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|Return to Table of Contents||Chapter 1. Introduction|
Richard L. Byyny, MD
Professionalism in medicine has been a core value for Alpha Omega Alpha Honor Medical Society (AΩA) since the society’s founding in 1902. Demonstrated professionalism is one of the criteria for election to membership in AΩA. In the Winter 2000 issue of AΩA’s quarterly journal The Pharos, Executive Director Edward D. Harris, Jr., MD (1997–2010), wrote, “The profession of medicine is under siege. Our resistance must be professionalism.” In 2009, AΩA established an annual Edward D. Harris Professionalism Award that encourages teaching faculty to create appropriate learning environments for professionalism, or new programs to ingrain professionalism in medical students and resident physicians. Since then, AΩA has made annual awards and continued its work to promote, understand, and support medical professionalism.
Because medical professionalism is a core value of the society, the board of directors of AΩA has discussed how the society can serve as a leader and a catalyst to improve medical professionalism. We wanted to better understand medical professionalism, professionalism issues, and learn about teaching and supporting research and scholarship related to medical professionalism, identifying methods of evaluating aspects of professionalism, and finding a leadership focus for AΩA in medical professionalism.
In 1914, U.S. Supreme Court Justice Louis Brandeis defined a profession:
First. A profession is an occupation for which the necessary preliminary training is intellectual in character, involving knowledge, and to some extent learning, as distinguished from mere skill.
Second. A profession is an occupation which is pursued largely for others and not merely for one’s self.
Third. It is an occupation in which the amount of financial return is not the accepted measure of success.
Our efforts in medical professionalism are a work in progress. As physicians, we are gradually and continually learning about medical professionalism and how to maintain and improve a standard of physician behavior. We need to remember that we call our work “the practice of medicine” because we are always practicing our profession to learn and improve. We also need to remember that our goal is not perfection, but continuous learning, improvement, and focusing on what is best for the patient. We recognize medical professionalism as an important issue for doctors and society that must be taught and then practiced in the interests of both patients and our profession.
We have begun to make progress, but the challenges are huge. Since AΩA developed the Edward D. Harris Professionalism Award a few years ago as our society’s contribution to promote professionalism in medicine, we have made awards for some interesting projects but haven’t had a clear focus about AΩA’s leadership role and how the society’s programs and projects can make a positive difference in medical professionalism—is it in curriculum reform, remediation, or some other important step toward the future?
We are committed to focusing our efforts at AΩA to define our role in the development of professionalism in medicine. Many AΩA members are leaders in medicine. We recognize that developing effective leadership in medicine must continue to be grounded in professional values. It is clear that the combination of leadership and professionalism can have a synergistic and positive impact on our members and profession.
To learn more about medical professionalism, we sponsored and hosted an AΩA Think Tank Meeting on Medical Professionalism in July 2011. We brought together experts in medical professionalism to review and discuss the status of and challenges in the field. That meeting was based on the assumption that the last twenty years have seen good progress in defining professionalism and in devising charters, curricula, assessment strategies, and accreditation criteria. However, participants recognized that there has been insufficient evidence to inform best practices in medical professionalism. This is especially true for interventions and remediation strategies for those who demonstrate lapses in professionalism and professional behaviors. The meeting resulted in the publication in Academic Medicine of “Perspective: The Education Community Must Develop Best Practices Informed by Evidence-based Research to Remediate Lapses of Professionalism.”1 The meeting participants identified two issues as very important to medical professionalism:
- How can we use existing data on professionalism remediation?
- What new evidence is needed to advance approaches to remediation of unprofessional performance?
Participants also recommended that the education community focus on interventions and remediation by performing studies about improving medical professionalism when lapses occur, identifying best evidence-based remediation practices, widely disseminating those practices, and moving over time from a best-practice approach to remediation (which does not yet exist) to a best-evidence model.
This monograph, Medical Professionalism: Best Practices, is the result of a subsequent AΩA sponsored meeting, Best Practices in Medical Professionalism, which had two themes:
- Use of systems to enhance professionalism
- Best practices for the remediation of lapses in professionalism
The authors in this monograph presented some of the identified best practices, followed by discussion, questions, and debate. We thank the Josiah Macy Jr. Foundation for its President’s Grant, which funds the publication and distribution of this monograph. The Foundation’s president, Dr. George E. Thibault, participated in our meeting and has written the concluding chapter.
