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European Journal of Internal Medicine 20 (2009) e85–e89

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European Journal of Internal Medicine j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / e j i m

Education in internal medicine

The concepts of professionalism and professional behaviour: Conflicts in both definition and learning outcomes Walther N.K.A. van Mook a,⁎, Scheltus J. van Luijk b, Helen O'Sullivan c, Valerie Wass d, Jan Harm Zwaveling e, Lambert W. Schuwirth f, Cees P.M. van der Vleuten f a Internist-intensivist, Departments of Intensive Care and Internal Medicine Maastricht University Medical Centre, Maastricht, The Netherlands; Chair of the Committee on Professional Behaviour, Department of Medical Education Development and Research, Maastricht University, Faculty of Health, Medicine, and Life Sciences, Maastricht, The Netherlands b Medical doctor, Associate professor of Medical Education, Institute for Education and Educational Research, Free University of Amsterdam VU Medical Center, Amsterdam, The Netherlands c Director of the Centre for Excellence in Developing Professionalism, School of Medical Education, University of Liverpool, Liverpool, United Kingdom d Professor of Community based Medical Education, Manchester Medical School, University of Manchester, Manchester, United Kingdom e Internist-intensivist, Professor of Intensive Care Medicine, Chair of Department of Intensive Care Medicine, Maastricht University Medical Centre, The Netherlands f Professor of Medical Education, Department of Medical Education Development and Research, Maastricht University, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands

a r t i c l e

i n f o

Article history: Received 30 June 2008 Received in revised form 8 October 2008 Accepted 24 October 2008 Available online 5 December 2008

a b s t r a c t This article is the second in a series on professionalism in the European Journal of Internal Medicine. The current article will first focus on these different views and definitions that are currently adopted by the various researchers, and subsequently discuss the consequences for the training and assessment of professionalism and professional behaviour in medical education. © 2008 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Keywords: Professional behaviour Professionalism Assessment Concept Definition Learning Outcome

1. Introduction This article is the second in a series on professionalism in the European Journal of Internal Medicine. The first article described the evolution of the concept of medical professionalism. The current importance of this subject is underscored by the abundance of articles published over the last decade devoted to the topics of professionalism and professional behavior. In contemporary medical education, two mainstreams of thought relating to professionalism can be identified. One defines professionalism in terms of (character) traits. The other defines it in terms of observable professional behaviour. This article will first focus on the different definitions and views currently adopted by researchers, and then discuss the consequent implications

⁎ Corresponding author. internist/intensivist, Chair of the Committee on Professional Behaviour, Department of Educational Development and Research, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Departments of Intensive Care and Internal Medicine, Maastricht University Medical Centre, P. Debeyelaan 25, 6202 AZ Maastricht, The Netherlands. Tel.: +31 43 3876385; fax: +31 43 3874330. E-mail address: w.van.mook@mumc.nl (W.N.K.A. van Mook).

for educationalists aiming to develop a curriculum for medical professionalism. 2. The definition of professionalism: lack of consensus A review in 2002 established that half of the medical schools in the US had identified between 4 and 9 elements of professionalism, and had developed written criteria and specific methods for their assessment [1]. A survey of 23 UK medical schools in 2006 revealed that, although all had written ‘attitudinal objectives’, only 19 used some form of in-course assessment to measure whether these objectives had been achieved [2]. Professional values common to the undergraduate medical curricula, on both sides of the Atlantic, are altruism, respect for others, and additional humanistic qualities such as honor, integrity, ethical and moral standards, accountability, excellence and duty/advocacy [3]. There are, however, some differing views. Some medical educationalists, for instance, add the values of “autonomy”, “self-regulation” and “dealing with uncertainty” [4]. Others discard these notions of “mastery”, “autonomy”, “privilege” and “self-regulation” [5]. The Royal

0953-6205/$ – see front matter © 2008 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2008.10.006


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Table 1 Set of professional responsibilities as defined in the Physicians' charter on Professionalism by the American Board of Internal Medicine, the European Federation of Internal Medicine, and the American College of Physicians and American Society of Internal Medicine[6]. Number

Commitment

Actions including, amongst others

1 2 3 4 5 6 7 8 9

Professional competence Honesty with patients Patients' confidentiality Maintaining appropriate relationships with patients Improving quality of care Just distribution of finite resources Scientific knowledge Maintain trust by managing conflicts of interest Professional responsibilities

