To become a medical professional is to have navigated a specified course of advanced education, prepared academically, and emerged with a longing to accept a career path in the pursuit of a higher purpose for the good of society and themselves. 1
Medical professionalism encompasses the proficiency, skills, competence, and effectiveness with which professionals conduct themselves in the practice of their chosen profession. Medicine is a challenging career, but the medical professional can not only survive, but excel throughout the years-long process of intense studying, late nights and early mornings, moments of uncertainty in life-or-death situations, “difficult” patients who may refuse or forget about their recommended treatment, and on-call nights where everything seems to go wrong. Indeed, it is challenging to be a physician. However, for most physicians, the satisfaction and joy associated with serving patients far outweigh the challenges that they face. Those who have demonstrated their ability as critical thinkers, appreciate the principles behind medical professionalism, and show self-awareness and the ability to grow from their failures and successes have a greater capacity to reap the benefits associated with being a physician.
Becoming a member of the medical profession is not a matter of passing milestones but of embodying the values, behaviors, and identity of a physician. Forming a professional identity requires, however, that you hone your skills as an observer and, even more significant, as an engaged, reflective person. Understanding and internalizing professionalism and reflecting on your role in the profession are not simple tasks. This book, read thoughtfully and with an open mind, will help you on your journey toward being a conscientious, professional physician.
Challenges of and to professionalism
Medical professionalism is challenging to define. If you search for a definition, you are sure to find a long list of impressive personal qualities, behaviors, and competencies that capture an inspirational—almost superhuman—ideal. Some definitions, such as those advanced in the Physician Charter of the Medical Professionalism Project, 2 present a detailed list of values, traits, and behaviors. These include adherence to high ethical and moral standards and demonstration of a continuing commitment to excellence. Others succinctly summarize the many discrete manifestations of professionalism by calling for “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection … for the benefit of the individual and community being served.” 3p226
All of these various definitions recognize that professionalism is “more than a demonstration of isolated competencies.” 3p227 Thinking holistically about professionalism not only changes how we understand its individual dimensions, but also acknowledges that professionalism is necessarily greater than the sum of these parts. One cannot overestimate the importance of this quality amidst the inherent uncertainty of so many situations that physicians must negotiate. Unquestionably, medical professionals have an obligation to look after their patients. The physician–patient bond is a fiduciary relationship in which patients must place their faith in the abilities and intentions of their physicians, and, in return, physicians must act in their patients’ best interests even at a cost to themselves. Yet, this exchange is often easier said than done.
You may encounter values and behaviors that conflict with the definition of professionalism and work against your own best efforts to maintain it. These discrepancies are known as the informal and the hidden curricula, and they can have a significant impact on your development:
• The informal curriculum covers exchanges of information and uncensored commentary of faculty, staff, and other colleagues that take place outside of the classroom, lab, or other formal academic settings, such as in the elevator, corridors, the lounge, cafeteria, or the on-call room. For instance, you may witness role models violating a patient’s confidentiality, making derisive comments about a patient’s race or ethnicity, making fun of a patient, or critiquing other colleagues.
• The hidden curriculum encompasses organizational policies, decisions, and customary practices that reveal a different political and values system at work than the one that is formally acknowledged. You may note that certain tenets of professionalism are valued over others, for example, prioritizing time spent completing paperwork over time spent with patients. 4 In some cases, professionalism may be interpreted as loyalty to the academic hierarchy as opposed to a promise to society. In such a scenario, “covering up minor mistakes is far more likely to be evaluated as ‘professional’ than will other avowed professional values such as honesty and respect for patients.” 4p1011
Institutions may inadvertently reveal the value they place on professionalism in their handling of (or failure to handle) lapses in it. When institutions have systems in place to effectively work through infractions, complaints are more likely to be lodged, and difficult situations dealt with to the satisfaction of all involved. When few, or none, of these systems are in place, the message is clear: you report at the peril of yourself and your colleagues, so it might be best to remain silent. However, silence causes small offenses to fall by the wayside, often causing serial offenders to become so entrenched in their wrongdoing that—by the time the administration is forced to act—there is no way to remediate their behavior adequately.
