Can professionalism be taught?

As medical students, we fall under the scope of ‘future physicians’ and the public expects us to behave as such. A patient needs to be able to trust their physician to exercise good judgment and to act in the best interest of their health. This trust is rooted in the confidence that physicians will put their patients’ overall well-being ahead of all other considerations. In kind, medicine as a profession has increasingly worked to protect this relationship, which is reflected in the escalating focus on the education and evaluation of professionalism in medical students.

But how can we define something as subtle and complex as professionalism and then evaluate it in a meaningful way?

CanMEDS (Canada’s framework for medical education) describes professionalism as a commitment to clinical competence, the ability to deliver the highest quality of care with integrity, altruism, honesty and compassion, to exhibit appropriate personal and interpersonal behaviors, and to practice medicine in a consistently ethical way. We are taught in medical school that this behavior should extend beyond the hospital walls, and should permeate our every action in the community.

Despite its apparent importance, I believe that any attempt to define professionalism (by using either vague or concrete terms to describe its expectations) limits a broad personal interpretation of what it means to be professional. In turn, this forces academic institutions to create a quantifiable way to examine and evaluate its students on behaviors that may well be entirely insincere and hence serve no purpose to enhance the trust-driven physician-patient relationship.

A comprehensive report discussing the future of professionalism in medicine published by the CMA went on to say that,

‘…understanding professionalism, and future methods of evaluating professionalism, must focus on behaviors rather than personality traits or vague concepts of character.’

I could not disagree more. Professionalism cannot, and should not be defined. It is an abstract concept whose only purpose is to establish trust between the physician and the patient. This demands a physician to possess a dynamic personality that guides their interactions with patients and colleagues alike – to adjust it appropriately to engage the other person in those interactions with them. Its only guiding standards are framed in the accepted social norms of our society, and that is how we evaluate circumstances where a physician is charged with being unprofessional. Each physician has their own unique personality, and thus we cannot create a discrete set of behavioral benchmarks instructing them how to act. Professionalism is an inherent quality that we are able to recognize when its there (or not there) but it is not something we can distill down to a standard set of criteria.

Once we have accepted this idea we can instead focus on how to model professionalism in practice. But this must be done in such a way that students integrate these modeled behaviors as a genuine component of their personality and not a conditioned set of responses to a generated list of pre-conceived circumstances. The most difficult question is how?

A truly excellent review of the erosion of professionalism is discussed in a recent report commissioned by the OMA and makes what I think is a key recommendation regarding the future of professionalism education:

‘Positive role models — those perceived as having a high degree of professionalism and encouraging similar behavior — were said to have the greatest impact on students’ professional development. Making role modeling a more active process by intentional attempts to transmit professional values and attitudes throughout the course of day-to-day activities, would seem a fundamental step to increasing medical professionalism [and as such], medical schools must hold their entire faculty to the highest professional standards.’

Students will follow their own interpretation of what they feel it is to be professional despite their institution’s official policies on the subject. We arrive at a personal definition by the set of behaviors that serve to establish an early trust with our patients – a sort of real-time feedback mechanism. Yet any attempt to distill this down to a concrete description of these behaviors will ultimately fail. These behaviors are infinitely variable and entirely dependent on an individual. They are acquired through observation and experience, and may be encouraged with guidance from a mentoring physician aimed at recognizing the establishment of trust with a patient based on a student’s repertoire of individual behaviors. Our educational focus should instead be on selecting these positive role models. Good role models, not good definitions, will help shape good physicians.