Life long learning to maintain medical knowledge and skills Complete and honest information, including reporting of medical error Disclosure of patient's information Avoid sexual advances, financial gain Reducing medical error and increase patient safety, optimize outcome Wise and cost-effective management of limited clinical resources Promote research, create new knowledge Recognize, disclose and deal with conflicts of interest Collaborate respectfully, participate in process of self-regulation, and standard setting

College of Physicians emphasized, amongst others, the commitment to working in partnership with members of the wider healthcare team, and the role of leadership [5]. Despite differences in systems of health care delivery, in 2002 the European Federation of Internal Medicine (EFIM), the American College of Physicians and the American Society of Internal Medicine (ACP-ASIM), and the American Board of Internal Medicine (ABIM) simultaneously published [6] very similar views on professionalism creating a ‘Physician's charter on professionalism’ [6]. It aimed to provide an ethical, educational, and practical framework for professionalism to guide physicians in the practice of medicine and support a relationship with patients, colleagues, and society, which embraced different cultures and political systems [6]. The charter mentioned three fundamental principles; “primacy of patients' welfare”, “patients' autonomy”, and “social justice” [6]. A set of professional responsibilities required for the physician to reach these high standards was created (Table 1). Despite the apparent achievement of consensus across these organizations, the concept of professionalism has continued to evolve. An expanding range of empirical definitions from numerous authors and organizations continues to emerge. These offer varying interpretations most relating to differences in overlap and emphasis on essentially the same individual elements [1,7]. For example, the American Board of Internal Medicine [3], Society of Academic Emergency Medicine [8], the Accreditation Council on Graduate Medical Education (ACGME) [9], the UK General Medical Council [10,11], the Royal College of Physicians in the UK [5,12], and the Royal College of Physicians and Surgeons of Canada [13,14] have each

defined professionalism separately and differently (Tables 2–4). More recently, in 2005, the Royal College of Physicians' publication Doctors in Society has defined and described medical professionalism. The report formulates a wide range of recommendations raising awareness and encouraging reflection on its meaning. Recommendations on leadership and teamwork, education, appraisal and management of medical careers and the urgent need for research on professionalism are made [10,15]. So far, there is no common understanding of what professionalism actually means. Thus, inevitably operationalisation has been limited [7]. 3. Professionalism and professional behaviour: identity and idealism versus feasibility and applicability Alongside the variation in definition, there are striking intercontinental differences in approaches to professionalism. In the United States professionalism is mainly a theoretical construct, and described in abstract, and idealistic terms. As previously mentioned, these often mirror character traits rather than behaviours. Although recognizable, and difficult to challenge, their practical consequences are harder to envisage. Since professionalism is not readily observable, how can it be assessed? Or to rephrase, “professionalism remains a perfectly valid concept, but is it achievable?” [16] and can it be measured? A more practical definition of professional behaviour has been proposed by the Netherlands' so called Consilium Abeundi working group of the Association of Universities in the Netherlands (see Table 5)[17]. This frames professionalism as observable behaviours

Table 2 Elements of professionalism as identified by the American Board of Internal Medicine [3]. Number Element 1

2 3

Description

Excellence

Commitment to competence in technical knowledge and skills, ethical and legal understanding and communication skills Humanism Includes respect, compassion and empathy, honor and integrity Accountability Procedures and processes by which one party justifies and takes responsibility for its activities

4

Altruism

To advocate the interests of one's patients over ones' own interest Free acceptance of a commitment to service

5

Duty

6

Honor and integrity

The consistent regard for the highest standards of behaviour and the refusal to violate one's personal and professional codes

7

Respect for others

Essence of humanism

Remarks/examples Life-long learning improvement of quality of care, promotion of scientific knowledge and technology E.g. admitting errors, crediting the work of others appropriately One is responsible to (patients, families, society) One is accountable for (quality of care, upholding principles, reporting conflicts of interest) Includes self-regulation, standard setting, duty, and responsibility Could be placed in domain of excellence (demanding the best for patients), accountability (avoiding self-interest), or humanism (selfless behaviour) Being available and responsive when “on call”, accepting inconvenience to meet the needs of one's patients, seeking active roles in professional organizations Being fair, being truthful, keeping one's word, meeting commitments, and being straightforward. They also require recognition of the possibility of conflict of interest and avoidance of relationships that allow personal gain to supersede the best interest of the patient. The essence of humanism, and humanism is both central to professionalism, and fundamental to enhancing collegiality among physicians.


