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CONTEXT Despite considerable advances in RESULTS The key precepts needed for a
the incorporation of professionalism into the robust presentation of professionalism can be
formal curriculum, medical students and resi- grouped under two headings: Professionalism
dents are too often presented with a mechani- as a trust-generating promise (representing
cal, unreflective version of the topic that fails commitment to patients interests, more than
to convey deeper ethical and humanistic aspi- a mere business, a social contract, a public
rations. Some misunderstandings of profes- and collective promise, and hard work), and
sionalism are exacerbated by commonly used Professionalism as application of virtue to
assessment tools that focus only on superfi- practice (based on virtue, deeper attitudes
cially observable behaviour and not on moral rather than mere behaviour, and requiring of
values and attitudes. practical wisdom).
METHODS Following a selective literature CONCLUSIONS These key precepts help stu-
review, we engaged in philosophical ethical dents to avoid many common, unreflective
analysis to identify the key precepts associated misunderstandings of professionalism, and
with professionalism that could best guide the guide faculty staff and students jointly to
development of an appropriately reflective address the deeper issues required for success-
curriculum. ful professional identity formation.
1
Institute for the Medical Humanities, University of Texas Medical Correspondence: Howard Brody, Institute for the Medical
Branch, Galveston, Texas, USA Humanities, University of Texas Medical Branch, 301 University
2
Department of Family Medicine, University of Texas Medical Boulevard, Galveston, Texas 77555-1311, USA.
Branch, Galveston, Texas, USA Tel: 00 1 409 772 9386/2376; E-mail: habrody@utmb.edu
3
Division of Medical Humanism and Ethics, Department of
Family and Geriatric Medicine, University of Louisville, Louisville,
Kentucky, USA
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Professionalism: a framework
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H Brody & D Doukas
Professionalism as a commitment to the interests of consulting the list.1,2,4,6,7 We suggest instilling in stu-
the patient dents the core of what professionalism is and then
helping them to see how the core logically gener-
Professionalism represents a commitment to placing ates the list. It is still helpful to share the list with
the interests of the patient ahead of those of the students, but ideally as a set of illustrations with
professional. which to expand the core precept.
Most definitions agree that the goal of the profes- Professionalism means that health care can never be
sional interaction is the benefit of the patient and merely a business
only secondarily the benefit of the physician.
(Although a technical term for this attribute is self- In a world in which all human relationships tend to
abnegation, we will use the more widely under- be recast as business arrangements, it is worth stat-
stood, if less precise, term altruism.21) Such a ing this key precept explicitly, even if it is merely a
claim may seem both self-evident and vacuous, but restatement of the first.24 If health care were pri-
it is actually quite pregnant with important issues marily a business, making a profit could be seen as
that students and residents need to discuss. its first principle, thereby contradicting the precept
that the good of the patient comes before the good
At what point, for example, do the professionals of the professional. Health care in todays world is
own interests have a legitimate claim in patient indeed a business: professionals are not indepen-
care? How much is the professional expected to dently wealthy, and someone must pay the rent and
sacrifice to benefit the patient? When do lifestyle keep the lights on. However, health care should
issues or moral commitments owed to other indi- never be viewed merely or primarily as a business. The
viduals supersede ones obligations to the patient? commercialisation and commodification of medi-
These are issues with which students and residents cine are among the most important threats to pro-
should grapple under faculty guidance and thus it fessionalism today,25 and students are immersed in
is helpful that this key precept stimulates such a world that views every aspect of human life as
questions. occurring in a marketplace.26,27 This aspect of pro-
fessionalism therefore deserves emphasis. For exam-
Placing the patients interests first entails a list of ple, Hafferty and Castellanis proposal that
related behaviours entrepreneurial professionalism and lifestyle pro-
fessionalism merely represent further recognition
Placing the patients interests first logically entails a of professionalisms complexities in todays world
list of related professional behaviours and obliga- requires a greater examination of their ethical foun-
tions. Contrary to the perception of the medical stu- dations and implications.14
dent described in the Introduction, definitions of
professionalism can also assume the form of lists Professionalism is derived from the verb to
of desirable behaviours.22 For example, many defini- profess, which means to promise
tions grant technical competence equal status with
giving priority to the patients interests.23 However, In a classic article, Pellegrino stated that the verb
when learners understand that professionalism in form was more informative than the noun.28 This
practice must be guided by the patients best inter- key precept relates the other precepts to the impor-
est, they readily see that this beneficence-based duty tant goal of public trust. Medicine requires public
requires the physician to be technically competent in trust, a concept that embraces the patients trust in
order to truly be able to serve. Similarly, the priority the individual practitioner. Patients will not give an
of the patients interests implies other professional honest, exhaustive medical history, or allow their
behaviours, such as respecting confidentiality, truth- bodies to be examined and probed, without this
fulness and shared decision making. trust, but without the information thus gleaned
from patients, practitioners will be helpless to com-
When professionalism is presented as a laundry list plete their tasks. Why should patients trust practitio-
of behaviours (whether positive or negative), stu- ners, including those they have never previously
dents equate the learning of professionalism with encountered? The answer this key precept offers is
the memorising of such a list, which implies that that health professionals have promised the commu-
whether a behaviour is professional or unprofes- nity at large to place the interests of the patient
sional can be determined by mechanically foremost.
