A Behavioral and Systems View of Professionalism

Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence but rather we have those because we have acted rightly. We are what we repeatedly do. Excellence then is not an act but a habit.—Aristotle¹

Even after the passage of comprehensive legislation, vigorous debate continues about how to reform the US health care system. Patients, payers, politicians, and physicians all agree that something must be done to improve health care delivery, but the consensus ends there. Great enthusiasm exists for performance reporting and payment linked to patient outcomes, but evidence that these mechanisms significantly improve patient care is not uniformly positive.^{2 - 4} Missing from public discussion is the role professionalism and professional values can and should play in supporting health system improvements.

Health care is a fundamentally human activity that occurs in the course of innumerable interactions that ultimately must be guided by an overarching ethos or value set, and those values need to be cultivated alongside performance metrics and payment strategies intended to instill greater accountability in the system. A growing body of social science literature calls attention to the limits of financial incentives as a motivator and identifies pride of purpose and intrinsic motivation as more powerful forces underlying human behavior.⁵ Particularly in a field as complex and as high stakes as health care, professionalism has long been recognized by economists and medical ethicists as an essential mediating force in patient care.^{6 - 8} Professionalism may not be sufficient to drive the profound and far-reaching changes needed in the health care system, but without it, the health care enterprise is lost.

There are many reasons the concept of professionalism and core professional values typically are not an explicit part of discussions about health reform. Patients and consumer groups are unclear about the meaning of the word professionalism. They often view it negatively, as a set of guildlike privileges and entitlements focused entirely on the physician. Physicians may feel bludgeoned by admonitions to “be professional” in systems that foster and reward unprofessional behavior. Medical students have long been aware of the observed disconnect between values articulated in the classroom and those actually exhibited in clinical settings. Formal statements attempting to define professionalism tend to be abstract and principle based, without clear description of what professional behavior is in practice, particularly in the context of the complexities of the current health care environment.

In recent years, there have been several efforts to advance a contemporary definition of professionalism and identify specific behaviors that exemplify professionalism in the current practice environment.^{9 - 10} In addition, there is greater awareness that context matters; ie, professional behaviors are influenced by environmental forces.^{11 - 12} However, there remains a perception of professionalism as a somehow static quality that if strong enough, should transcend or withstand the pressure of negative influences.

Professionalism should be considered in more dynamic and behavioral terms, and this perspective has important implications for why professionalism matters and for how professionalism can be strengthened. Professionalism is not simply a set of text-based ideals for practice, rather it is an approach to the practice of medicine that is expressed in observable behaviors. This lived approach to the practice of medicine ultimately mediates physicians' countless, day-to-day interactions delivering care. A more behaviorally based perspective on professionalism underscores the importance of professionalism in daily practice and makes the pursuit of professionalism more accessible and attainable.

In addition, there is a need to evolve from thinking about professionalism as an innate character trait or virtue. Consistently exhibiting behaviors that reflect professional values requires sophisticated competencies that can and must be taught and refined over a lifetime of practice. Also, professional behaviors are profoundly influenced by the organizational and environmental context of contemporary medical practice, and these external forces need to be harnessed to support, not inhibit, professionalism in practice.

Seen from this perspective, professionalism can be thought of as an emerging quality of the health care system, a quality that can and must be cultivated by multiple actors including individual physicians; the medical education, training, and assessment establishments; delivery system leaders; and policy makers. Together, these stakeholders can foster the competencies and create the conditions to promote professional behaviors in practice.

Professionalism is grounded in a series of intentional commitments physicians make to their patients and to society. The Physician Charter on Medical Professionalism⁹ offers a contemporary definition of professionalism that resonates with many physicians today. A 2007 survey by Campbell et al¹³ found that most physicians agree with the core commitments expressed in the Physician Charter, including physician responsibility to minimize health care disparities due to patient race or sex (98%), to provide necessary care regardless of the patient's ability to pay (93%), and to put the patient's welfare above the physician's financial interests (96%). The survey also found strong concordance with the charter call for physicians to participate in improving quality of care and reducing medical errors (93%-98%).¹³

Since the charter was issued in 2002, there have been a number of efforts to make more explicit what constitutes professional behavior in the current environment. For example, Swensen et al¹⁴ recently offered a vision of the modern-day good doctor:

 In the past, a stereotypical good doctor was independent and always available, had encyclopedic knowledge, and was a master of rescue care. Today, a good doctor must have a solid fund of knowledge and sound decision-making skills but also must be emotionally intelligent, a team player, able to obtain information from colleagues and technological sources, embrace quality improvement as well as public reporting, and reliably deliver evidence-based care, using scientifically informed guidelines in a personal, compassionate, patient-centered manner.

