Professionalism in medicine is defined by three principals 1) a specialized body of knowledge that its physician members must teach and expand upon, 2) a code of ethics and a duty of service which puts patient care above self-interest, and 3) the privilege of self-regulation granted by society.1,2,3 The American Academy of Physical Medicine and Rehabilitation (AAPM&R) describe professionalism in physiatry as behaviors that promote humanism, ethics, and communication, which lead to patient-centered care for individuals with physical and cognitive impairments.1
Herbert Swick. MD described 9 specific behaviors that exemplify medical professionalism. Physicians should:
- subordinate their own interest to that of the interest of others, and thus reflecting the intrinsic component of the duty to serve (altruism)
- adhere to high ethical and moral standards of beneficence and non-maleficence (beneficence is the duty to do right; non-maleficence is to avoid doing wrong)
- respond to societal needs with behaviors that both reflect a social contract with the community, and address the duty of social leadership
- display core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others, and trustworthiness
- exercise accountability for themselves and for their colleagues
- demonstrate a continuing commitment to excellence, quality, and persistence in acquiring new education and skills
- exhibit a commitment to scholarship and to advancing the field
- exercise appropriate judgement, even when dealing with high levels of complexity and uncertainty
- reflect upon their actions and decisions; this includes self-reflection on knowledge, skills, and work-life balance4
Professional forums and accrediting agencies, including the AAPM&R, the American Medical Association (AMA), and the Accreditation Council for Graduate Medical Education (ACGME), specify expectations to maintain professionalism. These expectations include a code of ethics, a code of conduct, declarations of professional responsibility, and position statements.1,5, 6, 7, 8 Expectations of the professional physiatrist also encompasses the nuances of dealing with capacity and competence in a population that is considered vulnerable — the disabled, and education for learners on these topics is critical.9,10 The ACGME defines the qualities of professionalism and states that an individual meeting graduation level professionalism at the end of residency should participate in organizations/committees, recognize the role of cultural factors over disease and clinical management, and promote a collegial spirit and a high standard of moral behavior that includes patients, education of residents, and research.11
Professionalism also impacts public trust and society in a much larger scale with the ubiquity of social media. How a physician or medical student portrays his or her opinions and private life to the online public can spread to a very broad audience. While individual institutions vary on how they teach social media etiquette, the AMA created guidelines regarding social media and an online presence. In their Code of Medical Ethics, it states that maintaining an online presence should include
- being cognizant of the standards of patient privacy and confidentiality in all environments
- following ethics guidance regarding confidentiality, privacy, and informed consent, even when using social media for educational purposes or to exchange professional information
- using privacy settings to safeguard personal information, even when using social media for networking
- maintaining proper boundaries if interacting with patients
- maintaining appropriate boundaries between personal and professional online content
- taking responsibility to alert a colleague if unprofessional content is posted
- recognizing that online actions may negatively affect his/her reputation.12
Relevance to Clinical Practice
Professionalism is part of the academic curriculum and includes learning activities and assessment tools that evaluate the achievement of this competency. However, there continues to be concerns about the ability to teach and transmit these expected values and behaviors and how it can be promoted through appropriate role modeling, mentoring and coaching, professionalism.7,13
The ACGME Milestones aim to determine if the resident has achieved expected competencies, both for all physicians and specialty specific, and include a category on professionalism. The ACGME believes that via the Milestones, faculty can observe the developmental steps of professionalism, promote clear communication of appropriate educational goals, and identify the residents who are lagging behind and need remediation or mentoring earlier on in training. Training programs are responsible for identifying the learning activities and assessment tools utilized to measure all milestone achievements, including professionalism. Levels of competency range 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. Based on the developmental continuum of the professional growth model, residents demonstrate either achievement or delays in attaining any level of competency at any postgraduate level of training, at any moment of their training period.13, 14 Since its induction, use of the ACGME Milestones has been helpful in monitoring outcomes in teaching professionalism. An updated Milestones 2.0 will soon arrive for PM&R and other residency specialties.
