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Chapter 10. Concluding Thoughts
George E. Thibault, MD
Today there is more and more interest in professionalism, and more discussion of it as something that we can and should teach. At the same time, there are more threats to professionalism and more examples that run counter to what we would think should be the professional behavior of physicians, other health professionals, and institutions.
So we are at this moment of tension. We actually know more about professionalism, and we have evolved from the point of thinking this is some kind of intrinsic moral quality to understanding that it is a set of behaviors that can be taught, can be learned, can be rewarded, and can be incented or dis-incented. But at the same time, we understand that the other changes that are going on, such as the commercialization of medicine, intense competition, resource constraints, and organizational changes that threaten autonomy all represent a continued threat to professionalism.
I suggest three ways I think we should be broadening the discussion for us as educators and leaders. First, the professionalism discussions should be about how we raise the consciousness and behavior of all students and trainees (not just those who need remediation). Second, we need to think about professionalism in the context of the organizations in which we all function and how these organizations can have positive or negative influences on professional behavior. And third, we should be thinking about an inter-professional professionalism that involves the other health professions that are our partners in caring and teaching.
I want to offer a definition of professionalism provided by U.S. Supreme Court Judge Louis Brandeis a century ago. Brandeis identified three characteristics of the learned professions. First, a learned profession is in possession of a special set of knowledge and skills that it is responsible for mastering, for improving, and for passing on to the next generation. Second, a learned profession puts others’ interests ahead of its own. Third, a learned profession is self-regulating.
This has been a helpful framework for me, and I think I can link most of the behaviors we are seeking to teach and measure to these three principles. Reductionism to the particular behaviors is important to define a curriculum and an assessment system, but I believe it is important that this be done within a higher framework.
There are two important parts to realizing that professionalism does not happen in a vacuum: one has to do with the entire educational environment and the second has to do with the relationship between education and health care delivery.
Structures to help us monitor and correct behaviors will not mean anything if they are not consistent with everything else that we say and do from day one on. It does matter what we teach in the curriculum, and it does matter how we structure the curriculum. But it also does matter how we form relationships between faculty and students and how we set examples and model behaviors. Talk about the resistance to “forward feedback” reminds me of how broken our system is. Because we are so worried that students and faculty will have nothing other than very casual encounters, we don’t believe that constructive feedback will or can be given. If we do not do something about that, then we are not being consistent when we say we are going to put a system in place to remediate unprofessional behavior. The whole structure and environment have to support what it is we want to accomplish. Understanding there are a lot of impediments, we have a responsibility to deal with the things that are getting in the way of our goals. Unless we do that, then the best measurement and remediation system in the world is not going to work. We have to show that we really care, and that we are fixing things that don’t work in our educational system. We must be consistent in how we set up our whole educational process so that it fosters continuity of relationships and models the behaviors we want our students to learn.
The second part of this not occurring in a vacuum is that the medical school and the medical students are part of a larger health care system. While the medical school in most instances does not control the rest of that system, it must interact with it. We have a responsibility to our students and to our profession to do a better job at building the bridges between the educational system and the delivery system. We will not be successful in our professionalism goals unless we do that. That is hard work, and it is frustrating at times. We often feel like we live in different worlds and cultures, but we have got to bridge that gap or we are not going to succeed. We need to articulate how the educational goals connect with the rest of the health care system. We need to make clear how the rest of the health care system shares the responsibility for creating the ideal educational environment for our next generation of health professionals. We will not succeed unless we build those bridges with others. Education needs to be informed by the needs of the public and the changing delivery system; and the changing delivery system must embrace and incorporate the educational mission.
The last observation I would make is that this is about culture change. Some have compared professionalism to the quality and patient safety movement. Yes, it is a professional responsibility not to harm patients and to constantly improve, but professionalism is more than that. It is also a professional responsibility to work with and respect other health professionals and acknowledge when they know more than we do. It also is a professional responsibility to assure one’s own competency and the competency of the next generation of our profession. It also is our professional responsibility to work with other health professions in setting the standards for those competencies. And we do all of this because we exist as professionals to serve the public, and we earn our special privileges only if we do that. So we are back to the Brandeis definition of professionalism, but with a realization that this professionalism is not a solo activity. To accomplish it (and teach it) we need to effect a culture change in which we break down the silos between the professions and function in a non-hierarchical way; we must become truly patient-centered rather than profession-centric; we must focus on the needs of the community in designing both education and care; and we must create the kind of caring and collaborative environment in which our students see professionalism modeled and receive the constructive feedback they deserve.
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Updated on May 14, 2015.