Professionalism and Beyond!

Earl J. Reisdorff, MD, FACEP

Director of Medical Education

Ingham Regional Medical Center
Lansing, Michigan
Associate Professor
College of Human Medicine
Michigan State University
residoe@irmcmail.irmc.org

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 Baton Rouge, LA
September 5, 2003

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ACGME Definitions of Professionalism
a. Patient Care that is compassionate, appropriate, and effective for the treatment of
health problems and the promotion of health
b. Medical Knowledge about established and evolving biomedical, clinical, and cognate
(e.g. epidemiological and social-behavioral) sciences and the application of this
knowledge to patient care
c. Practice-Based Learning and Improvement that involves investigation and
evaluation of their own patient care, appraisal and assimilation of scientific evidence,
and improvements in patient care
d. Interpersonal and Communication Skills that result in effective information
exchange and teaming with patients, their families, and other health professionals
e. Professionalism, as manifested through a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population
f. Systems-Based Practice, as manifested by actions that demonstrate an awareness
of and responsiveness to the larger context and system of health care and the ability
to effectively call on system resources to provide care that is of optimal value

Expanded Language

ACGME GENERAL COMPETENCIES Vers. 1.3

(9.28.99)

The residency program must require its residents to develop the competencies in the 6 areas
below to the level expected of a new practitioner. Toward this end, programs must define the
specific knowledge, skills, and attitudes required and provide educational experiences as
needed in order for their residents to demonstrate the competencies.

PROFESSIONALISM

Residents must demonstrate a commitment to carrying out professional responsibilities,

adherence to ethical principles, and sensitivity to a diverse patient population. Residents are
expected to:

 demonstrate respect, compassion, and integrity; a responsiveness to the needs of

patients and society that supercedes self-interest; accountability to patients, society,
and the profession; and a commitment to excellence and on-going professional
development
 demonstrate a commitment to ethical principles pertaining to provision or withholding
of clinical care, confidentiality of patient information, informed consent, and business
practices
 demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and
disabilities

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Professionalism Curriculum Matrix (Modified from The
Charter on Medical Professionalism)

Item Experiential Didactic Reading Special/Workshop

Principle of
primacy of
patient welfare.
Serves the interest All ED rotations Intro to Ethics House Officer House staff orientation
of the patient All off service Lecture Manual Attends at least one
rotations Orientation The Charter on Ethics Council
Medical Meeting
Professionalism
Jacobs Ch. 8
“Bioethics”
Market forces,
societal pressures,
and administrative
exigencies are not
permitted to
compromise care.
Principle of
patient
autonomy
Is honest with
his/her patients
and empowers
them to make
informed decisions
about their
treatment.
Patients' decisions
about their care
must are seen as
paramount, as long
as those decisions
are in keeping with
ethical practice
and do not lead to
demands for
inappropriate care.
Principle of
social justice.
Works actively to
eliminate
discrimination in
health care,
whether based on
race, gender,
socioeconomic
status, ethnicity,
religion, or any

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other social
category.
Commitment to
professional
competence.
Physicians must be
committed to
lifelong learning
and be responsible
for maintaining the
medical
knowledge and
clinical and team
skills necessary for
the provision of
quality care.
More broadly, the
profession as a
whole must strive
to see that all of its
members are
competent and
must ensure that
appropriate
mechanisms are
available for
physicians to
accomplish this
goal.

Commitment to
honesty with
patients.
Patients are
completely and
honestly informed
before the patient
has consented to
treatment and after
treatment has
occurred.
Whenever patients
are injured as a
consequence of
medical care,
patients should be
informed promptly
because failure to
do so seriously
compromises
patient and societal
trust.
Takes
responsibility for
his/her medical

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errors.
Commitment to
patient
confidentiality.

Does not discuss

patient’s condition
or care beyond
immediate care
providers.