The hidden curriculum also pervades institutional identity in less obvious ways. The choices that medical schools make in selecting their curriculum, shaping their promotional materials, establishing evaluation methods, allocating their budget, and discussing their programming also suggest their priorities. 5p15 These decisions do not necessarily indicate nefarious motivations, but show an institutional opacity that contrasts with the transparent ideals of professionalism as currently defined.
Challenges to professionalism are certainly not limited to the training arena. It’s not surprising that part of the current focus on physician professionalism in the educational environment came about, in part, because of increased public scrutiny of the profession. Medical professionalism hasn’t necessarily deteriorated since the mid-20th century, but media of all kinds have brought infractions to the public’s attention. Although the cases that have gained the most media attention are far from representative, their sensational status has elevated their importance. In one, a man who discovered that his phone had accidentally recorded his colonoscopy found that his operating team had insulted him while he was unconscious and that his anesthesiologist had described his diagnosis as “a shot in the dark.” 6 Clearly, incidents of this type are devastating for a society’s trust in the benevolence and empathy of its physicians. Medicine’s regulating bodies take swift action to prevent similar incidents from occurring and restore confidence in the profession, but often once it has happened, harm cannot be rectified.
Structural aspects of today’s healthcare system are also prone to scrutiny. Media reports of healthcare costs and negative outcome rates have led the medical community to undertake further self-examination. If action is not rapid enough (or where even physicians cannot effect much change, such as in matters of insurance or hospital pricing), other players become involved. Outside of the realm of state and federal governments, regulating committees such as the American Medical Association and state medical licensing boards are allowed to decide on the proper code of conduct for physicians as well as which physicians are qualified to practice. When the public becomes displeased with the performance of the medical profession, the government often is called on to act to protect the common good. Although they may have good intentions, legislators and executives rarely have any experience in providing healthcare, patient care, insurance claims, or undergoing the process of maintenance of certification and continuing medical education.
As one example, administrators and policymakers are more involved in healthcare decision-making than ever before. These decision makers are often distanced from the impact and repercussions of their decisions, as many of us have observed during the COVID-19 pandemic. For example, decisions on how to ration personal protective equipment, allocation of hospital bed space to sick patients, and uncertainty around hospital policies regarding physicians who become ill are often made at a corporate level with limited physician input. At the same time, clinicians responded with exemplary medical professionalism even during a time of great uncertainty. Physicians often need to weigh the pros and cons of focusing on self-care versus their obligation to society, a concept that we discuss in more detail in Chapter 3 of this volume. Further thoughts on the physician’s role as an employee will be provided in Chapter 16 of this volume.
For better or for worse, medicine has been continuing to move in the direction of the separation of the roles of clinician and financial decision maker. It is important to understand that there will always be political, economic, and managerial factors that influence the provision of care. To do best by their patients and themselves, medical professionals must make sure their voices rise as decisions get made about the future of healthcare. This kind of engagement is equally important in maintaining physicians’ powers of self-governance: one of the essential tenets of professionalism. For quality improvement measures and medical processes to continue to be in the hands of those with the most experience, physicians must fastidiously maintain exemplary professionalism.
The commitment to maintain professionalism, amid a variety of pressures and challenges, has made its way down the medical hierarchy and into medical schools. There is an ongoing effort to devise better methods for imparting the fundamental tenets of medicine to future physicians, as well as a continuing struggle to determine when students have achieved mastery. Recent studies suggest that lapses in student professionalism in medical school correlate with future infractions associated with disciplinary action. For instance, one study led by Papadakis and colleagues shows that “twice as high a proportion of disciplined physicians as of control physicians demonstrated unprofessional behavior in medical school.” 7p2676 What can medical schools do to better prepare graduates and help prevent future disciplinary actions from occurring? One option is to incorporate professionalism into the curriculum and work with students who have lapsed to remediate and hopefully improve their behavior. Many medical schools are beginning to utilize both of these strategies.
