The Western approach to professionalism has its origin with Hippocrates in the 4th century, BCE. The Hippocratic Oath states a commitment to the best interests of the patient, honors the teachers and mentors of the medical profession, and speaks to the ethics and morals of the physician, in the context of medical practice. It addresses the importance of patient confidentiality and trust. This oath has guided our expectations of Western physicians’ ethical and moral behavior for over 2000 years. However, the specific relevance and application of the Hippocratic principles applied to modern issues (e.g., health information portability protection, medical euthanasia, organ recovery) are complex, and thus “code of professional conduct” committees have become commonplace in medical schools and hospitals, to review and enforce good clinical and professional conduct.

Starting in the mid-1900s, the tenets of professionalism became more society-norm based than individually focused. Modern society expects that the members of a profession be specifically trained, demonstrate competency, and have a mechanism to ensure maintenance of competency throughout medical practice. Most societies allow the profession to be largely selfregulating and develop professional guidelines for education, performance, and discipline. In exchange, society generally accords members of the profession high stature and respect.

Over time, changes in society and medical systems have led to concerns about the self-regulated medical profession, and specifically the behavior of individual members of the profession. External pressures from rising healthcare costs, the stress of changing mechanisms of physician documentation and reimbursement, and increased reliance on complex technology have affected perceptions of what constitutes appropriate professional behavior.

Guidelines and standards for most accreditation councils of graduate medical education require that professionalism be taught to residents and fellows (1,2). In the USA, standards for maintenance of certification (MOC) of the American Board of Pediatrics (ABP) require evidence of ongoing professional behavior in its diplomats (3). Other requirements for MOC in the USA include excellence in patient care, evidence of practicebased learning and improvement, evaluation of interpersonal and communication skills, demonstration of the understanding of the components of systems-based practice and satisfactory completion of the traditional standardized secure examination.

In 2003, the Institute of Medicine (IOM) (4) recommended that modern medical professionals should provide patient-centered
care, work in interdisciplinary teams, employ evidence-based principles, apply quality-improvement methodologies, and utilize informatics in the practice of medicine. These five noncognitive concepts were adapted by graduate medical training and oversight committees into five “core competencies”: patient care, practice-based learning and improvement, interpersonal communication skills, professionalism, and systems-based practice (1). The relationship between the core competencies and medical professionalism was addressed (5,6) in a summit of North American and European medical societies, resulting in a call to action. Ten elements of professionalism were chartered (Table 3.1) that guide the ethical principles of supporting patient welfare, patient autonomy, and social justice. However, a roadmap to reach the proposed optimal state of medical professionalism was not explicit in the charter. Concurrently, the Royal College of Paediatrics and Child Health (United Kingdom) (7) published a statement specific to the professional duties and responsibilities of pediatricians. The Royal College identified actions and behaviors that could cause loss of professional license registration. Specific examples of unacceptable behavior are provided, in each of eight major areas: (a) professional competence, (b) ensuring appropriate access to care, (c) maintenance of good medical practice, (d) teaching, training, appraising, and assessing, (e) relationships with patients (e.g., consent, confidentiality, trust, communication), (f) dealing with problems in professional practice (conduct and performance of colleagues, complaints, and malpractice insurance), (g) working with colleagues (treating colleagues fairly, working in and leading teams, arranging coverage, accepting appointments, sharing information, delegation and referral), and (h) “probity,” which deals with personal conflicts of interest including research, personal health, and financial interests (7).

The Competency-based Training programme in Intensive Care Medicine for Europe (CoBaTrICE) collaboration published a list of competencies expected of adult intensive care physicians that are based on consensus that was developed over a 3-year period. Professionalism was one of the 12 “domains,” weighted heavily in importance by the majority of the participants. Within the professionalism domain, CoBa-TrICE includes the following three competencies: (a) communication skills, (b) professional relationships with patients, relatives, and members of the health care team, and (c) “selfgovernance” (8). Surveys of trainees and of patients and their families confirmed the importance of maintaining these professionalism attributes throughout everyday practice (9,10).

Personal Attributes of the Medical Professional. These descriptions of professionalism place a great deal of emphasis on the outward (measurable or observable) conduct of the physician, but pay little attention to the intrinsic attributes that identify a physician as a true professional. The American Association of Medical Colleges (AAMC) has determined that the medical professional in today’s society should be knowledgeable, skillful, altruistic, and dutiful. To this end, the AAMC has encouraged schools of medicine to incorporate teaching of professional attitudes and behaviors into their curricula (11). Recommendations by others add qualities such as compassion, integrity, fidelity, and self-effacement as important in the “good” doctor (12). G. Luke Larkin, who writes about how to model and mentor students in professionalism, suggests that we first map virtues and vices in professional practice. He has identified “four valences” of professional behavior in the order of best to worst: ideal, desired, unacceptable, and egregious (13). For example, ideal behaviors would include showing altruism toward others and having humility regarding one’s own achievements. Desired behaviors would be acting in the best interest of the patient and arriving on time for work. On the negative side of the spectrum, unprofessional behaviors would include arriving late or breaching confidentiality, while egregious behaviors would include lying, falsifying medical records, and engaging in substance abuse.

Once we understand what actions, behaviors, and attributes are consistent with professionalism, the next question becomes: “How do we teach this?” The answer is both simple and complex. The most important aspect of learning to act as a professional appears to be having the appropriate role models (11,12

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