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Table 3 Aspects of professionalism as described by the Working Party of the Royal College of Physicians in the United Kingdom [5,32]. Number Aspects of professionalism currently included in the basket of professional qualities 1 2 3

Knowledge Clinical skills Judgement

4 5 6 7 8 9 10 11 12 13 14

Commitment Moral contract Mutual respect Integrity Compassion Altruism Individual responsibility Appropriate accountability Continuous improvement (Striving for) excellence Partnership with other healthcare team members

Remarks

Application of critical reasoning to a problem presented by a patient in order to arrive at an opinion about how to solve or ameliorate that problem To patient care, to continuous improvement, to striving for excellence etc Substituted for social contract and morality

Number Aspects of professionalism discarded from the basket Remarks of professional qualities 1 2

Mastery Autonomy

3 4

Privilege Self-regulation

Could also suggest control, authority, power, and superiority Apart from independence and freedom from external control, it could also suggest the right to self-governance, an appeal to personal authority, the authority to act independently of both the wishes of the patient and the preponderance of medical evidence Could suggest special freedom or immunity from, for example, liability Judged irrelevant to the essential values and behaviours that underpin professional practice

from which the norms and values of the medical professional can be visualized It is obvious that the use of observable behaviour as the basis for assessment and guidance facilitates its practical implementation. However assessment of the inner attitudinal values of professionalism within the individual remains difficult. This carries certain risks, as outlined below.

4. The limitations and drawbacks of setting and measuring learning outcome for professional behaviour assessment Indeed so far, the focus of the academic literature has primarily been on the measurement of professional behaviour, consequently ignoring the attitudinal elements of professionalism. There are some

Table 4 Elements of the competency domain Professional as defined as part of by the CanMeds 2005 Physician competency framework of the Royal College of Physicians and Surgeons in Canada [14]. Number Element

Key competency

Enabling competency

1 2 3 4

Altruism Integrity and honesty Compassion and caring Morality and codes of behaviour

Demonstrate a commitment to their patients, profession, and society through ethical practice

Exhibit appropriate professional behaviours in practice including honesty, integrity, commitment, compassion, respect and altruism

5

Responsibility to society

6

Responsibility to the profession, including obligations of peer review Responsibility to self, including personal care in order to serve others Commitment to excellence in clinical practice and mastery of the discipline Commitment to the promotion of the public good in health care Accountability to professional regulatory authorities Commitment to professional standards Bioethical principles and theories

7 8 9 10 11 12 13 14 15 16 17

Medico-legal frameworks governing practice Self-awareness Sustainable practice and physician health Self-assessment Disclosure of error or adverse event

Demonstrate a commitment to delivering the highest quality care and maintenance of competence Recognize and appropriately respond to ethical issues encountered in practice Appropriately manage conflicts of interest Recognize the principles and limits of patient confidentiality as defined by professional practice standards and the law Maintain appropriate relations with patients Demonstrate a commitment to their patients, profession, and Appreciate the professional, legal, and ethical codes of practice society through participation in profession-led regulation Fulfill the regulatory and legal obligations required of current practice Demonstrate accountability to professional regulatory bodies Recognize and respond to other's unprofessional behaviours in practice Participate in peer review Demonstrate a commitment to physician health and sustainable practice

Balance personal and professional priorities to ensure personal health and a sustainable practice

Strive to heighten personal and professional awareness and insight Recognize other professionals in need and respond appropriately


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Table 5 Dimensions of professional behaviour as defined by the Project Team Consilium Abeundi of the Association of Universities in the Netherlands [17]. Dimension

Aspects

Dealing with Time management tasks/work Information management Ability to work independently Requesting supervision when necessary Preparation and presentation of patient demonstration Punctuality Honouring commitments Observable dedication, commitment and sense of responsibility Coping with stress Leadership Dealing with Communicating in understandable language others Adequate command of Dutch language Adequate non-verbal behaviour Adequate behaviour in gathering and giving information Giving a presentation/reporting Ability to construct a structured consultation Honouring commitments Collaborating Dealing with privacy and doctor patient confidentiality Empathizing with patient's expectations Clearly explaining one's role as clerk and its possibilities and limitations Handling conflict Handling emotions of others Adequate interaction with colleagues and nurses Being courteous and respectful Negotiating skills Dealing with Ability to self-reflect oneself Dealing with feedback and criticism Good personal appearance Self management/setting boundaries Dealing with uncertainty Handling own emotions