Another option that is gaining traction with medical schools to improve the professionalism of their graduates is to strike at the root of the problem: the medical school application process. They have tried to select for moral maturity and other traits that indicate a predisposition for professional behavior. 8 While grade point average and Medical College Admission Test scores are strong indicators of a student’s potential for success in medical school, admission officers have long recognized that these two numbers don’t tell the entire story. Personal statements and interviews can give medical schools an idea of an applicant’s ability to reflect on past events and demonstrate an understanding of issues affecting the profession and society as a whole, as well as his or her proficiency in communication and introspection. Although these characteristics are by themselves crucial components of professionalism, some admissions offices have sought to standardize this process through a different method: the multiple mini-interview (MMI). 9
The MMI requires applicants to complete several short interactions at separate stations, each of which is assessed by a different reviewer. Some of these interactions are similar to those an applicant might confront in a traditional interview, such as questions about their motivation to pursue medicine or about ethical issues (e.g., “Should placebos be given to patients?”). Others may test an applicant’s critical thinking under pressure (e.g., “Is it reasonable to believe aspartame causes multiple sclerosis?”) or ability to engage with a hypothetical situation (e.g., a coworker refuses to fly to a conference because of past trauma). 10 This flexible interviewing model allows reviewers to assess communication skills in a more practical way, such as through a scenario with an actor playing the role of a disgruntled patient or a small group project in which applicants must complete a task together. 8 One of the more significant advantages of the MMI is that it enables reviewers to measure an applicant’s spontaneity and ability to adapt to unexpected scenarios in a high-stress environment. As such, the MMI aims to approximate the pressures that applicants may encounter in medical school and later in the profession.
Professional identity formation
While the movement toward MMI offers one promising approach to gauge an individual applicant’s critical thinking ability and interpersonal skills, it does not address the myriad of topics covered in a comprehensive professionalization program. This book assumes that all students can benefit from a curriculum that builds on their self-awareness and socialization as these develop during their undergraduate years, forging connections between the curriculum and experiential learning, the individual, and the broader community. This process is called professional identity formation (PIF). 11
Professionalization, as a process of identity formation, has not always been the norm in the field of medical education. In a recent article that portrays current pedagogical controversies and the curriculum and assessment of the frameworks focusing on medical professionalism, Irby and Hamstra discuss PIF as a framework in relationship to two earlier professionalization frameworks: the virtue-based approach and the behavior-based approach. 12 The virtue-based sense of professionalism emphasizes the personal qualities, beliefs, and character traits of exemplary physicians. “Internal habits of the heart” 11p1607 not only testify to the moral and ethical compass of the individual physician but also inform current professional guidelines, such as those that govern ethical confidentiality and clinical best practices such as effective doctor–patient communication.
Not surprisingly, as Irby and Hamstra note, 12 virtue is quite challenging to assess. For this reason, medical educators developed a second model that identifies measurable proxies for these values. This behavior-based model identifies discrete, carefully delineated, and progressive sets of behaviors that manifest a student’s growth into a competent, ethical, and caring physician. In other words, the model seeks to identify what a physician does as a measure of what he or she believes, thinks, and feels. We can easily see the influence of these models in current definitions of professionalism. The behavior-based model is still the dominant framework in medical education. 11p1607
However, the behavior-based model is imperfect, because it runs the risk of minimizing the complexity and nuance of professionalism by reducing it to a checklist of traits and standard operating procedures. Medical professionalism necessarily transcends such lists and uniform characteristics. 12 Instead, it ought to be “the motivational force—the belief system—that leads clinicians to come together, in groups and often occupational divides, to create and keep shared promises.” 13p713 A sense of accountability and self-regulation at the level of the community is crucial to maintaining trust, especially as new policies, regulations, and technologies reshape the healthcare field.
