Professionalism embodies the relationship between medicine and society, founding this relationship on the value of trust, and reflected by the attitudes, behaviors and characteristics consistently performed in clinical practice. Professional forum and accrediting agencies, including the American Academy of Physical Medicine and Rehabilitation, the American Medical Association, and the Accreditation Council for Graduate Medical Education (ACGME), center practice expectations for the professionals they represent through code of ethics, code of conduct, declarations of professional responsibility, and position statements.1-4The American College of Physicians Ethics Manual5 describes medical professionalism as a specialized body of knowledge that its members must teach and expand, by a code of ethics and a duty of service, which put patient care above self-interest, and by the privilege of self-regulation granted by society. Others define medical professionalism as a series of attributes that reflects societal expectations as they relate to physicians’ responsibilities to the patient and the community.6 A common item among all of these guidelines is the particular interest to promote the highest quality of patient care, including physiatric care.1 The physiatrist has a responsibility for the quality of care offered to the patient being served. This responsibility should altruistically take precedence over individual needs by modeling behaviors that promote humanism, ethics, and communication, which lead to patient-centered care.
Professionalism should be treated as a multidimensional competence, and this has gained great attention from the community and medical professional accrediting bodies. The ACGME encompasses professionalism as the set of skills necessary to practice good medicine, and as one of the elements required to enhance the quality of patient care; this includes commitment of carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Qualities described as professional are compassion, integrity, and respect; responsiveness to patient needs that supersedes self-interest; respect for patient privacy and autonomy; accountability to patients, society, and the profession; and sensitivity and responsiveness to a diverse patient population.7
For physiatrists, the ACGME expands the requirements to include expectations about participation in organizations and committees, humanism, recognizing the role of cultural factors over disease and clinical management, the promotion of a collegial spirit, and a high standard of moral behavior that includes patients, education of residents, and research.8 Professionalism has grown to impact the academic curriculum, the learning activities, and the assessment tools that properly assist in evaluating the achievement of this competency. Years of discussion have only led to raise more concerns about the ability to teach and transmit the expected values and behaviors and how through inappropriate role modeling a hidden curriculum about professionalism could be promoted that fails to fulfill the council’s expectations, calling for change.4,9
In regard to society, there are other concerns that impact the public trust, such as the boundaries when using social media, the relationship of professionalism to safety and quality of care, the role of honesty in reporting duty hours, the sense of responsibility identifying how fatigue may lead to errors and quality issues when taking care of patients, and the quality of care associated with structured hand off.10,11
Relevance to Clinical Practice
Recent changes in the ACGME accreditation system have led to an outcome-based model of evaluation that establishes new expectations and demands for faculty and their training programs in the evaluation of all competencies, including professionalism.6 This new accreditation system has several aims, including the following:
- Enhance the ability of the peer review systems to prepare physicians for practice in the 21st century.
- Accelerate the ACGME movement toward accreditation on the basis of educational outcomes.
- Reduce the burden associated with the current structure and process-based approach.
The rationale behind this new model is that resident’s professional development moves through a continuum that goes from novice to expert. Specific milestones are proposed in order to determine if the resident has achieved the expected competency. The intention is observing the developmental steps, promoting clear communication of educational goals, and the early identification of trainees who are lagging behind and need remediation or mentoring. Training programs are impacted with the challenge of identifying the learning activities and assessment tools that will be used to measure milestone achievements. In addition, training program directors and faculty are imposed the responsibility of dedicating more time to observe and document the achievement of these milestones.12
Other operational challenges of training programs are the need to:
- Redesign all evaluation forms so that appropriate documentation of the achievement of these milestones and the level of competency by learning activity is evidenced
- Establish and/or structure competency evaluation committees that include enough faculty representation with the administrative responsibility of aggregating and reviewing all the evaluations done to the individual resident, and make recommendations about competency achievement twice a year
- Promote continuous communication between the committee, faculty and training program directors to assure continuous awareness about milestones achievement that leads to progressive responsibility
The proposed ACGME milestones on professionalism are still under revision.