The co-chairs of the meeting, co-editors of this monograph, and authors of two chapters are Dr. Maxine Papadakis and Dr. Douglas S. Paauw.
AΩA and medical professionalism
Medicine is based on a covenant of trust, a contract we in medicine have with patients and society. Medical professionalism stands on the foundation of trust to create an interlocking structure among physicians, patients, and society that determines medicine’s values and responsibilities in the care of the patient and improving public health. AΩA supports and advocates for medical professionalism as a core value of the society.
The founding of AΩA is interesting and important to medical professionalism. William Root and other medical students at the College of Physicians and Surgeons of Chicago founded AΩA in 1902, before the Abraham Flexner report and the subsequent transformation of medical education. Root and likeminded fellow students were shocked by the lack of interest in high achievement, especially high academic achievement, by the faculty and their fellow students. They found the behavior of students and faculty to be boorish and clearly lacking in professional values. They decided to establish a medical honor society based on the model of Phi Beta Kappa. They wrote, “The mission of AΩA is to encourage high ideals of thought and action in schools of medicine and to promote that which is the highest in professional practice.” They defined the duties of AΩA members: “to foster the scientific and philosophical features of the medical profession and of the public, to cultivate social mindedness as well as an individualistic attitude toward responsibilities, to show respect for colleagues and especially for elders and teachers, to foster research, and in all ways to strive to ennoble the profession of medicine and advance it in public opinion. It is equally a duty to avoid what is unworthy, including the commercial spirit and all practices injurious to the welfare of patients, the public or the profession.” They established the AΩA motto: “Be worthy to serve the suffering.” Since its founding, AΩA has celebrated, advocated, and supported the principles of high academic achievement, leadership, demonstrated professionalism, service, research and scholarship, and teaching in medicine. Election to membership in AΩA is based on outstanding scholarly achievement and these core professional values.2
AΩA expanded rapidly throughout the early twentieth century and continues to expand in the twenty-first century. There are now 126 AΩA chapters in medical schools, with more than 150,000 members. Member dues provide nearly three-quarters of a million dollars to support the following AΩA programs and awards each year: the Robert J. Glaser Distinguished Teaching Awards, the Carolyn Kuckein Medical Student Research Fellowships, AΩA Visiting Professorships at medical schools, Medical Student Service Leadership Project Awards, Postgraduate Awards, Volunteer Clinical Faculty Awards, Administrative Recognition Awards, Student Essay Awards, the Pharos Poetry Competition, three AΩA Fellow in Leadership Awards, and the Edward D. Harris Professionalism Award. The society’s quarterly journal, The Pharos, publishes essays at the intersection of medicine and the humanities, as well as news about activities, awards, and programs.
The history of medical professionalism
The first oath for medical ethics was apparently written as the Code of Hammurabi in 2000 BC. Hippocrates and Maimonides subsequently developed oaths codifying the practice of medicine as the sacred trust of the physician to protect and care for the patient and a set of values for physicians appropriate for their times.3,4 Both emphasized teaching and learning, and the primacy of benefiting the sick according to one’s ability and judgment while adhering to high principles and ideals. These oaths were also a form of social contract that partially codified what patients and society should expect from the physician.
The physician Scribonius apparently coined the word “profession” in 47 AD. He referred to the profession as a commitment to compassion, benevolence, and clemency in the relief of suffering, and emphasized humanitarian values.5 While patients and societies and the concept of medical professionalism have changed over time, many of the professional values in medicine are timeless. To paraphrase Sir William Osler: “The practice of medicine is an art; a calling, not a business; a calling in which your heart will be exercised equally with your head; a calling which extracts from you at every turn self-sacrifice, devotion, love and tenderness to your fellow man.” He also wrote, “No doubt medicine is a science, but it is a science of uncertainty and an art of probability.”6
The science of medicine has progressed dramatically in the last hundred years. Up until the mid-1900s, doctors could diagnose some illnesses based on the patient’s history, but they had few diagnostic tests or effective therapies. Thus one of the special roles of doctors—the art of medicine—was to relieve patients’ suffering. Scientific and technical advances brought more effective treatments, which paradoxically led many doctors to become less capable of compassionately caring for the suffering patient.