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Professionalism: a framework
The promise suggested by to profess is both a A public, collective promise to dedicate oneself to
public and a collective promise putting the patients interests first suggests on
reflection that the physician has undertaken a very
Why should patients find this promise compelling? challenging task. Humans are probably pro-
What makes professionals worthy of the trust they grammed to be altruistic on occasions when, for
expect? In the end, professionals actual behaviour example, those with whom they feel close ties of
will establish their trustworthiness. Yet most patients kinship are threatened by physical danger. By con-
are nevertheless willing at least provisionally to trust trast, it is difficult to put someones interests ahead
practitioners. This trust is driven by the sense that of our own when we feel tired or threatened. It is
the promise made by practitioners to the commu- even harder to prioritise the interests of those with
nity is both public and collective. whom we feel no natural identity, and towards
whom we may even feel animosity. Yet the promise
Medical students best grasp this key precept when of professionalism requires that all such patients, in
they consider the ceremony at which a physicians all such circumstances, receive our best care, predi-
oath is sworn upon graduation. Firstly, the ceremony cated on our diligence in knowledge and skill acqui-
is public; the class does not retreat behind closed sition, our directed efforts towards the patients
doors to recite the oath. Secondly, swearing the oath benefit, and our public trust.30 Larson and Yao
is a collective action of the entire class; it is a promise make a similar point about empathy and point out
to the public and to each other. Individual students are that bringing ones deeper attitudes into congru-
not asked whether or not they wish to recite the oath, ence with surface behaviours requires considerable
or whether they would like to alter the wording to cre- emotional labour.31
ate their own versions. All participants take for
granted that the ceremony will lack meaning unless Admitting that keeping the promise of professional-
all students swear the same oath at the same time. ism is difficult accomplishes three critical pedagogic
tasks. Firstly, it establishes the importance of a pro-
The precept of a public, collective promise may be fessionalism curriculum and justifies time and
a challenging one to convey to students in a society energy devoted to the topic. Secondly, it takes the
so wedded to the ideal (or myth) of individualism. faculty member off the pedestal and opens up real
Students may initially resist the idea that they are dialogue with students as all reflect together upon
bound by a collective promise that they did not ways to deal with predictable challenges to profes-
individually negotiate. Reflection, however, will sional behaviour. Finally, understanding how hard
show them that if the promise is not both public professionalism is leads naturally to the next set of
and collective, patients will have little reason to key precepts that identify professionalism with vir-
trust a physician who happens to be on duty in the tue. Virtue comprises our positive aspirations for
emergency department and whom the patient has character that will achieve the goods of health care
never previously met. One pedagogic technique by translating our deeper values, attitudes and
that nicely bridges individualism with the precept beliefs into effective behaviours.
of the collective promise involves having students
write their own oaths or codes.29 The notion of a Professionalism as an implied contract between
public, collective promise leads directly to the fur- society and the profession
ther precept of professionalism as a social contract,
which we address below. Professionalism can be viewed as an implied con-
tract between society and the medical profession, in
Professionalism, properly understood, is hard work which mutual benefits are conferred, and which can
be renegotiated if conditions change.
A further problem with unreflective assessment
tools, in which professionalism is equated with the At first glance the sociological literature on the pro-
checking by faculty staff of boxes that refer to obser- fessions might appear to be distinct from an ethical
vable behaviours, is that they create the impression approach, as sociology attempts a descriptive
that meeting the minimum threshold is easy and account, whereas ethics addresses the ought rather
that only learners with serious ethical flaws will be than the is.14,32 The notion of a social contract,
deficient in professionalism. This undermines the however, provides an important meeting ground
important message that professionalism is an aspira- between sociological and ethical accounts. Cruess
tional goal which even the best physicians must and Cruess have reminded us that the idea of the
struggle to attain. social contract can usefully frame the way in which
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H Brody & D Doukas
professionalism is taught.18,33 For example, without tue perspective, students may wonder why they are
the social contract, students will be unable to under- being asked to adopt this seemingly idiosyncratic
stand the ethical importance and context of ade- approach when addressing professionalism.
quate physician self-regulation.
Students will best understand a virtue approach
The concept of the social contract reminds the stu- when they are reminded of how hard it is to keep
dent that trust involves a two-way relationship. Ide- ones public promise to put the interests of patients
ally, trust exists on the patients side and trust- first, as the maintenance of public trust requires. To
worthiness on the physicians. A dedication to profes- do this not only on good days, but also on bad days
sionalism, viewed as character, establishes the condi- when we are tired and irritable and no-one is watch-
tions for trustworthiness. ing, requires more than simple rules; it requires that
we devote ourselves to becoming certain sorts of persons.