Similarly, the “Guide to Good Medical Practice”¹⁰ describes the desirable characteristics of the “competent” physician, identifying specific behaviors that map to the core principles articulated in the Physician Charter as well as the 6 domains of competence advanced by the Accreditation Council for Graduate Medical Education. These definitions of professionalism importantly include new responsibilities of physicians to improve systems of care and optimize the health of the population, to be accountable to individual patients and society for quality of care, and to act as stewards of health care resources.

To further build on this important work, we offer a framework for conceptualizing professional behaviors in 2 key domains: individual interactions with patients, family members, and colleagues in the health care team (Table 1) and organizational interactions in the management and governance of care delivery settings and in professional organizations (Table 2). The framework draws on the Physician Charter⁹ to identify 4 core values of contemporary medical professionalism: (1) compassionate, respectful, and collaborative orientation, with a focus of being “in service” of the patient; (2) integrity and accountability; (3) pursuit of excellence; and (4) fair and ethical stewardship of health care resources. Within each area, there are some specific examples of behaviors that would exemplify professionalism in practical terms. The behaviors described in the exhibit are intended to be illustrative only. However, this level of specificity and emphasis on behaviors, rather than attitudes, is important to make more explicit what types of actions demonstrate professionalism in practice.

For example, in practical terms, integrity and accountability in interaction with patients and family members involves maintaining patient confidentiality and appropriate relationships with patients, promptly disclosing medical errors and taking steps to remedy mistakes, and actively managing conflicts of interest and publicly disclosing any relationship that may affect diagnostic and treatment recommendations. In interactions with colleagues and team members, practical expressions of integrity and accountability include reporting impaired or incompetent colleagues, participating in peer-review and 360-degree evaluations, and specifying standards and procedures for handoffs across settings of care to ensure coordination and continuity. At the organizational level, physicians can advance integrity and accountability in their practice settings by fostering organizational supports for error disclosure, advocating for clear and stringent policies regarding conflict of interest and patient confidentiality, and providing performance feedback to the care team and reinforcing accountability for results. At the national and state level, physician advocacy and professional standard−setting organizations can advance integrity and accountability by pursuing development of systems to report and analyze medical mistakes and pursuing disclosure of meaningful performance information.

The critical message of this framework is that professionalism is not a static or amorphous construct. Rather, it can be defined in concrete behaviors and should be understood as a lived approach to the practice of medicine that emanates from physicians' many varied interactions in the care delivery system.

Viewing professionalism through the lens of observable behaviors reinforces the notion that professionalism is a multidimensional competency that can be nurtured over time and points to the range of judgment and skills physicians need to exhibit in practice. For instance, interactions with patients, family members, colleagues, and members of the health care team require effective communication skills, cultural competence, the ability to express empathy, self-awareness, and skills related to conflict resolution. Other skills related to system-level professional behaviors include proficiency in quality improvement, use of clinical information systems, avoiding conflict of interest, and advocating for patients’ needs. Applying these skills in practice requires sophisticated judgment and decision-making skills.

Conceptualizing professionalism as a set of behaviors, enabled by a specific set of skills, challenges the traditional notion that professionalism is a strictly attitudinal competency based on immutable character traits and suggests instead a more explicit growth and development model. Lucey and Souba¹⁵ suggest that professionalism requires firsthand learning experiences and is a capacity that can be developed and deepened over time. Leach¹⁶ similarly notes that whereas adult learners may enter medical school with the desire to exhibit the values of professionalism, they have no experience in maintaining professional behavior under the challenging circumstances that confront practicing physicians. Achieving professionalism in practice requires the capacity to navigate competing priorities and make sound judgments and decisions, often under pressure or in stressful situations. Simply knowing right from wrong or having a strong internal compass does not suffice. Consistently exhibiting professionalism is a practiced skill. Moreover, like other competencies, professionalism follows a developmental curve from beginner to expert that evolves over the course of a physician's career.¹⁵

Lucey and Souba¹⁵ further suggest that the challenges to exhibiting professional behaviors in practice should be considered routine, not anomalous, and that development of professionalism competency should focus on building resiliency and adaptability to effectively respond to such challenges. They identify a number of key teachable skills, including self-awareness and self-control, situational awareness, alternative strategy development, crisis communication skills, and peer coaching. They also point to the principles of emotional intelligence, reflective practice, and mindfulness as critical to nourishing professionalism in practice.

