Medical Professionalism:

The concept of professionalism according to Frederic

Hafferty dates as far back as 400 B.C., with Hipppocrate’s oath
of professional ethical standards and has evolved over time.
The professionalism of yesterday is not the professionalism of
today, nor will it be the professionalism of tomorrow. Its
evolution has come in a series of waves of pulses. One such
change was made by Herbert Swick who identified nine key
behaviors of professionalism that focused on individuals. The
other ways of thinking about professionalism delved less about
the action and acts of individuals and was about a profession as
a whole that parallel notions of collective responsibilities. This
way of conceptualizing professionalism was developed when
the American Board of Medical Specialties formed a committee
on professionalism and ethics to come up with some
definitional framings that could be adopted by the medical
profession. The definition that was framed states “Medical
Professionalism is a belief system about how best to organnize
and deliver health care which calls on group members to jointly
declare what the public and individual patients can expect
regarding shared competency standards and ethical values to
implement trustworthy means to ensure that all medical
professionals live up to these promises.” What is apparent in
thee definition is the shift from the individual to the collective
and from the framing of professionalism now as srelational and
a dynamic conversation between the professionals and the
public. This underscores the fact that professionalism is not so
much a noun but a verb, a dynamic entity that changes over
time. Some core elements of professionalism are the same but
the shadings change depending on the issues that arise and get
discussed. The notion that professionalism is relational and a
dynamic conversation between the professional and the publlic
gives the idea that there is an agreement or a “social contract”
between them. This so called social contract will be discussed
later.

One element that is evident from the definition is the notion

of trustworthiness. The trust that is embodied is not merely a
trust between the clientele or the public and the profession but
that the profession in some way becomes worthy of that trust.
Professionalism is the process through which a profession, and
in this case the medical profession becomes worthy of the trust
of patients and the public. This notion exemplifies the thinking
around how health professionals can ensure they are worthy of
trust. Professionals can do so by putting forward a set of
practice standards, making the standards public and listing the
standards as specific behaviors to which the health professions
will then hold themselves accountable. These lists of desirable
professional attributes are seen as critical for behavioral
assessments and for training but they are not professionalism
per se for professionalism is not the list of things health
professionals say they are going to do but rather
professionalism among health professionals is the reason why
the list was developed.

What is this social contract?

Within health care, the social contract lays out expectations

between society and the health professions, expectations that
are constantly evolving as societies and culture change. The
assumption in this social contract is that each side will live up to
the terms of the contract as they are redefined. When one
party fails to meet their expectations there is a loss of trust. For
health professionals this loss of trust results in decreased
autonomy for the profession (example: the regulation of the
profession may shift from the professional organization where
the profession is allied to the government who may legislate
reforms that will regulate implementation of health policies or
it may strip the profession of its privilege to self-regulate its
members. On the other hand when society fails to meet
expectations of the health professionals there is a similar loss
of trust, although the outcome is less clear which can be shown
when health professional lose their drive to practice their
profession how they see fit when they begin to view their work
as a job rather than a calling (Example: when a physician loses
trust in his patient he may give up the care for the patient but
instead give him or her to some other health care institution, or
when the community fails to meet what is expected of it the
rural health physician may lose interest in his work and gives up
his or her job.)

The way societies are oriented shape the social contract

that exists between the health professional and the community.
In societies where individualism and individual performance is
emphasized the corporate (entrepreneural) sector strongly
influences elements of health and health care whereas in a
society where collective responsibility is stressed the social
contract is dominated by the state or the government where
government funds the health care system of that society (ex:
Cuba, Great Britain, Canada)

A social contract involved two parties, the profession and

the community. At present what the health care system is best
on doing in order to craft a viable social contract is to employ
greater patient engagement. Patients are not an afterthought,
they are part of everything health professionals do. Today and
future or next generation health professional must be educated
with this patient-centered focus to better prepare them for
work in clinical and community health settings. This notion of
greater engagement of community members and users of the
health system will have the following advantages:

1. Improve communication and collaboration among

health professionals that will improve safety and quality of
care.

2. Respond to the desires of the public to participate

actively in deciding the future of their personal health and to
influence how health care could be structured.

3. Avoid the impingement of the political process on health

care.

4. Create a health care system in which learners and

practitioners across the professions work collectively with
patients, families and communities and with each other.

And the reason professionalism should be the tie that binds

health professions to each other and to the public are:

1. To strengthen the trust among the health professionals

and between the professionals and the public.

