Professionalism must be taught

Introduction

The subject of professionalism is often referred to in the medical literature, but the word itself is rarely defined—and it is assumed that physicians understand what it means to be a professional and use this understanding as they make decisions in their private and professional lives. Though this may have been true in the past, the lack of literature dealing with professionalism available to the average doctor is striking. When this is coupled with the absence of relevant material in the curriculum of most medical schools, it is understandable why, in a rapidly changing world, doctors may not have a clear understanding of what the public expects from its professionals.

The General Medical Council's approach to professionalism and self regulation is a response to the rapidly changing relation of all professions to society and is designed to allow medicine to meet new societal demands and expectations. Dealing with problems having to do with doctors' performance and attitudes, Irvine presented the subject in the overall context of professionalism in the modern world.1 2 He emphasised the importance of independence (which some call “autonomy”) and stated that it depended on the three pillars of expertise, ethics, and service. He then linked the concept of an independent profession, as granted by the state, to self regulation. As have almost all observers of the present scene,3 Irvine emphasised the importance of trust to the relationship between patient and doctor and the profession and society. In outlining the structures within which self regulation takes place, he emphasised the “leadership role of leaders in influencing the behaviour of future physicians.” In doing so, he noted that an admirable role model was important.

We would like to extend this concept. Elsewhere we have said that leaders are required to do more than simply provide excellent role models.4 Most doctors do not fully understand the obligations they must fulfil to satisfy public expectations and maintain professional status. We believe that doctors will meet their obligations if they understand their origins and their nature. Thus, professionalism must be taught.

The healer and the professional

Doctors simultaneously fill two overlapping but none the less distinct roles: the healer and the professional. From early times there have been healers in society. In Western culture the traditions go back to Hippocrates, and for centuries the Hippocratic oath served as the foundation of the morality of medicine.5 The professions, on the other hand, arose in guilds and universities during the middle ages,6 but they remained ill defined and touched only a small percentage of the population until the industrial revolution made it possible for the public to pay for services—and science made medicine effective enough to be worth purchasing. These two important roles are recognised in the literature, but they are rarely separated for analysis. This is unfortunate, as many doctors feel that fulfilling the role of healer is sufficient and do not willingly accept professional obligations. For example, the healer is under no obligation to sit on audit committees or to engage in other administrative activities, but the professional must.

The relationship of the professional and the healer is not complicated. Society requires the healer, but there must be an organisational framework within which the services of the healer are dispensed. In the Anglo-American world, professional status is used as a method of organising the delivery of complex services.6 This status is granted by the state and defined by laws outlining licensing and in the charters and regulations of the various certifying bodies. It can be modified or withdrawn if society is not satisfied with the performance of its professionals, and there is ample evidence that the status of all professions has changed over the past three decades.7

The definition and characteristics of a profession

If doctors are to understand the source of their obligations they must understand professionalism. The Oxford English Dictionary states that a profession is “the occupation which one professes to be skilled in and to follow. (a) a vocation in which a professed knowledge of some department of learning or science is used in its application to the affairs of others, or in the practice of an art founded upon it. (b) in a wider sense: any calling or occupation by which a person habitually earns his living.” 8

The word “professes” is important, because in this way a professional becomes dedicated to service. It requires the command of a body of knowledge or skills, and it also specifically refers to “art,” something that is clearly important in medicine. The definition, however, does not adequately describe the complexity of modern professions. These characteristics of professions (box), which have changed with time, are drawn from the literature; most observers will agree that they are correct. These characteristics are not listed in order of importance. At the heart of every profession is a legally sanctioned control over a specialised body of knowledge, and a commitment to service.9 As the average citizen cannot fully comprehend the body of knowledge, the Anglo-American world has granted the professions the right to self regulation. Autonomy is given on the understanding that professionals will put the welfare of both the patient and society above their own, and that they will be governed by a code of ethics.

Those who write about professionalism are united in believing that professions must be “moral” or devoted to the public good. In addition, professionalism as a concept is believed to be an ideal to be pursued.10 It is understood that physicians are human, and that they will not always achieve the ideal, but in striving for it they should reach ever higher levels of performance.

The evolution of professionalism

Changes in the medical profession and in public expectations have been documented extensively in books and journals not generally read by doctors—those in the fields of the social sciences and bioethics. This literature offers perceptive, often critical, but generally telling, insights into the interface between professions and society. Early work was largely favourable to the concept of professionalism, and it was felt that the service orientation of the professional would benefit society.11 12 13 In the mid 1960s and 1970s the tone changed, and professionalism as a concept was viewed as being flawed, partly because of the inherent conflict between altruism and self interest. The medical profession was criticised for its emphasis on remuneration, its failure to self regulate adequately, its apparent inability to address problems felt to be important by society, and the fact that the profession often puts its own welfare above that of both society and individual patients.14 15 16 17 18 19 Without question, this literature reflected public opinion and had an influence on the public perception of the medical profession.