There are basic attributes of professionalism, such as the code of ethics and duty of service to patients, that are foundational to the definition and its application that must be followed by all physicians and medical students. It falls upon the faculty to teach these attributes to trainees. By teaching professionalism and ethical principles, one assures that fellows, residents and students learn early in their training about the expectations set up for their practice.10, 14 For the physiatrist who teaches, it enforces the responsibility of learning about performance evaluation, coaching, mentoring, and role-modeling, and about the role they play in the promotion of a learning culture. A longstanding and effective way of teaching professionalism and ethics is via bedside teaching.15 Teaching these topics at the bedside reinforces “the relationship between technical competence and ethical decisions.”9 Case presentations can also be useful in educating learners on certain topics of professionalism.15 But overall, it is of utmost importance that learners be taught topics of competence, personal belief systems that may impact decisions, decision makers and alternative decision makers, medical futility, and the broader psychosociological impact of disability including items like the American with Disabilities Act.9
Teaching and evaluating professional behaviors may 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, residents, and providers who should be dismissed from their functions.15 But, in addition, it gives faculty the opportunity to provide developmental feedback that contributes to the continued growth of a trainee, reward/reinforce the behaviors on those who are highly professional, 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.16
Teaching professionalism does not guarantee that learning will occur, and transitioning from the theoretical concept to clinical practice application is not an obvious consequence. The literature agrees that multiple assessment tools should be used to complete a comprehensive picture about professionalism development, but this can be very time consuming. Additionally, lapses in professionalism may manifest in other ways. For instance a learner’s refusal to study or learn may result in a lack of Medical Knowledge in his or her ACGME Milestones or can manifest as deficits in the Interpersonal Communications Skills Milestone. While it is easier to evaluate medical knowledge and even interpersonal skills, the problem of professionalism may be overlooked. Brennan et al. performed a systematic review of the literature looking into tools to measure professionalism. There were limits in the studies reviewed, but the authors noted that overall, continuous and multi-source feedback was effective in assessing professionalism.16 Some reliable and/or valid tools include the following:
- Observed Clinical encounters: examples are the Mini Clinical Evaluation Exercise (mini-CEX)17,18 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.18 For physiatric residents, the Resident Observation and Competency Assessment (ROCA) can be used to monitor professionalism during a real-time patient encounter.19
- 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 multiple disciplines, who will focus on the different competencies.16, 20 However, despite broad appeal of utilizing multi-source evaluations, a small study within PM&R demonstrated skepticism by residents in the use of peer review/peer evaluations on influencing professional behaviors of their co-residents.21
- Simulation: standardized scenarios resemble real life situations and can be used to assess unpredictable situations, including practicing communication skills and professionalism. 16, 22
- Other tools that can be used: supervisor’s global view, paper based test, and patient’s opinion.16
Remediation of professionalism, much like the assessment, is difficult as well. Based on Brennan et al.’s systematic review, methods include self-awareness/self-reflection activities, mentorship, and coaching. For those whose professionalism lapses result in other milestone deficits, those other deficits are often remediated rather than the underlying professionalism issue.16 It would be wise for such individuals to remediate both (all) milestone deficiencies – for instance Medical Knowledge, Patient Care – Procedural Skills, and Professionalism.
Cutting Edge/Unique Concepts/Emerging Issues
Many consider mentoring and role-modeling as the most important tool to follow professional development, both when the trainee lags behind and for career progression.23 Future research may want to try and identify how to best pair a mentor with a mentee. Self-reflection and training in emotional intelligence can also be helpful for training professionalism in our learners.
Gaps in Knowledge/Evidence Base
More options for objective, standardized measurements of professionalism are needed. Additionally, tools that are easily and quickly used to measure professionalism in our trainees will help make the clinical and teaching workflow easier. Similarly, effective remediation techniques and training in self-reflection and emotional intelligence can be helpful. More guidance and education on the effectiveness of mentorship and different coaching style can help train our teachers. For faculty attendings, ethics lectures and grand rounds, required by the ACGME and many state medical boards, also educate individuals on professionalism. More online resources for ethics education and discussion may be warranted to aide in maintenance of certification.