2. To hold health professionals accountable to professional

standards.
 The importance of the notion of a social contract cannot be
overemphasized and the concept can be used to teach and
learn about professionalism. When this is imparted it is
emphasized that health care professionals are both healers and
professionals. Separating the roles into two distinct categories
makes the concept easier to understand and explain even to
future health professionals.

What are the attributes of these two categories:

As Healers:

- Caring/compassion, listening

- Insightful about patient and his/her own feelings

- Openness to different cultures

- Respect for the healing function/ being aware of his role

- Respect patient dignity/autonomy

- Advocate for the patient

- Present/accompany

As a Professional:

- Autonomy

- Self-regulation by association and institutions

- Responsibility ro society
 - Team work

These define degree of professional autonomy that allow

health professionals to set their own rules and regulations for
entry or exit from the profession.

These two categories can be at odds but they are also linked
by the codes of ethics that describe the behavior of both like:

- Commitment to help patient

- Confidentiality

- Altruism to put the patient’s needs above his own

- Trustworthiness

- Possesses integrity, honesty

- Moral and ethical behavior

- Responsibility to the profession

When professionalism and the social contract are impressed

early in a health professional’s journey to a fulfillment of
his/her future career and destiny they will a) better understand
what professionalism is and what their obligations as health
professionals will be to society, b) they will develop their
professional identity early, 3) they will create an opportunity to
shape their views by looking at where health professional have
failed society. Some may not be altruistic as society expects
because they also have to balance their lifestyle with altruiusm
and responsibility to society with financial gains, also the
mal-distribution of health resources may be seen negatively as
lack of social justice.

The structure of the social contract is influenced by the

environment which alters the responsibilities of the
professionals between these to individuals and the community.
A clinician and a public health professional deal with different
clients. Patients in the clinical setting are sick and vulnerable
while those in public health setting tend to be more
ambulatory and are often part of a wider community such that
the clinic based professional derive their concept from the use
of biomedical thinking whereas in public health their concepts
are derived from ethical practice, human rights and social
justice thus will have different expectations although there are
values that may be similar for both like that involves principles
of justice and respect (ex. The altruistic attribute a physician).
Also both may share professionalism processes in that both
have to weigh the burdens and benefits in deciding the right
course of action in any particular situation.

Finally what are the desirable behaviours that can be used to

assess inter-professional professionalism. Inter-professional
professionalism overlaps conceptually with broader definitions
of professionalism, and it builds upon previous research on
team functioning, inter-professional education (McNair, 2005;
Clark, 2006),
Inter-professional care, and relational coordination (Gittell et
al., 2008). The goal is to develop and articulate those elements
of professionalism that are uniquely relevant to collaboration
across health professions.

Earlier it was mentioned that Swick identified key behavior

of professionalism. This is because professionalism as a belief
can be manifested only be behaviors of individuals that can be
measured, monitored, improved, taught, and evaluated. The
assessment would recognize the personal motivations that
influence individuals to behave in the way that it is defined by
the profession. It was also mentioned that professionalism is
evolving and remains a changing target. In fact professionalism
is a changing set of behaviors rather than a belief system. In
order to demonstrate proficiency, professionals must adopt
behaviors that can be measured and assessed rather than
beliefs. The desirable behaviors are categorized into six:
a) Communication – communicates with other members of
other health professions in a way they can understand.
b) Respect – demonstrates confidence without arrogance while
working with members of other health professions.
c) Altruism and caring – place patients/clients needs above his
or her own needs and those of other health professionals.
d) Excellence – contributes to decision about patient care
regardless of hierarchy/profession based boundaries.
e) Ethics – Report or addresses unprofessional and unethical
behavior when working with members of other health
professions.
f) Accountability – accepts consequences for his/her actions
without redirecting blame to members of other health
professions.

Professionalism is not an end in itself but rather it supports

the ultimate goals of patient/client/family-centered care,
quality and patient safety. The potential for professionalism to
contribute to safe, high-quality patient/client/family-centered
care is intimately connected to the health professional’s ability
to work inter-professionally. Professionalism combined with
cooperation among members of multiple health professions is
key to achieving patient care goals. In the context of increasing
complexity of care, focusing narrowly on professionalism
without including cooperation may actually undermine quality
and safety by detracting clinicians from the need to collaborate
effectively across professions.

As parting words, professionalism when practiced by all

professions not only the medical profession will improve health
care quality and outcome for patients and clients and their
families, promote a culture that values and fosters individual
competence and enhance both education and practice
environments or setting