Subcategory

Details

Monitoring level of competence

Keeping up to date in the professional field, loyally to the profession, responsibility and independence

Monitoring limitations of competence

Indicating where competence ends, abstaining from behaviour/statements that are not within one's competence, even when colleagues put pressure on one to exceed these limitations Forms of teamwork to achieve team competence, delegating and division of tasks, chairing meetings, substituting for others, honouring commitments, loyalty to decisions made

Participation in team competence

Gathering information from another person's perspective

Includes empathy, being unprejudiced, finding contextual information, active awareness of the emotional implications of information

Providing information from another person's perspective

All behaviours directed at information and advice tailored to the recipient: e.g. adapting information to the other person's emotions and capabilities for understanding, presenting concrete information, checking whether the information has actually been received, inviting response

Aligning other person's perspective and one's own competence in decision making

All behaviours directed at facilitating decision making, taking into account both the other person's perspective and the doctor's competence. E.g.. encouraging someone to respond, meta communication, implementation of informed consent procedures

Reflection on own behaviour and the underlying dynamics

Self observation, gaining insight into and dealing with one's emotions, motivation, cognitions including values, standards, prejudices, as well as how these have evolved, and their effect on one's own behaviour Testing one's reflections against the Being receptive to and stimulating feedback on the and opinions of others criticism on one's own behaviour Implementation of the results of reflections Developing and experimenting with behavioural alternatives on against the opinions of others the basis of self-reflection and feedback

drawbacks to this approach as recently pointed out by Rees and Knights [18]. The first is the lack of a common “gold” standard within which to frame learning outcomes. When staff members were asked to respond to videotaped scenarios in which students were placed in professionally challenging situations, little agreement between faculty was observed. There was no apparent ‘shared standard’ for professional behavior across faculty members, which could be applied uniformly and consistently to support students' learning. Interpretation differed widely with some behaviours being interpreted as professional by some and unprofessional by others [19]. Secondly, behaviour can be defined as consisting of four components; “action”, “target”, “timing” and “context”. Unfortunately, the latter two are frequently forgotten [18]. The assessment of behaviour cannot be divorced from context, social pressure being one of the strong contextual determinants of behaviour. It is essential to explain to students the importance of being aware of the context in which behaviours occur. In reality, the relationship between attitudes and behaviours is relatively weak whereas external constraints, such as social pressure to behave in a particular way, are strong. A metaanalysis of the relationship between examined extrinsic behaviours and intrinsic attitudes reported a mean correlation of 0.41 (when individuals experienced an average degree of social pressure to perform a specific behaviour of average difficulty). When social pressure and the difficulty of the behavioural task both increased by one standard deviation above the mean, the correlation dropped to 0.30. Under these circumstances, with strong social pressure, and high behavioural challenge, the individual's attitudes accounted for only 9% of the variance of a person's behaviour [20]. Some students are

unfairly labelled as “unprofessional” in their attitudes by observers who have ignored important contextual circumstances. In reality the students' behaviour related to that particular context only and the judgement is not generalisable to other contexts [18]. Students with unprofessional behavioural lapses but underlying correct ethical attitudes can occasionally fail to graduate [18]. Furthermore, once we start to measure professionalism, we risk encouraging students to “fake” professional behaviour to gain positive but artificial reactions such as praise or high grades from observers. To use a quote by N. Sherman from an article by Rees and Knight [18]: ‘when we follow codes of conduct or rituals of decorum, we are often just play acting, acting appropriately in outer conduct, irrespective of what is in our hearts’. Faking professional behaviour for observers is indeed perfectly displayed by some students, and is an inevitable manifestation of the “Hawthorne effect” [18,21]. Professional behaviour is thus subject to “impression” management, whereby individuals manage other's impressions. This again identifies a potential disconnection between professional attitudes and professional behaviour. The former represents deep values connected with identity. The latter is relatively superficial. Students with professional acceptable behaviours but unprofessional attitudes can graduate [18]. The question “do we want physicians who are professional, or will we settle for physicians who can act in a professional manner?” is essential [22]. To what extent can inner virtues and outer conduct be allowed to differ? What action, if any, should be taken when this “disconnection” remains undetected in our current structures for assessing professional behaviour? Do we have any methodology for dealing with this possibility? Although discomfort with this disparity is evident, there are no current solutions to