This need for a broader belief system that can reinforce accountability and self-regulation has prompted recent interest in PIF. Professional identity can be interpreted as a “representation of self, achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalized,” 11p1447 and its formation, in medical school and beyond, is paramount to a physician’s professionalism amidst challenging circumstances. To be clear, PIF does not eschew teaching and assessing values and behaviors; instead, it makes these values and behaviors more relevant by embedding them in a framework that “socialize[s] learners into thinking, feeling, and acting like a physician” through “participation in a community of practice.” 12p1608 If we developed a shorthand description of the three frameworks, we might think of the virtue-based context as one that emphasizes knowing; the behavior-based, doing; and PIF, being. 11p1448
In its mission of promoting a state of being, PIF draws upon many of the same pedagogical methods that shaped earlier curriculum strategies, including facilitated discussions, case studies in ethics, reflective writing, and role modeling. 12p1609 PIF departs from earlier methods in foregrounding positive role modeling as a means of affecting socialization. Group work, dialogue, feedback, and coaching play are also instrumental in fostering a spirit of communal growth. Students themselves must be active participants in this process, and the PIF framework presumes an “aspirational” stance concerning professional identity. 12p1609 In this vein, PIF offers a refreshing departure from predominantly achievement-based assessment approaches. While these types of assessments are certainly here to stay, they do little to indicate progress in developing professional identity. PIF is not a matter of memorization and regurgitation: it requires receptivity, a spirit of anticipation, and an openness to change.
The theory of PIF acknowledges that internalizing a belief system does not occur overnight, but is, in fact, a lifelong process. Our understanding of this process has been shaped by the influential work of Cruess, Cruess, and Steinert, 14 who themselves drew from work by Piaget and Inhelder, Kohlberg, Erikson, Kegan, Marcia, and others in the field of developmental psychology. Erikson states that, generally, identity formation is the primary psychological process that happens during adolescence. 15 According to this model, people construct their identity in adolescence as they deal with a crisis between identity and role confusion. Marcia expands this model by defining four different statuses in which adolescents occupy according to their progress in the process of identity formation: identity diffusion, identity foreclosure, identity moratorium, and identity achievement. 16
The concept of identity formation within the medical profession draws heavily upon the theories of Robert Kegan. He described the evolution of professional identity in terms of movement across a set of stages, some of which an individual might never reach. 17 At the early stage of the instrumental mind, individuals express a more limited view of their environment and exhibit a strong desire for external validation. As they progress, individuals attain a more socialized status in which they demonstrate an awareness of the expectations of the group to which they aspire to belong and attempt to meet these expectations. Developing still further, they may reach the self-authoring mind stage in which they can examine the values of their communities with a more critical eye and begin to form a sense of their unique persona within an organization. The final (and most elusive) stage, the self-transforming mind, describes those highly evolved individuals who draw upon and intersect a variety of frameworks for understanding the world while remaining aware of the limitations of these structures; they are further able to manage complex and contradictory information without disorientation.
Table 1.1 Kegan’s Stages: The Four Broad Levels of Mental Complexity Relevant to Professional Medical Education
The Instrumental Mind a
This stage is characterized by external definitions of self, a predominance of either-or thinking, limited perspective-taking ability, and an emphasis on the mastery of technical skills. This stage is characteristic of adolescence and early adulthood.
This stage involves increase ability to have perspective, to learn organizational norms from others, and to emphasize mastery beyond technical skills.
The Socialized Mind
This stage is characterized by increased social perspective-taking ability among allies or one’s in-group members. Understanding and expectations of the professional role is externalized, shaped by interpersonal relationships, observing others, and following the norms and status quo within organizations without question. Some adolescents and most adults are in this stage.
This stage is characterized by a greater understanding of one’s self in the professional role and greater awareness of choices in dealing with influences that work against a professional’s integrity.
The Self-authoring mind
This stage involves the ability to step back enough from the social environment to generate a seat of judgment or personal authority that evaluates and makes choices about external expectations. The independence of judgment and problem-solving abilities of stage 4 translates to greater fidelity to one’s sense of self within the professional role. At stage 4, one can discern negative social influences that can erode one’s professional identity and integrity. Effectiveness within high-level professional or leadership roles requires stage 4 capacities.
This stage one can understand and reconcile multiple contradictory ways of thinking and being.