Level of competency is divided from 1 through 5, expanding from basic recognition of priorities on patient care and bioethical principles to the consistent use of ethical principles and mentoring in the field.12 Based on the developmental continuum of the professional growth model, residents could demonstrate either achievement or delays in attaining any level of competency at any postgraduate level of training, at any moment of their training period.
There are basic attributes of professionalism that are foundational to the definition and its application; these must be understood by faculty, residents, and students before being communicated and evaluated. By teaching professionalism, one assures that residents and students learn early in their training about the expectations set up for their practice. For the physiatrist who teaches, it enforces the responsibility of learning about performance evaluation, coaching and mentoring, remediation when unprofessional behavior is observed, and about the role they play in the promotion of a learning culture. Teaching and evaluating professional behaviors also allow the early recognition of individuals who will have a higher risk of having disciplinary actions in the future; including the identification of students, trainees, and providers who should be dismissed from their functions.13 But, in addition, it gives faculty the opportunity to provide developmental feedback that contributes to the continued growth of a professional, reward/reinforce the behaviors on those who are highly professionals, and measure quality indicators on patient care. A challenge in doing objective evaluations will be having the right tools that will reliably assist in the development of the educational activity and the measurement of this competency.14
Swick6 describes 9 specific behaviors, as follows, that facilitate understanding professionalism. Physicians:
- Subordinate their own interest to the interest of others – this reflects the intrinsic component of the duty to serve (altruism)
- Adhere to high ethical and moral standards – this reflects the duty to do right (beneficence principle) and to avoid doing wrong (non- maleficence)
- Respond to societal needs, and their behaviors reflect a social contract with the community served – addresses the duty of social leadership by responding to the community of society’s needs
- Evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others and trustworthiness – the practice of medicine is a human endeavor, so humanistic values are core
- Exercise accountability for themselves and for their colleagues – being accountable for actions and decisions is key to maintaining the public’s trust physicians demonstrate a continuing commitment to excellence – life- long learning efforts send a message about recognizing limitations; it promotes knowledge and competency improvement that leads to improved care
- Exhibit a commitment to scholarship and to advancing their field – including knowledge about cutting edge discoveries, and cost effective practices
- Deal with high levels of complexity and uncertainty – this includes the ability to exercise appropriate judgment in decision making
- Reflect upon their actions and decisions – this includes reflection about own knowledge and about a balanced life
Teaching professionalism does not guarantee that learning will occur, and transitioning from the theoretical concept to clinical practice application is not an obvious consequence. Specific activities should be used to assess professional behaviors, and for some time, the main activity was the reporting of duty hours. In 2011, an ACGME Task Force11published a comprehensive review of the impact of professionalism on quality of care. Through their review, they recognize that isolated changes in duty hours and supervision were not enough to support the expected learning environment and to promote safe patient care. Restricted duty hours indirectly intended to promote the practice of honesty, accountability, and self-responsibility; instead, it ended up changing the resident’s perceived educational experience and the time dedicated to direct patient care. The ACGME Task Force began to question if time frames dedicated to training were enough to graduate competent providers, which led to the discussion of milestones as the marker for competency achievement.
The literature agrees that multiple assessment tools should be used to complete a comprehensive picture about professionalism development, but this can be time consuming. Among the recommended tools are the following:
- Observed Clinical encounters: examples are the Mini Clinical Evaluation Exercise (mini-CEX) and the Professionalism Mini-Evaluation Exercise (P-MEX). These tools are used to observe snap shots of the interaction doctor/patient, short lasting (between 15-30 minutes), and conducted with real patients. The fault to this tool is the involvement of a single evaluator, and the inability to generalize the results beyond that specific encounter. The advantage is the opportunity for more accurate feedback. [ix], [x] What about PM&R specific tool–the ROCA?