During the last fifty years, social changes have altered the relationship of the doctor and patient. In what is sometimes referred to as the corporate transformation of health care, many components of medicine have become businesses that do not put the patient first and dismiss the special relationship between patients and their doctors. At the same time, the profession of medicine has not responded as effectively as it should have to protect the primacy of the care of the patient. We believe that serving as a physician and practicing medicine must be based on core professional beliefs and values, and that those entering and practicing our profession must understand the values of medical professionalism and learn and demonstrate the aptitude and commitment to behave professionally. Physicians work primarily in the service to others and our success is measured in human terms, by how well we benefit those under our care, not necessarily in financial returns. We are evaluated and respected because of what we actually do and how we meet our responsibilities. A physician’s work is compassionate and includes a commitment to service, altruism, and advocacy. Our profession of medicine is self-directed and therefore self-regulating. The privilege of self-regulation is granted to us by patients and society when we prove ourselves worthy of their trust by meeting our professional responsibilities to them.
Professionalism is a required core competency for physicians. A few decades ago, medical professionalism became an important issue. Many researchers concluded that an integrated patient-centered approach was needed, one that included both the science and the art of medicine. While a disease framework is required to reach a diagnosis and select appropriate therapy, the illness framework in which the patient’s unique and personal experience with suffering, including individual worries, concerns, feelings, and beliefs, is equally important. Some recognized that what Francis W. Peabody wrote earlier was both straightforward and profoundly important: “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”7
Medical professionalism today
In dissecting medical professionalism to better understand the concept and determine how to address issues of concern both to the profession and society, most researchers have concluded that the profound and rapid advances in medical knowledge, technology, specialized skills, and expertise have inadvertently resulted in a loss of our professional core values. Many writers and professional organizations have proposed a renewed commitment to restore professionalism to the core of what doctors do. It seems self-evident that we should practice medicine based on core professional beliefs and values. In my opinion, this relates first and foremost to the doctor-patient relationship. It starts with physicians understanding their obligations and commitments to serve and care for people, especially the suffering. Physicians must put patients first and subordinate their own interests to those of others. They should also adhere to high ethical and moral standards and a set of medical professional values. These values start with the precept of “Do no harm.” They include a simple code of conduct that explicitly states: no lying, no stealing, no cheating, nor tolerance for those who do. I also believe that the Golden Rule, or ethic of reciprocity, common to many cultures throughout the world—“one should treat others as one would like others to treat oneself”—should be the ethical code or moral basis for how we treat each other.
Professional organizations and leaders in medicine have recently defined the fundamental principles of medical professionalism. CanMEDS 2000 stated it well: “Physicians should deliver the highest quality of care with integrity, honesty, and compassion and should be committed to the health and well-being of individuals and society through ethical practice, professionally led regulation, and high personal standards of behaviour.”
The American College of Physicians and the American Board of Internal Medicine have developed a physician charter with three fundamental principles:
- The primacy of patient welfare or dedication to serving the interest of the patient, and the importance of altruism and trust
- Patient autonomy, including honesty and respect for the patients to make decisions about their care
- Social justice, to eliminate discrimination in health care for any reason.8
Professional organizations have also developed a set of professional responsibilities:
- Professional competence
- Honesty with patients
- Patient confidentiality
- Maintaining appropriate relations with patients
- Improving quality of care
- Improving access to care
- Just distribution of finite resources
- Scientific knowledge
- Maintaining trust by managing conflicts of interest
- Professional responsibility
I also believe explicit rules and values are important in medicine and I have taken the liberty to rephrase some and add others in the following table.1 Learning requires a clear, straightforward set of expectations combined with learning opportunities, reflection, evaluation, and feedback, and these principles may provide an important basis for physician learning.
|PROFESSIONALISM IN MEDICINE|
|Responsibilities to patients|
|The care of your patient is your first concern||Care for patients in an ethical, responsible, reliable, and respectful manner|
|Do no harm||Respect patients’ dignity, privacy, and confidentiality|
|No lying, stealing, or cheating, nor tolerance for those who do||Respect patients’ rights to make decisions about their care|
|Commit to professional competence and lifelong learning||Communicate effectively and listen to patients with understanding and respect for their views|
|Accept professional and personal responsibility for the care of patients||Be honest and trustworthy and keep your word with patients|
|Use your knowledge and skills in the best interest of the patient||Maintain appropriate relations with your patients|
|Treat every patient humanely, with benevolence, compassion, empathy, and consideration||Reflect frequently on your care of patients, including your values and behaviors|
|Social responsibilities and advocacy|
|Commit and advocate to improve quality of care and access to care||Respect and work with colleagues and other health professionals to best serve the patients’ needs|
|Commit and advocate for a just distribution of finite resources||Commit to maintaining trust by managing conflicts of interest|
While I hope that most physicians understand, practice, and teach with professionalism and its core values, the literature indicates that unprofessional behaviors are common. This raises the question: Can you teach professional behaviors to students and physicians? Although medical schools would like to select students who already have professional values and ethics, they lack reliable tools to find those candidates and so primarily rely on academic performance for admission.
