of others before the self, or to subvert one's own ambitions to the service of society [Stage 3 or 4].” However, a study of EM residents suggested that may not happen for about half of medical students by the time they enter residency. In response to the question “Why is medicine important to you?” about half of incoming EM residents expressed self‐focused answers (Kegan Stage 2), while the balance gave other‐focused answers (Kegan Stage 3; i.e. altruistic, virtuous).22 This is not surprising, since the process continues to evolve throughout a clinician's career, with individuals adopting their professional identity at different rates.21, 23 Unfortunately, clinicians progressing more slowly through the stages (or stalled at a lower level) require more professional remediation than do those at the higher level.22

For some physicians, their professional identity stems from a “calling.” For many others, it is a gradual acculturation process, involving clinical experience with patients and their families24 and time spent with respected teacher–role models and mentors. Role models are physicians who are “admired for their ways of being and acting as professionals.”25 Mentors are “experienced and trusted counselors,”26 affecting professional identity through close and prolonged contact with learners.27 Both role models and mentors generally exert their influence by modeling professionalism, spurring trainees to envision their professional future. While consciously observing, imitating, and practicing this behavior, trainees also absorb the knowledge these teachers have gained from experience.28, 29 At every stage, peers also exert influence through modeling behavior and formal and informal feedback. Although trainees will inevitably observe supervisors or peers that periodically model unprofessional behaviors, every practicing physician is powerfully affected by behaviors that they want to emulate.30

While multiple authors have proposed that professional identity formation be a major focus of medical education, at present, there is no generally recognized method to assess individuals’ progress in beginning to “think, act, and feel like a physician.”23, 24, 31 The purpose of asking clinicians to reflect on their professional identity (Tables 2 and 3) is to have them identify how their behavior, essentially professionalism, will enhance or prevent them reaching their goals. The additional benefit is that rather than being static, professional identity formation is an active, developmental process dynamic that dynamically evolves throughout physicians’ careers.32 While the proposed discussion format (Table 2) seems to focus on those at lower professional identification levels, it usefully reinforces the information and initiates career‐goal reflection for all recipients.

Lapses in Professional Behavior

Educators, trainees, practicing clinicians, and the public benefit from defining and publicizing specific elements of professionalism that accompany clinical competence. This helps trainees understand the accepted rules they must follow to successfully acculturate in their chosen career path and ensures public trust in the medical community.

The physician's social contract rests on the assumption that practitioners possess the qualities embodied in professionalism. This contract grants them unique (legal) access to restricted pharmaceuticals, high‐level decision‐making authority over patients (e.g., despite patient autonomy, clinicians generally decide how and when to perform invasive procedures), and permission to violate major societal norms (e.g., viewing and touching strangers). Failing to adhere to the elements of professionalism may void this contract and threaten a physician's career goals, since “professionalism lapses are viewed as acts of inappropriate behavior and reflect a lack of skill in negotiating conflict‐prone situations.”9 Ultimately, such lapses are “associated with poor adherence to practice guidelines, loss of patients, low staff morale and turnover, medical errors and adverse outcomes, and malpractice suits.”7 Papadakis et al.39 noted that the most common physician lapses in professional behavior relate to severe irresponsibility (e.g., lateness or absenteeism, unreliability), an unreliable working relationship (e.g., cheating, falsifying data, disrespecting other members of the team), resistance to self‐improvement (e.g., arrogance, defensiveness), and impaired relationships with patients and families. These professional lapses may occur when dealing with patients, colleagues, and society (e.g., health care facility, payers, and policy makers).9

The most egregious examples of unprofessional behavior are labeled “disruptive,” implying behavior that is overtly and even dramatically offensive, disrupting patient care, damaging interprofessional relationships, and demonstrating erroneous role modeling for trainees.33 Both Swiggart et al.34 and The Joint Commission35 have recognized that this behavior can be both overt (aggressive) and passive (passive‐aggressive) and is sometimes used to intimidate those with less power within the organization.36 The College of Physicians and Surgeons of Ontario describes disruptive behavior as instances “when the use of inappropriate words, actions or inactions by a physician interfere with his or her ability to function well with others to the extent that the behavior interferes with, or is likely to interfere with, quality health care delivery.” They go on to say that, while single events, such as assaulting a patient or colleague, may warrant the label, it usually defines a pattern of behavior that can include both verbal (insults, abusive language, outbursts of anger, inappropriate arguments) and nonverbal (refusal to comply with standards, failure to respond to calls, etc.) actions.37

Those most at risk for unprofessional behavior may gain the most if their medical schools, residency programs, and health care institutions provide didactic and counseling interventions. Studies suggest that unprofessional behaviors that occur during medical school and residency may predict future unprofessional behavior.38 Papadakis et al.39, 40 found that irresponsible or unprofessional behavior in medical school indicates a greater likelihood of later receiving state board disciplinary action. Brenner et al.41 found that the presence of any negative comments in the dean's letter from the resident's medical school of origin correlated significantly with future performance problems and also with state medical board disciplinary action. Multiple researchers have found that unprofessional behavior during medical school correlates with applicants’ California Psychological Inventory scores in the domains of irresponsibility, lack of self‐improvement, and poor initiative.40, 42 Unfortunately, although educators, administrators and medical boards believe that interventions are helpful in reducing later unprofessional behavior, no one has shown that to be true.