The Self-Transforming Mind
This stage is characterized by the ability to examine one’s self-authored personal authority, recognize the limits of any one system of constructing meaning, and seek out novel or alternative systems. A recognition of the interdependencies of different system or ways of being and an ability to reconcile contradictory or seemingly paradoxical ways of constructing meaning is a hallmark of the emergence.
a Stage 1 is qualified as childhood.
From A. Kalet, L. Buckvar-Keltz, V. Harnik, V. Monson, S. Hubbard, R. Crowe, H.S. Song, and S. Yingling, “Measuring Professional Identity Formation Early in Medical School, Med Teach 39, no. 3 (2017): 256, reprinted by permission of the publisher (Taylor & Francis Ltd. http://www.tandfonline.com).
The students were asked to complete a professional identity essay to measure their progression against Kegan’s model of identity evolution. These questions addressed the medical profession and their place in the community, such as “What does being a member of the medical profession mean to you?” and “What would be the worst thing for you if you failed to live up to the expectations of your patients?” They further completed the Defining Issues Test that evaluated their inclinations in responding to moral problems. 18p256 They discovered that more than half of the students were at the instrumental or socialized stages, only a very small percentage had reached the self-authoring stage, and no students had attained self-transformational status. 18p258 This might seem disheartening at first glance, but it confirms students’ malleability even at the graduate level and validates the project of addressing identity formation much earlier in a student’s development. Students are likely be in the instrumental or socialized stages. This is not only understandable but also expected. According to Kegan’s stages of professional development, perfection is not the goal, nor is it expected.
Another useful model to use when thinking about the process of PIF is Miller’s pyramid. It was originally postulated in 1990 and recently amended by Cruess, Cruess, and Steinert as illustrated in Figure 1.1 . 19
In the medical profession, Miller’s pyramid has had a lasting impact in shaping how we assess physicians and physicians in training. In its original formulation, there are four levels (Knows, Knows How, Shows How, and Does) through which medical professionals move as they develop their professional identity. At the lowest level, Knows, the physician is building the foundational knowledge base necessary to be a professional, which ranges from basic anatomy to epidemiology to ethics. At the Knows How level, the physician takes that knowledge and develops an understanding of how to use it. For example, given a list of patient symptoms, the medical professional can make a diagnosis and suggest an appropriate treatment. At the Shows How level, physicians can put their understanding into action. At this point, they can integrate their knowledge and skills to deliver successful care in the clinic. You may think that this is the final goal, but in fact, the Does level is the ultimate objective wherein physicians function independently to deliver a high standard of care.
The 1990 Miller’s pyramid measures medical competency as a set of standards to reach and master, but evolving definitions of medical professionalism include the concepts of a never-ending process of professional identity formation. 20 Cruess and colleagues suggested adding a new level to the apex of the 1990 Miller’s pyramid, titled Is. 19p181 At the peak of the pyramid, physicians have internalized how to think, act, and feel like a physician and now organically display this newfound evolving identity. At the Is level, physicians not only exhibit the professionalism and clinical skills of the Does level but live it.
Although assessment of the success of PIF involves categorizing a student’s progress through these different levels of development, it is not meant to assess the basic foundational knowledge necessary to ensure that medical learners can proceed to the next stage in their education. At this time, assessment of competency in foundational knowledge is best achieved through the framework of competency-based education (CBE). CBE seeks to ensure that students master specific proficiencies and skills. In many instances, however, the rigors of CBE often ignore the unique identities that medical professionals bring to the healthcare system. Diversity (whether of race, ethnicity, age, ability, gender, sexual orientation, religion, geography, language, or socioeconomic status) is valued within the profession, because it contributes to societal equality and adds to the mission of providing healthcare to a diverse populace (see Chapter 7 of this volume). The governing philosophy of PIF supports this mission in prompting medical professionals to reflect on the individual identities they bring to the profession and imagine how they meld with others as they advance through their training. This identity formation process is necessarily messy and requires students to venture into uncharted and, at times, uncomfortable terrain as they negotiate the parts of their identities that don’t readily fit into this new framework. PIF is, nonetheless, a crucial part of the process of professionalization and serves to create a distinct range of experience from which the medical professional can draw for a lifetime.