Continued revision of ACGME Milestones to reflect professionalism and all that it encompasses with changes in healthcare and society are needed. Continued research on professionalism, how to teach it uniformly, assess it objectively, and remediate it effectively are all needed. Further guidance and education for the teachers on how to effectively mentor, role-model, and coach those we train is also needed.
The authors would like to acknowledge Dr. Maricarmen Cruz and Dr. Mario Sanchez, from which much of this manuscript was adapted from.
- 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 March 17, 2020.
- Tsou A, Creutzfeldt C, Gordon J. The good doctor: Professionalism in the 21st century. Handb Clin Neurol. 2013;118:119-132.
- Sulmasy LS, Bledsoe TS. ACP Ethics, Professionalism and Human Rights Committee. American College of Physicians Ethics Manual 7th Edition. Ann Inten Med. 2019;170:;S1-S32.
- Swick H. Toward a normative definition of medical professionalism. Acad Med. 2000;7:612-616.
- 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 March 17, 2020.
- 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 March 19, 2020.
- ACGME Board of Directors Resolution on Professionalism. ACGME. http://www.acgme.org/Portals/0/PDFs/ACGMEBODResolutionAdopted.pdf. Accessed March 19, 2020
- 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 March 19, 2020.
- Sliwa J, McPeak I, et al. Clinical Ethics in Rehabilitation Medicine: Core Objectives and Algorithm for Resident Education. Am J Phys Med Rehabil. 2002;81(9):708-717.
- Silver J, et al. The Vital Role of Professionalism in Physical Medicine and Rehabilitation. Am J Phys Med Rehabil. 2020;99(4):273-277.
- Accreditation Council for Graduate Medical Education: The Physical Medicine and Rehabilitation Milestone Project. A Joint initiative of the Accreditation Council for Graduate Medical Education and The American Board of Physical Medicine and Rehabilitation. http://www.acgme.org/portals/0/pdfs/milestones/pmrmilestones.pdf Accessed March 17, 2020.
- Professionalism in the Use of Social Media. Code of Medical Ethics Opinion 2.3.2. AMA. https://www.ama-assn.org/delivering-care/ethics/professionalism-use-social-media Accessed March 16, 2020.
- 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.
- Nasca T, Philibert I, Brigham T, Flynn T. The next GME accreditation system–rationale and benefits. N Engl J Med. 2012;366:1051-1056.
- Siegler M. A legacy of Osler. Teaching clinical ethics at the bedside. JAMA. 1978;239(10):951-956.16. Kirk L. Professionalism in medicine: definitions and considerations for teaching. Proc (Bayl Univ Med Cent). 2007;20:13-16.
- Brennan N, Price T, Archer J, Brett J. Remediating professionalism lapses in medical students and doctors: A systematic review. Med Educ. 2020;54:196-204.
- Hejri S, et al. The utility of mini-Clinical Evaluation Exercise in undergraduate and postgraduate medical education: A BEME review: BEME Guide No. 59. Medical Teacher. 2020;42(2):125-142.
- Wilkinson T, Wade W, Knock L. A blueprint to assess professionalism: results of a systematic review. Acad Med. 2009;84:551-558.
- Musick D, et al. Reliability of the physical medicine and rehabilitation resident observation and competency assessment tool: a multi-institutional study. Am J Phys Med Rehabil. 2010;89(3):235-244.
- Berk R. Using the 360 multisource feedback evaluation model to evaluate teaching and professionalism. Med Teach. 2009;31:1073-1080.
- Bonder J, et al. Implementation of Peer Review into a Physical Medicine and Rehabilitation Program and its Effect on Professionalism. PMR. 2010;2(2):117-124.
- Waltz M, et al. Professionalism and Ethics: A Standardized Patient Observed Standardized Clinical Examination to assess ACGME Pediatric Professionalism Milestones. MedEdPORTAL. 2020;16:10873.24.
- Galicia A, Lima R, Date E. Mentorship in physical medicine and rehabilitation residencies. Am J Phys Med Rehabil. 1997;76:268-275.
Original Version of the Topic
Maricarmen Cruz, MD, Mario Sanchez, MD. Professionalism in rehabilitation: peer, student, resident and fellow recommendations. 9/20/2013.
Kim Barker, MD
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Caroline Smith, MD
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