Friday, January 2, 2015

Can you define "professionalism"?

A while ago, I wrote about a medical student whose school tried to dismiss him just prior to graduation for unprofessional behavior.

A judge ruled that the school could not do so because it had tolerated some similar behavior earlier in his medical school career and had not considered it important enough to mention in his letters of recommendation.

In that post, I said, "'Professionalism' is difficult to define, especially when trying to do so in a courtroom."

In the comments section, a medical student wrote that he had been given a two-week suspension for unprofessional behavior for silencing his phone during an exam.

Another commenter told of several students who were caught colluding on a take-home final exam in statistics. Their punishment was that they had to agree to do their residencies at the medical school. [Digression: What does that say about the school?]

The Accreditation Council for Graduate Medical Education defines professionalism, one of its six core competencies, as follows:

"Professionalism—Demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles."

I'm always a bit confused when the definition of a term contains the term itself, and this is no exception.

Three internal medicine foundations combined to publish a somewhat clearer definition that is two pages long, but does not mention specific behaviors like cheating on a test, falsifying a medical record, or being arrested for driving under the influence of alcohol.

The American Board of Internal Medicine Foundation produced this "Word Cloud," which is supposed to help one better understand what professionalism is. But all it did was remind me why I hate word clouds.

It is said to depict "words physicians most associate with medical professionalism."

If you are having trouble reading some of them, I can help. Here are a few: "empathize, compassion, respect, responsibility, ethics, integrity, caring, honor."

Those sound pretty good, but here are some more: "tougher, smoker, diet, sick, job, prevent, financial, good insurance, disease, death." What do those words have to do with medical professionalism?

Since we have trouble defining professionalism, we can hardly blame the judge in the case I wrote about before for ruling in the student's favor.

He said, "Although courts should give almost complete deference to university judgments regarding academic issues, the same deference does not follow university character judgments, especially on character judgments only distantly related to medical education."

I disagree with the last part of his statement. I think character judgments are strongly related to medical education, but how are medical schools and residency programs supposed to teach professionalism and assess whether their trainees possess it, if it is so ill-defined?


Anonymous said...

Pornography is equally hard to define it, but you can recognize it when you see it. Professionalism is similar in an inverted way, hard to define, but you can recognize its absence.

Skeptical Scalpel said...

Maybe, but some of the things I mentioned are debatable.

artiger said...

If you have to ask what professionalism is, you probably won't understand the answer.

Skeptical Scalpel said...

The problem is that if you are going to discipline someone for unprofessional behavior, you will have to define it when the target of your discipline inevitably takes you to court. Saying you know it when you see it simply will not do.

DrWes said...

Dear Skeptical Scalpel:

Clearly the reason you have not been able to define "medical professionalism" is because you did not create a Foundation to do so and purchase a $2.3 million condominium complete with a chauffer-driven Mercedes S-class town car to promote your cause. This, sir, is the epitome of professionalism, especially when you use your colleagues' board certification testing fees to do so.

Now, can we move on?

Anonymous said...

I'm not sure you can define professionalism. Its going to be up to the judges. In that case, you would want to ask: is this behavior that is going to enhance the profession of medicine, or is it going to chase patients, other health care personnel, away? Is it something that we could put on the front page of the news and people agree as a whole this enhances the reputation of the doctor?

Skeptical Scalpel said...

DrWes, you have certainly defined a new aspect of professionalism. Interesting that the people from the ABIM who tried to define it don't practice it.

Anon, the problem with your definition is that it has to be applied after the fact. I'm looking for clear cut guidelines that you can tell a student BEFORE an act occurs.

JediPD said...

Clearly the term is bedded with the "Conforming Principle" of compliance without hesitation with all guidelines and mandates. The proponents of the terms as Dr. Wes points out, seem to suggest through Doublespeak (Animal Farm) form "All Animals are equal. But some animals are more equal than others."
Thus Professionalism is a "Control" mechanism at its root!