Medical schools transmit knowledge, teach skills, and try to embed the values of the medical profession. During this curriculum and learning process do students learn to put the needs of patients first? Most of the data indicate that students begin with a sense of altruism, values, and open-mindedness, but they learn to focus on what is tested to pass examinations. They observe self-interest, a focus on income, and nonprofessional behaviors by their seniors in our profession and unfortunately grow progressively more cynical and less professional, especially once they get to clinical experiences. This is worsened by the lack of moral and professional values in the business and political components of medicine that often disregard the patient and the patient’s needs and interests.
Although most schools have curricula related to professional values, what students learn and retain is from what is called the “hidden curriculum”—the day-to-day experiences of students working in the clinical environment while watching, listening, and emulating resident and physician behaviors. It is not a good story. Fortunately, some schools and teaching hospitals have implemented effective interventions to improve medical professionalism, and some have attempted to develop methods of evaluating aspects of professionalism. Having a few courses, however, does not seem to make a difference in learning professionalism and professional behaviors. The most effective programs, so far, lead by changing the institutional culture and environment to respect and reward professional behavior, while at the same time exposing and working to change the negative impact of the “hidden curriculum.” Many of these interventions are top-down and bottom-up institutional changes that focus on faculty, house staff, students, and staff members, and have shown promising reports of changes in professionalism.
We shouldn’t presume that professional core values in medicine are intuitively apparent. I recognize there is continuing debate about the importance and value of a physician’s “oath” or “solemn promise,” but I believe we must have clear professional expectations that are explicit for all physicians and a commitment from physicians to respect and uphold a code of professional values and behaviors. In my opinion, these include the commitment to:
- Adhere to high ethical and moral standards: do right, avoid wrong, and do no harm.
- Subordinate your own interests to those of your patients.
- Avoid business, financial, and organizational conflicts of interest.
- Honor the social contract you have undertaken with patients and communities.
- Understand the non-biologic determinants of poor health and the economic, psychological, social, and cultural factors that contribute to health and illness.
- Care for patients who are unable to pay, and advocate for the medically underserved.
- Be accountable, both ethically and financially.
- Be thoughtful, compassionate, and collegial.
- Continue to learn, increase your competence, and strive for excellence.
- Work to advance the field of medicine, and share knowledge for the benefit of others.
- Reflect dispassionately on your own actions, behaviors, and decisions to improve your knowledge, skills, judgment, decision-making, accountability, and professionalism.9
The chapters in this monograph, Medical Professionalism: Best Practices, present their authors’ experiences both in building cultures of medical professionalism and dealing with lapses in professionalism. We hope that it will support medical schools, professional organizations, practitioners, and all involved in health care in their very important work on professionalism in medicine.
Bibliography and references
- Papadakis MA, Paauw DS, Hafferty FW, et al. Perspective: The education community must develop best practices informed by evidence-based research to remediate lapses of professionalism. Acad Med 2012; 87: 1694–98.
- Byyny RL. AΩA and professionalism in medicine. The Pharos Summer 2011; 74: 1–3.
- Edelstein L. The Hippocratic Oath: Text, Translation and Interpretation. Baltimore (MD): Johns Hopkins University Press; 1943.
- Tan SY, Yeow ME. Moses Maimonides (1135–1204): Rabbi, philosopher, physician. Singapore Med J 2002; 43: 551–53.
- Hamilton JS. Scribonius Largus on the medical profession. Bull Hist Med 1986; 60:209–16.
- Bliss M. William Osler: A Life in Medicine. New York: Oxford University Press; 2007.
- Oglesby P. The Caring Physician: The Life of Dr. Francis W. Peabody. Cambridge (MA): Harvard University Press; 1991.
- ABIM Foundation, American Board of Internal Medicine; ACP-ASIM Foundation, American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002; 136: 243–46.
- Byyny RL. AΩA and professionalism in medicine—continued. The Pharos Spring 2013; 76: 2–3.
|Return to Table of Contents||Chapter 1. Introduction|
Updated on May 14, 2015.