W.N.K.A. van Mook et al. / European Journal of Internal Medicine 20 (2009) e85–e89

these difficult questions. The current structure of assessment of professional behaviour has significant limitations [18]. If morality is regarded an important aspect of professional behaviour, difficulties inevitably arise when setting learning outcomes and objective assessments. No objective description of human action can capture its moral aspects [23]. Biochemical investigation results alone cannot tell a practicing physician how sick a patient actually feels. Checking whether ’the student grasped the patient's hand’ or “smiled appropriately” may be objective, but does not assess the students inner values. It is not a moral assessment. The subjective, holistic judgment ’the student acted compassionately’ however does attempt to capture the moral aspect of the student's action. Subjectivity may not be as significant problem as it seems, as long as educators and assessors in this aspect of professionalism agree a common moral outlook in relation to the problem under discussion. Scales and standards that claim to be an objective measure of a trainee's professionalism are thus not ideal. [23]. 5. Consequences for medical education As a consequence, we recommend multiple, subjective and objective, complementary methods are used to assess professionalism in an attempt to assess these important aspects of professionalism as well as professional behaviour. A balance should be sought between reproducibility in assessing professional behaviour and validity in an attempt to assess the moral aspects of professionalism [23]. Observation in vitro (in simulated circumstances) and in vivo (in daily work), as well as small group discussions (for example significant events in the Emergency Room (ER)) [24,25], can be coupled with interviews or “conversations” designed to explore moral reasoning and stimulate self-reflection on observed self and peer actions [18,19]. The reflective portfolio [26] is another example of a tool that can provide a framework for exploring the moral values underpinning professional behaviour [18,27]. In our opinion when discussing the concepts of professionalism and professional behaviour, the terms complementary is more appropriate than contradictory. Current methodology and the tensions between reliability and validity however are constricting. The need to assess professionalism as a whole is not yet adequately addressed [28]. Some educators remain optimistic that by constantly monitoring and assessing students' professional behaviours they will ultimately internalize appropriate attitudes (the so called cognitive dissonance theory). Sherman clarifies this by stating “decorum, can, in some cases, change inner states” [29]. There is weak evidence from retrospective studies that practicing physicians facing disciplinary action from medical licensing boards had a higher incidence of prior unprofessional behaviour in medical school [30] and internal medicine residency training [31]. However no research is as yet available to support the assumption that the inclusion of teaching and learning on professionalism in the medical school curriculum, will impact positively on attitudes towards professionalism and professional behaviour in medical school and subsequent practice [28]. 6. Conclusions The concept of professionalism can be traced back to Hippocrates but has undergone substantial modification over the last century due to changes in society and advances in medicine. Several large organizations have re-defined professionalism for the 21st century. There is so far no universal understanding of what the term means and it is unlikely that any one definition is applicable across all relevant contexts. Apart from these differences in definition there are also striking contrasts in approach to professionalism. The conceptualization of professionalism versus professional behaviour differs to a large extent. Assessment of only professional behaviour, fails to be either appropriate or adequate for modern medical practice and has significant limitations. Our view on the assessment of professionalism is that, in an attempt to overcome

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these deficiencies, multiple complementary methods which are both subjective and objective, holistic and focused should be used. We should strive to assess both the inner values of professionalism as well as the outward aspects of professional behaviour. References [1] Arnold L. Assessing professional behavior: yesterday, today, and tomorrow. Acad Med 2002;77(6):502–15. [2] Sullivan WM. What is left of professionalism after managed care? Hastings Cent Rep 1999;29(2):7–13. [3] American Board of Internal Medicine Committee on Evaluation of Clinical Competence. Project Professionalism. Philadelphia: ABIM; 1995. [4] Swick HM. Toward a normative definition of medical professionalism. Acad Med 2000;75(6):612–6. [5] Royal College of Physicians. Doctors in society: medical professionalism in a changing word. Report of a Working Party of the Royal College of Physicians of London. Suffolk, Great Brittain: Lavenham Press Ltd. 1-86016-255-X; 2005. [6] Project Medical Professionalism. 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The concepts of professionalism  

The concepts of professionalism and professional behaviour: Conflicts in both definition and learning outcomes

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