Michael G. Katz, M.D. said...

I'm not sure I can define what "professionalism" means... but I suppose it probably is related to "being a professional."

My understanding is that a Profession (as opposed to a Trade, Guild, Association, Cartel, etc), has a social contract: members of a Profession are allowed special rights, privileges, and recognition. (They can even do taboo things like see people naked, or cut into them.) In return for this special status, Professionals must regulate themselves according to additional rules, regulations, and laws beyond what is already required by the state...

So, in essence, this necessitates a professional code. Hence the code that differentiated the Hippocratic practice from that of the Asclepians. No matter what you think of the Hippocratic Oath, it's explicit and clear nature has to be commended... pretty good language for something that's 2,400 years old.

I challenge the AMA/FSMB/ABMS to come up with something that clear and enduring.

Skeptical Scalpel said...

Jedi and Mike, thanks for commenting. It's like the blind men and the elephant. What part you touch seems to determine how you define it.

Vamsi Aribindi said...

I actually sit on my school's student ethics committee, and I think our professional behavior code is pretty good. It's on ~page 50 at this link, relevant section copy-pasted below

The students of the Keck School of Medicine of USC, in order that our activities reflect the high standards of moral character demanded by the medical profession, do subscribe to the following CODE OF PROFESSIONAL BEHAVIOR:

Honesty and Integrity:
 We will conduct ourselves with the highest degree of integrity and honesty.
 We will truthfully conduct our research and report our research findings, and will not represent others’ work or
ideas as our own.
 We will not seek, by action or implication, oral or otherwise, to create an incorrect impression of our abilities or to create an unfair advantage over our colleagues.
 We will not tolerate or support unethical behavior in ourselves or in our colleagues and will report such behavior when it occurs through established procedures as detailed in the Student Handbook.

Responsibility, Reliability, and Accountability:

 We accept our professional responsibility to be punctual and to respect the time and effort of others.
 We hold ourselves accountable to policies and procedures of the school and its associated clinical sites including, but not limited to, evaluations, charting, and documentation requirements.
 We will respond in a timely manner to all official KSOM communication.
 We recognize our own personal limitations and will seek help when needed. We will not assume responsibilities
beyond our capabilities.
 We will represent the Keck School of Medicine of USC appropriately in all relevant settings including all forms
of electronic communication.

Respect for others (students, colleagues, faculty, staff, patients):
 We will treat others with respect and honor their dignity.
 We will not discriminate nor tolerate discrimination based on race, ethnicity, language, religion, gender, sexual
orientation, age, disability, disease, or socioeconomic status.
 We will respect the confidentiality of our patients at all times.
 We recognize the importance of team work and will work respectfully in collaboration with others.
 We will demonstrate respect for our patients and colleagues by maintaining an appearance that is appropriate to
learning and patient care.

Vamsi Aribindi said...

There are also 22 examples of professional expectations (don't wear a long white coat, don't forge an MD signature even if asked, don't cut and paste, don't do a procedure without authorization, etc.) in the original text, but it's a bit large to copy-paste.

Skeptical Scalpel said...

Vamsi, thanks very much. It's a really detailed policy. Is it maybe too detailed? Rules that attempt to cover every possible occurrence never really do. Does that "cut and paste" rule apply only to research? What about cutting and pasting in progress notes?

Vamsi Aribindi said...

Sorry, the cut-and-paste rule applies applies mainly to humanities and essay assignments- mainly in the first two years but we occasionally get 1 per six-week rotation during clinicals. Of course, you are also expected to not cut and paste a research presentation without attribution. Cutting and pasting in progress notes is done all the time- but we get a couple of lectures about it and I think we're pretty good about not abusing the ability. Cut, paste, and update is what we're taught.

There is also a catch-all with our code that apparently didn't get copy-pasted: "Specific violations of the KSOM Code of Professional Behavior include but are not limited to the following examples. It is not just the letter, but also the spirit of the Code of Professional Behavior that is to be upheld by students."