Students often focus only on the dyadic nature of If students engage in honest reflection, they will
the physicianpatient relationship and need to be agree that little in their previous lives has taught
reminded of social context. This key precept them to be the sorts of persons who routinely put the
reminds students that the benefits conferred by soci- interests of others first, even if to do so requires
ety on physicians, which include a comfortable level some significant sacrifice. If students see that profes-
of income that is sufficient to pay off student loans, sionalism, properly understood, requires them to
are conditional upon societys belief that it is receiv- grow into the sorts of persons who not only engage
ing the hoped-for benefits from the profession. If in that hard work, but who do so willingly and
society decides that caregivers have strayed from the cheerfully, they then understand what character and
path of virtue and are no longer trustworthy, the virtue have to do with their education.3638
privileges and authority now granted to health pro-
fessionals may be withdrawn. Furthermore, if society Virtue is sometimes misunderstood because of a
makes it difficult for professionals to provide care focus on the listing of specific virtues, such as altru-
according to the appropriate ethical standards as ism, compassion and honesty, as if these, too, could
happened most dramatically in Nazi Germany the be understood separately and memorised as a list of
professionals ought to demand that the contract be desirable behaviours. We recommend instead focus-
renegotiated and may refuse to assume their ing on the core idea of virtue as it relates to lifelong
assigned social roles. character formation.
984 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 980987
Professionalism: a framework
in certain ways is never enough. Albeit that get- Being virtuous requires more than having incul-
ting trainees to behave in accord with a list of cated good values; it means having the practical wis-
professional attributes is a good way to start the dom to discern precisely how the virtuous
process of character development, it is not the professional should respond to any given concrete
intended moral destination. Making virtuous situation.41 As one aspect of good character, this
behaviour ones default requires that virtuous atti- practical wisdom is a skill that must be cultivated
tudes percolate deep into ones being. An ongo- over a lifetime.
ing challenge for evaluators is to use behavioural
measures of professionalism appropriately, with Students can understand these aspects of basic vir-
full awareness of their limitations, and not to tue ethics by reflecting on their own experiences.
employ them in ways that send the wrong message For example, Year 1 medical students struggle with
to students and residents. the basic skills of history taking and physical exami-
nation. They often ignore the patient while focusing
Cohen seems to advocate restricting the domain of on their memorised checklist of tasks. Yet they
professionalism solely to observable behaviour, rele- understand that, with further practice, they will be
gating deeper values and attitudes to the realm of able to perform a smooth, competent history and
humanism.24 However, Cohen immediately adds: physical examination, while also attending fully to
In the absence of humanistic grounding, profes- the patients words and feelings. Faculty staff can
sionalism lacks authenticity; it is a thin veneer. . .24 make an analogy between this experience and how
As Cohen clearly calls for both professionalism and the practitioners approach to the patient in a mor-
humanism as he defines them, we think it better to ally complex situation improves with practice.
require a professionalism curriculum that addresses
both observable behaviours and deeper attitudes, Even students who have had no experience with
and find in virtue the required integration among clinical mentors in school have probably encoun-
these concepts. Medical education must do more tered practitioners in their own and their familys
than teach to the test of expected behaviours, and lives, and have seen both positive and negative role
must also promote the cultivation of virtue as a life- models. Getting students to focus on their own
long quest in the face of numerous challenges.39 vision of the sort of practitioner they most wish to
resemble in their future career, and the sort of prac-
Virtue requires integrating a set of values, attitudes titioner they most wish to avoid becoming, allows
and behaviours them to reflect upon the importance of practical
mentoring in the development of the virtuous pro-
Virtue in professionalism requires integrating a set of fessional.
values, attitudes and behaviours into the core of ones
being, and applying practical wisdom to determine These key precepts about virtue help to immunise
how the virtuous professional would respond to a students to two common misuses of professional-
given clinical situation; this is the sort of wisdom one ism, which unfortunately feed cynicism rather than
ordinarily gains from observing trusted mentors. professional development.2 One misuse is that of
professionalism as a bludgeon, a term that refers
If professionalism is applied virtue ethics, and most to the use of professionalism as a threat or
students have not been introduced to virtue ethics, weapon with which to punish students who dont
a short course in virtue is required as a part of pro- follow the administrations rules. The other misuse
fessionalism education. This key precept represents involves reducing professionalism merely to a req-
the essentials that students must grasp. Being a vir- uisite competency that can be exhaustively evalu-
tuous professional requires doing the right thing ated solely according to a checklist of concrete
(whatever puts the patients interests first and fore- behaviours.1,7 Unfortunately, professionalism in
most) in the right way and with the right attitude, education must do double duty.42 A small number
and doing so consistently and reliably as an expres- of trainees will indeed behave in grossly unprofes-
sion of deeply formed character; it requires getting sional ways and must (according to the social con-
medical virtues like altruism right into the marrow tract) either be remediated or terminated for the
of ones moral bones. However, the virtuous physi- safety of the community. For this group, profes-
cian is more than altruistic; he or she also exempli- sionalism must serve as a minimal threshold of
fies those aspects of character that promote the acceptable behaviour. However, this message com-
patients best interests (such as compassion, perse- municates the wrong view of professionalism to
verance, integrity and practical wisdom).40 the much larger group that ideally will see
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H Brody & D Doukas
986 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 980987
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Nixon LL, Carrese JA, Shapiro JF, Green MJ, Kirch Received 29 January 2014; editorial comments to author 4
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