Emphasizing behaviors in how professionalism is conceptualized underscores the importance of context, or the notion that cultural norms and stressors in the environment influence physician behavior. The role of context has gained a great deal of attention in the professionalism literature in recent years, particularly in terms of how the learning environment shapes professionalism in medical education and training.^{11 - 12}

Others have called for physicians' professional responsibilities to extend to improving systems of care and population health¹⁷ and have noted the impact of societal and organizational forces on physician professionalism.^{12 ,18} Building on the notion of context and multiple layers of influence on physician behavior, the Figure conceptualizes physician professionalism as emerging in a series of nested settings—in interactions with individual patients and family members, with the physician's immediate care team or microsystem, within the larger practice environment in which that care team is situated, and within the broader external environment in which the practice environment operates. Each of these spheres requires the physician to navigate multiple interests and, at times, competing priorities. The patient sphere requires engaging support from and addressing concerns of the patient and the patient's family and friends. The microsystem sphere involves working with the immediate care team and members of the physician's practice. The larger practice environment requires the physician to juggle institutional priorities. The broader external environment introduces the influences of insurance company and federal or state regulations, payer expectations, and socioeconomic determinants of health. Acting professionally requires the physician to balance complex and competing values and perspectives across these spheres of influence.

This systems view of professionalism is grounded in understanding health care as a complex adaptive system, characterized by a dynamic network of interactions across multiple dispersed and decentralized agents whose actions influence one another. Professional behaviors are profoundly influenced by the organizational and environmental context in which care is delivered, and likewise, the environmental context is shaped by physician behaviors in these domains.¹⁸

This perspective is important because it implies that strengthening professionalism in practice will require strategies that go beyond improving individual physicians' resiliency and competency. Efforts to strengthen professionalism also need to focus on the organizational and environmental context in which physicians practice, identifying ways to align these external forces to foster professional behaviors and eliminate the barriers that inhibit them. Cohen et al¹² proposed an alliance between society and medicine, advocating for policy and organizational change to eliminate the structural impediments to professionalism that result from uneven access to care, limited infrastructure to support improvements in quality and safety of care, and misaligned financial incentives inherent in the current payment system, among other barriers.

The systems view of professionalism reinforces the importance of such changes, but physicians themselves also have a professional responsibility to press for such changes across the spheres of influence that define their environment—from the immediate microsystem in which they practice to the broader external environment that shapes how care is delivered. Just as professionalism emanates from actions not virtues, the functionality of the health care system also emanates from the myriad intersecting and interacting behaviors of multiple agents. Physician leaders have a particular responsibility to create care environments that encourage and support physicians to act in a professional manner and to learn from challenging situations. Striving to create environments that cultivate professionalism in practice is perhaps the ultimate expression of professionalism.

Reconceptualizing professionalism to emphasize observable behaviors resulting from the interaction between physician attitudes, judgment, skills, and the health care system has implications for education and for system-level reform. Medical education needs to evolve from treating professionalism as a personal character trait to teaching professionalism as a multidimensional competency requiring critical thinking, skill building, and deliberate practice. Education programs can teach trainees how to anticipate, recognize, and manage challenges to their professionalism—essentially building physicians' adaptive capacity. Viewing professionalism as a competency that can be continually strengthened motivates a new approach to education and assessment that focuses more on building resiliency and inspiring renewal, as opposed to defining professionalism by the absence of a visible breach of conduct. Organizations responsible for physician competency assessment can help practicing physicians view professionalism as a skill set that needs to be nourished over the course of their careers and can share best practices for managing professionalism challenges in practice.

At the same time, understanding professionalism as behaviors shaped by the organizational and environmental context suggests that strengthening professionalism will require efforts beyond those focused on “the profession” alone. Rather, more attention is needed to develop strategies to overcome mitigating factors and strengthen those that support physicians' capacity to exhibit professionalism in practice. These changes will require partnership with delivery system leaders and policy makers who shape important influences such as financial incentives and organizational arrangements that can support or hinder professional behaviors. A systems view of professionalism suggests an important shift in the nuance of how such reform discussions unfold. For example, rather than looking to develop payment methods that incentivize physicians to behave in certain ways (eg, pay for performance linked to isolated patient outcomes), the systems view of professionalism suggests that payment methods should be reformed to better enable physicians to fulfill their professional obligations to both individual patients and society. For example, payment methods that drive a focus on total cost and outcomes rather than discrete patient encounters reinforce these dual obligations. Focusing on how to enable professionalism in practice provides a different guide for these discussions that affirms the importance of physicians' intrinsic motivation to do the right thing and creates structures to support them in this effort. Physicians have a professional responsibility to raise awareness about these influences and to work with stakeholders at the organizational and policy levels to advance system reforms that cultivate and support professionalism as a critical force in a well-functioning and effective health care system.

Adopting a fresh perspective on professionalism can inform why professionalism matters and how it can be strengthened. Further research is needed to explore how to create effective teaching and assessment strategies to support the development of key competencies that enable professionalism in practice. In addition, more research is needed to explore how health care delivery systems and public policy can effectively support professional behaviors. This reconceptualization of professionalism can stimulate such activity and professionalism can become a vital component of health system reform initiatives in the years ahead.