That said, we're actually considering adding on another coda about professional behavior in research activities, after some recent conflicts between students over authorships on papers (a few PIs told their students "decide amongst yourselves who will be 1st/2nd/3rd author". Chaos ensued).

In terms of the broader detail vs. not-detailed, I think there are areas which benefit from clarity, and areas which don't need as much of it. Don't steal is obvious. What about "don't start a research project without an understanding of who's going to do what and get an authorship"? Don't tell anyone you're a doctor is straightforward. But long white coats? Many students own white lab coats, any many non-doctors wear them around the hospital. But a medical student wearing one is considered unprofessional- something which might not be obvious to all students- especially ones without a family background in/awareness of the profession of medicine. And of course, one person's unprofessional conduct is another person's noble civil action- for example getting arrested while protesting anything.

WhiteCoat said...

Those making the smug comments that "professionalism" should be apparent on its face are uninformed and sadly mistaken.
I've been involved in cases in which a doctor was labeled as "unprofessional" because he ordered too many tests and slowed down patient flow. Another physician got into an argument with the hospital administrator and shortly afterwards was brought up on ethics charges and had to defend himself from the administrator's charges of "unprofessionalism" when it was the administrator who was being unprofessional. Yet another surgeon was labeled as "unprofessional" for refusing to follow the preoperative recommendations of other surgeons at the hospital ... which would have resulted in the patient's death had he actually followed their advice.
In each case, the physician accused of "unprofessional" actions had to hire an attorney to defend himself from frivolous accusations. In one case, the physician's contract was terminated, in the second case, the physician spent $50,000 defending baseless accusations, and in the third case, the physician was reported to the National Practitioner Databank for saving a patient's life in an "unprofessional" way.
The vague definition of the term "professionalism" can be used on a whim to unjustly decimate a physician's career (which took years of hard work and hundreds of thousands of dollars in loans to build). And the best that some of these shallow comments can come up with is "you know it when you see it" and "you probably won't understand the answer"? You're probably the same people who whine about getting less than perfect medical care and who moan about how much medical care costs.
In the future, maybe you should stop being so unprofessional and should learn about the consequences of your proposals before running your yap.

artiger said...

WhiteCoat, simmer down. My comment was directed not at the accused, but at the accusers, in the examples you stated. The accused probably didn't have to ask the questions. Furthermore, they shouldn't have needed to. Professionalism is like manners.

I certainly don't while about getting less than perfect medical care, I deliver less than perfect care; and if I moan about how much it costs I'd better not look in the mirror too much.

Skeptical Scalpel said...

Thanks for the spirited discussion. I think some items on the Keck-USC list are not exactly about professionalism. Deciding about who is going to be an author before a project is started is great advice, but I'm not sure it's a professionalism issue.

Vamsi Aribindi said...

True, but I believe the intent with clauses like those is to avoid giving rise to situations where unprofessional conduct can occur- I don't want to state details, as I was involved in adjudicating these cases, but worse things happened because of that failure to clarify things at the outset(and the failure of the PI to settle things firmly). It's like the clause that states that fraternizing with a felon is unprofessional conduct for a police officer- by itself, that act shouldn't be a problem, but it can lead to far worse situations when that officer's felon friend asks for a break. Same as the long white coat- its not what you are wearing, but what other people take from it and the situations it can lead to.

I am also reminded now of a blog post on a rad-onc's suicide in Southern Illinois after diagnosing Ogilvie's syndrome in a patient considered to be terminally ill. As I recall, his conduct was labeled unprofessional by his peers for 'presenting himself as an hero to the patient's family', despite the fact that he saved the patient's life. I suppose it goes to show how difficult it is to draw the line.

Skeptical Scalpel said...

Good points. I assume you are talking about my post that described the events around that radiation onc MD's death. Tragic case.

artiger said...