During the past 15 or so years the literature has been more supportive of professions,10 20 21 22 but the medical profession should not become complacent, as public trust in doctors and their associations has not improved greatly. Throughout the Anglo-American world, however, the medical profession is no longer viewed as being principally responsible for the direction of health care. This responsibility is shared with the state and the corporate sector, and they are now sharing blame for defects in the system. Thus there is an opportunity for the profession to address the issues facing it in an atmosphere that is less hostile. Individual doctors evidently retain the trust and respect of their patients, and patients continue to wish that major decisions concerning their health are made by doctors rather than corporations or the state. The public is the ally of the medical profession in this area.23

The educational challenge

Doctors are judged both as healers and as professionals, and when they do not fulfil their obligations in either role both they and the profession suffer. When the medical profession was smaller, more homogeneous, and had more truly shared values—and when the issues were simpler—professional values could be imparted during the process of “socialisation” of doctors in training. The profession is now diverse, as in almost every country doctors come from various cultural, ethnic, and economic backgrounds. Though this represents an advance in terms of equity and fairness, it makes the transmission of common values more difficult and, in our opinion, requires explicit teaching of the role of both the healer and of the professional. As Irvine noted, the leader in medicine retains a critical role,1 but this leader must teach professionalism in a structured way in addition to demonstrating professional values in everyday life.

Medical schools, teaching hospitals, and those responsible for continuing medical education should teach professionalism as a subject formally identified in the curriculum. The material to be taught will change in different cultures and certainly with time. The teaching of professionalism should include several components.

1. Identifiable educational content in the undergraduate medical school curriculum devoted to professionalism, which should be reinforced in postgraduate programmes and in continuing medical education. The subject should be part of the evaluation of all students.

2. The concept that to be a professional is not a right but a privilege with a long history and tradition of healing and service.

3. The separate but linked concepts of the physician as healer, and the physician as professional, and the fact that society uses professional status as a means of organising the delivery of services.

4. A clear definition of professionalism and its characteristics.

5. Professionalism as an ideal to be pursued, emphasising its inherent moral value. The concept of altruism and “calling” must be highlighted as essential to professionalism.

6. An understanding that proper professional behaviour is essential for the healer to function fully and to maintain the trust of patients and society.

7. Knowledge of codes of ethics governing the conduct of both the healer and the professional, as well as the philosophical and historical derivations of these codes.

8. The essential nature of the autonomy of the individual doctor, along with the legitimate limitations that have always existed. The degree of autonomy will vary in different societies, but a minimum is required for a doctor to exercise the necessary independent judgment to best serve the patient.

9. The nature of the collective autonomy of the profession, along with its legitimate and inherent limitations.

10. Relevant material drawn from sociology, philosophy, economics, political science, and medical ethics as related to professionalism, including interpretations of both the historical course of events and of doctors' behaviour that are critical of the medical profession. The profession must not be allowed to build and maintain its own myths while avoiding ideas challenging them.

11. The link between professional status and the obligations to society that must be fulfilled to maintain public trust. These obligations should be explicitly outlined and included in the teaching. They include obligations to know and be guided by the applicable codes of ethics and national and regional laws; to participate in more effective and transparent self regulation; to address health issues of concern to society; to maintain competence throughout one's medical career, to be prepared to be fully accountable for all decisions taken; to expand and ensure the integrity of medicine's knowledge base by supporting science in its broadest sense; to insist on the maintenance of sufficient individual and professional autonomy to enable the doctor to act in the best interests of the patient; and to be governed by professional standards of conduct no matter what role is being filled—private practitioner, employee of the state or corporation, manager, administrator, or a mixture of roles. Finally, of course, the obligation to put the welfare of the patient and of society above one's own is paramount.

Conclusion

A recent editorial entitled “Do professions have a future?” outlined the challenges facing the medical profession and suggested some responses.24 However, the question was not answered directly. For two reasons, professions not only have a future—and it is in the best interests of society that professional status be maintained. In the first place, self regulation in the profession should lead doctors to be better motivated than they would be if they considered themselves to be employees of the state or of a corporation. Secondly, if professionalism is an ideal to be pursued it should lead to ever higher standards which, by being constantly aimed at, lead to higher levels of performance.

Most doctors wish to meet their obligations properly. To quote Kultgen, “Entry into the profession is a voluntary act, and most people who perform it are disposed to learn its ways and take its ideology seriously. They need only to be told how.” 10 Properly informing them is one of the tasks of Irvine's medical leaders.