The road ahead
In October 2017, the World Medical Association, an international confederation of more than 10 million physicians from 114 nations, unanimously voted to revise the Geneva Declaration, a modern successor to the Hippocratic Oath, to include the clause, “I will attend to my own health, well-being, and abilities in order to provide care of the highest standard.” As the practice of medicine enters the modern era, a combination of disruptive factors, including the increased use of electronic health records and changes to the U.S. healthcare system, have left physicians struggling to find happiness in their careers. While systemic changes are necessary, doctors are beginning to realize that they have also neglected self-care, a crucial aspect of medical professionalism. This neglect may be contributing to alarming rates of physician burnout, depression, and suicide.
The reflective process and its life-long value is discussed in Chapter 2 of this volume. Each of the subsequent chapters frames the values of medical professionalism by describing a unique facet of the profession, and provides strategies for the reader to consider and reflect on their personal beliefs and explore their current and future role in the profession (see Chapter 16 ).
One of the main goals of the book is to inform future physicians and current practitioners that being a medical professional is not about being perfect, but rather about being human and recognizing their own limitations (see Chapter 3 ). Learners can manage their expectations about the profession while becoming more resilient to disruptions in the medical field such as artificial intelligence (see Chapter 4 ) and the changing patient–doctor relationship (see Chapter 5 ).
The Flexner Report, published in 1910, has often been noted to be instrumental in the transformation of medical education both positive and negative. It helped set admission and graduation standards to pass specific knowledge and attitudes surrounding medicine from physicians to students. However, currently, trainees are expected to rely on the example of professors and close mentors to develop their professional identity in what is referred to as the hidden curriculum. Although largely successful, this tradition has proven insufficient and, in many instances, unreliable, because the success of many medical students and residents still depends on their ability to “catch on” to informal aspects of training. Due to this educational gap and lack of support, students, residents, and physicians may encounter issues during medical practice, including boundary violations (see Chapter 5 ), declines in empathy (see Chapter 6 ), physician burnout (see Chapter 10 ), depression and suicide (see Chapter 11 ) and substance use disorder (see Chapter 12 ). It is also important to note that the Flexner Report, which caused the closing of all but two historically Black medical schools, in addition with other systemic forces, have arguably contributed to discriminatory practices in the field of medicine, leading to a need for cultural praxis and social justice (see Chapter 7 ).
Medical professionals must also understand the importance of team-based care (see Chapter 8 ); the impact of religion, spirituality, and humanism in healthcare (see Chapter 13 ); and the concerns that have arisen due to the aging physician workforce (see Chapter 15 ). Financial planning is another aspect of medical education that has long been neglected (see Chapter 14 ), as has been the value of preventative care and addressing chronic diseases through the evidence-based emerging field of lifestyle medicine (see Chapter 9 ).
This book is intended to serve as a guide for physicians as they develop their professional identity by encouraging them to reflect on who they are and who they want to become. In particular, the book’s emphasis is on how and why physicians ought to focus on self-care, happiness, and well-being as they advance through the process of socialization into the medical community of practice.
Chapter Quick Summary
• Medical professionalism is more than demonstration of individual competencies; it includes embodying the values, behaviors, and identity of a physician through a process of professional identity formation.
• Observation and the reflective process are key skills in forming a professional identity.
• The challenges of professionalism in the current institutional organization renew demands on physicians to fastidiously maintain exemplary professionalism.
• Encountering values and behaviors that conflict with the definition of professionalism can work against physicians’ best efforts. A discussion on the informal and hidden curricula and how they can have a significant impact on professional development can address this problem.
• All learners can benefit from a curriculum that scaffolds their self-awareness and socialization, forging connections between the curriculum and experiential learning, the individual, and the broader community.
• PIF broadens the scope of study for medical learners independent of the rigors of CBE strategies.
• This book is intended to serve as a guide for physicians as they develop their professional identity by encouraging them to reflect on who they are and who they want to become.
• This book focuses on the values of self-care and happiness and their importance for physicians.
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