Professionalism: Teaching and Counseling

Lectures on professionalism routinely center on abstract topics, such as rule‐based admonitions or the virtue‐based elements of professional oaths and codes, which trainees may view as lacking testable and personally relevant information. The elements of virtue can be explained, but it is unclear how to imbue them in individuals except through role modeling. As Pellegrino43 described it, “The virtuous person is someone we can trust to act habitually in a ‘good’ way‐courageously, honestly, justly, wisely, and temperately. He is committed to being a good person and to the pursuit of perfection in his private, professional and communal life. He is someone who will act well even when there is no one to applaud, simply because to act otherwise is a violation of what it is to be a good person.”

Alternatively, speakers may detail process‐driven ethical activities, such as writing do‐not‐attempt‐resuscitation orders, interpreting advance directives, determining decision‐making capacity, and soliciting help from bioethics committees and consultants. While these are vital skills for working through ethical dilemmas, they relate to professionalism only insofar as clinical competence is an essential component.3 Because professionalism and professional identity have overlapping and mutually reinforcing elements, speakers can frame their discussions as ways to use positive attitudes and behavior to advance listeners’ personal and professional goals and to avoid the short‐ and long‐term consequences of unprofessional behavior.

Similarly, when supervisors must counsel individual clinicians about professional lapses such as obvious disruptive behavior (passive, passive‐aggressive, or aggressive) or subtler rule violations,34 discussing professionalism tangentially by way of professional identity may be one strategy to avoid the problems inherent in addressing the topic head‐on. Because candid discussions of behavior may devolve into accusations, making them uncomfortable and often unhelpful for both parties, it may be more beneficial to demonstrate how professional principles are consistent with the individual's personal attitudes, values, and goals. Table 2 provides an outline that can be used both to present the topic and to provide remediation using the concepts of professional identity to personalize professionalism for the recipients. In this remediation schema, first have the trainee or clinician explicitly identify their personal and professional goals. Then, discuss his or her unprofessional behaviors (controllable factors) in terms of how he or she may hinder achieving those goals. At that point, specific methods to alter negative behaviors are discussed, including formal psychological counseling, monitoring with periodic feedback, or individual study plans (e.g., reading professionalism literature, preparing professional development self‐reflection essays).44 If appropriate, the individual providing the remedial feedback can also suggest extreme consequences (e.g., probation at or expulsion from training, loss of institutional privileges, or reporting to the medical board) of continued adverse behavior.

One method to highlight the benefits that individuals accrue by adopting professionalism's core competency elements is to pose questions that optimize listeners’ self‐reflection about their lives and aspirations—in essence, their professional identity (Table 3). Asking clinicians and trainees to identify what drew them to their medical career, what they want to accomplish, and what they like about medicine—as well as the dangers that unprofessional conduct could have on their career—may be more compelling to audiences in educational and remedial professionalism discussions than emphasizing altruistic motives, abstract rules, and bioethics procedures.

In the first decade of this century, studies showed that many health care organizations failed to effectively deal with unprofessional, including disruptive, behavior among physicians, applying codes of conduct selectively, reporting only the most serious violations, and treating high‐value practitioners more leniently than others.36 This is no longer the case, and clinicians must recognize that successful, or even continued, careers rest on professional conduct. Institutional and state medical board actions against unprofessional physicians affect postgraduate training, career advancement, maintenance of clinical positions and privileges, and, ultimately, medical licensure. This is both the carrot and the stick when presenting information on professionalism. To engage the recipients of this information (trainees, clinicians), such talks could emphasize how adhering to the elements of professionalism may determine their career opportunities, the professional respect they receive, and their career fulfillment and, ultimately, longevity. Approached in this way, a talk assessing and reinforcing positive attitudes around professional behavior could perhaps be titled, “What do you want from your medical career?”

Conclusions

Those tasked with discussing professionalism with physicians, other health care professionals, and trainees may want to consider approaching the topic tangentially, through the lens of professional identity. Asking listeners to reflect on their own professional aspirations encourages them to consider professional principles in light of their own values and goals as well as the consequences of straying from the profession's norms. This approach can be applied in didactic, small‐group discussion and counseling sessions. By bringing the abstract concepts of professionalism into the realm of one's professional identity, listeners will have the opportunity to interpret the information within the boundaries of their own professional lives. In this way, educators can better guide trainees and clinicians to understand their personal reasons for acting professionally, that is, doing the right thing, at the right time, in the right way, and for the right reason.

AEM Education and Training 2019;3:105–112.