- Collated views of coworkers: an example of this multisource instrument is the 360- degree evaluation. This is a systematic collection of data from knowledgeable persons above, below and at the same level of the individual. The main advantage is that it can incorporate multiples disciplines and patients, who will focus on the different competencies. [xi]
- Simulation: standardized scenarios resemble real life situations and can be used to assess unpredictable situations, including practicing communication skills
- Other tools that can be used: supervisor’s global view, paper based test, and patient’s opinion
Cutting Edge/Unique Concepts/Emerging Issues
Mentoring is considered by many as the most important tool to follow professional development, both when the trainee lags behind and for career progression.18 Mentoring is associated with academic success and preresidency decision about choosing physical medicine and rehabilitation as a career. Few studies exist regarding cross-race or cross-sex mentoring.
Gaps in Knowledge/Evidence Base
Professionalism attributes that require the development of better measurement tools are reflectiveness, advocacy, lifelong learning, dealing with uncertainty, balancing availability to others with care for oneself, among others.16
In the Next Accreditation System (NAS) era, attention should be placed on empowering faculty on assessment tools and mentoring skills that promote the development of professionalism.
1. American Academy of Physical Medicine and Rehabilitation. AAPMR Code of Conduct. 2013. Available at: http://www.aapmr.org/about/who-we-are/Pages/aapmr-code-of-conduct.aspx. Accessed June 1, 2013.
2. American Medicine Association. AMA’s Code of Medical Ethics. Available at: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page. Accessed June 1, 2013.
3. American Medicine Association. AMA Declaration of Professional Responsibility. Available at: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/declaration-professional-responsibility.page. Accessed June 1, 2013.
4. ACGME Board of Directors Resolution on Professionalism. ACGME. February 2012.
5. Snyder L. American College of Physicians Ethics Manual 6th Edition. Ann Inten Med. 2002;156:73-104.
6. Swick HM. Toward a normative definition of medical professionalism. Acad Med. 2000;7:612-616.
7. Accreditation Council for Graduate Medical Education. Common Program Requirements. July 1, 2011. Available at: http://www.acgme.org/acgmeweb/Portals/0/dh_dutyhoursCommonPR07012007.pdf. Accessed June 1, 2013.
8. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Physical Medicine and Rehabilitation. July 1, 2007. Available at: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/340_physical_medicine_and_rehabilitation_07012007.pdf. Accessed June 1, 2013.
9. Gillespie C, Paik S, Ark T, Zabar S, Kalet A. Resident’s perception of their own professionalism and the professionalism of their learning environment. J Grad Med Educ. 2009;1:208-215.
10. American Medical Association. AMA Opinion 9.124 – Professionalism in the Use of Social Media. June 2011. Available at: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion9124.page. Accessed June 1, 2013.
11. Philibert I, Amis S Jr. The ACGME 2011 Duty Hour Standards: Enhancing Quality of Care, Supervision and Resident Professional Development. Chicago: Accreditation Council for Graduate Medical Education; 2011.
12. Nasca TJ, Philibert I, Brigham TP, Flynn TC. The next GME accreditation system–rationale and benefits. N Engl J Med. 2012;366:1051-1056.
13. Kirk LN. Professionalism in medicine: definitions and considerations for teaching. Proc (Bayl Univ Med Cent). 2007;20:13-16.
14. Arnold L, Stern DV. Measuring Medical Professionalism. New York, NY: Oxford University Press; 2006.
15. Norcini JJ, Blank LL, Duffy FD, Fortna GS. The mini-CEX: a method for assessing clinical skills. Ann Intern Med. 2003;138:476-481.
16. Wilkinson TJ, Wade WB, Knock LD. A blueprint to assess professionalism: results of a systematic review. Acad Med. 2009;84:551-558.
17. Berk R. Using the 360 multisource feedback evaluation model to evaluate teaching and professionalism. Med Teach. 2009;31:1073-1080.
18. Galicia AR, Klima RR, Date ES. Mentorship in physical medicine and rehabilitation residencies. Am J Phys Med Rehabil. 1997;76:268-275.
Maricarmen Cruz, MD
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Mario Sanchez, MD
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