Scalpel, when was that post about the rad onc? I couldn't remember.

Skeptical Scalpel said...

It was in December of 2011. Here's the link.

pamchenko said...

I could never remember the difference between ethical or moral. Now adding this word "professionalism" to the mix further confounds things for me. It sounds like what the kid did may have been immoral, illegal and unethical. Because I never took a class in logic, it doesn't feel right to expel a kid from medical school for promiscuity (immoral), downloading music illegally off internet (illegal), smoking (unethical)

for all those perceived infractions the kid committed it doesn't make sense that they would have a hard on so bad for wanting him out. I'm glad the judge ruled the way he did because it would create too slippery a slope. I think that as a medical student, he's paying for an education/degree and unless he becomes ineligible to accomplish those tasks, he should be able to continue.
When he's a resident, if his actions jeopardize his ability to practice medicine, that's a whole different story.
I think we should give him (all all other people who do things differently) the benefit of the doubt. If he continues to act like a jack***, it will correct itself at the next level.

also do the six core compentencies apply to students? I thought it was just residents?

artiger said...

You know, a lot of time has been spent trying (unsuccessfully) to arrive at a consensus for professionalism. Maybe we're looking at this the wrong way. Maybe it would be easier to agree on recognizing a LACK of professionalism.

Skeptical Scalpel said...

Pamchenko, who knows whether the 6 core competencies apply to students? If you look at the list Vamsi provided in his comment, it's way more than 6.

Artiger, just as errors of omission are harder to define and correct than errors of commission, I think it would be hard to discipline someone for lack of professionalism.

artiger said...

I would suggest that a lack of professionalism is expressed as an error of commission. For example, having sex with a current patient indicates a lack of professionalism, and would seem to me to be an error of commission. Forcing your personal religious/political views on a patient is unprofessional, and seems to be one of commission again.

Maybe I'm just playing a game of semantics. I hope I did it in a professional manner.

Anonymous said...


Quite interesting. I asked the admin of a doctor if their "x" behavior was ethical? They said ethical. You ask patients and it was "rude", "hostile", "dismissive", "condescending". What was the behavior? Forcing their own views of treatments, refusing to discuss treatments and allowing patients to bring medical research in and see if fits in. Paternalism in a nutshell. Calling a patient non compliant because their diagnosis didn't fit the patients' symptoms & the patients complained & wouldn't do what they dictated ("all in their head" vs. at least 2 surgical issues"). Giving a "crazy" diagnosis to the insurance and on their records when another doctor (same specialty) found the problem, by doing 1 test.

You see, what patients call "non professional" is different than what admin/docs call "professional".

artiger said...

Anon, for the most part, I can agree. Just don't confuse "ethical" with "professional".

Skeptical Scalpel said...

I agree that ethics and professional behavior are not the same but there is some overlap.

Maud Kennedy said...

Hi,I know your post is quite old but I'd like you to ask you a question,as a surgeon and a physician.
I've learned lately by that case about what some called "dark humor" in the operating room and thought it was pretty disturbing,so I looked for answers in the internet and sadly,it seems a pretty common attitud,under the guise "the operating room is stressful". Isn't that a really convenient excuse to hide unprofessionalism and blatant lack of respect for patients from those health care providers? I understand the need to laugh as a stress reliever but is that really ethical to make fun of patients about their physical appearance(apparently,that's the most common) just for having a laugh?
To be honest,it makes you wonder if operating room teams really respect patients if as soon as they're asleep comments off color are made. That's pretty hypocritical and coward for me. They wouldn't want or their loves ones to be treated like that.
Once again,I don't know how common that attitud is.

Skeptical Scalpel said...

I can't really say how common it is. I don't think it's ever been studied. It would be difficult to study because everyone would behave differently if they knew they were being observed.

The case you cited (which involved an anesthesiologist, not a surgeon) made headlines all over. I suspect that case has influenced OR personnel to be more careful about what they say.

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