Effectively
balances a
commitment to
patient and
overriding
considerations in
the public interest
(for example,
when patients
endanger others).
Commitment to
maintaining
appropriate
relations with
patients.
The physician
never exploits
patients for any
sexual advantage,
personal financial
gain, or other
private purpose.
Commitment to
improving
quality of care.
Demonstrates
dedication to
continuous
improvement in
the quality of
health care in
regards to
maintaining
clinical
competence.
Demonstrates
dedication to
continuous
improvement in
the quality of
health care in
regards to working
collaboratively
with other

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professionals to
reduce medical
error, increase
patient safety,
minimize overuse
of health care
resources, and
optimize the
outcomes of care.
Actively
participates in the
development of
better measures of
quality of care and
the application of
quality measures
to assess routinely
the performance of
all individuals,
institutions, and
systems
responsible for
health care
delivery.
The physicians
assists in the
creation and
implementation of
mechanisms
designed to
encourage
continuous
improvement in
the quality of care.
Commitment to
improving
access to care.
The physician
works to eliminate
barriers to access
based on
education, laws,
finances,
geography, and
social
discrimination.
The physician
promotes public
health and
preventive
medicine.
The physician is a
public advocate,
without concern
for the self-interest

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of the physician or
the profession.
Commitment to
a just
distribution of
finite
resources.
Provides health
care that is based
on the wise and
cost-effective
management of
limited clinical
resources.
Works with other
physicians,
hospitals, and
payers to develop
guidelines for cost-
effective care.
Avoids ordering
superfluous tests
and procedures.
Commitment to
scientific
knowledge.
The physician
upholds scientific
standards,
promotes research,
and creates new
knowledge.

The physician
practices evidence-
based medicine.

Commitment to
maintaining
trust by
managing
conflicts of
interest.
Does not accept
gifts or personal
advantages from
for-profit
industries,
including medical
equipment
manufacturers,
insurance
companies, and
pharmaceutical
firms.

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The physician
recognizes,
discloses to the
general public, and
deals with
conflicts of interest
that arise in the
course of their
professional duties
and activities.
Commitment to
professional
responsibilities.
Works
collaboratively to
maximize patient
care.

Is respectful of
other physicians.

The physician
participates in the
development of
quality and
educational
programs.

The resident is
receptive to
external evaluation
and scrutiny of
their performance.

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Professionalism Evaluation Item Matrix

Core Content Item Evaluation Item Evaluation Format

Demonstrates respect Calls patients by last name Monthly evaluation
Does not call patients by OSCE
demeaning name
Introduces him/herself to
patients
Shakes hands with patients
Speaks to patient as an
equal
Avoids using medical-ese
Looks at patient eye-to-eye
Responds positively to
faculty during teaching
sessions
Respects hospital staff
Respects patient rights
Respects patient dignity
Respects patient privacy
Respects patient
confidentiality
Knocks on the door when
entering a patient’s room
Drapes/covers patient
appropriately during an
examination

Demonstrates compassion Comforts patients

Makes empathetic
statements
Listens quietly
Slow to interrupt
Is gentle with the debilitated
patient
Uses adequate pain
medication in non-
communicative patients
Avoids derogatory terms
Touches patients
Communicates bad news
with sincerity and
compassion
Deals with sickness, death

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Demonstrates integrity
Responsive to patients
needs
Response to societies needs
Accountable to patients
and dying in a professional
manner with patient and
family members
Admits errors
Admits omissions (e.g.,
forgot a question/did not do
a rectal examination)
Follows through – does
what they say they are
going to do.
Accurately expresses time
commitment (e.g., I’ll be
down in 30 minutes)
Calls when detained
Maintains privacy
Does not withhold
information from patient
Does not use coercive
language when obtaining
consent
Informs others when not
available (e.g., ill) and
secures replacement
Take on appropriate share
of teamwork
Arrives on time
Completes assignments on
time
Answers pages promptly
Avoids medical–ese
Answers patient call lights
Get patients simple needs
(e.g., water) when asked
Is truth-telling with patients
Involved in the community
(e.g., volunteerism)
Graciously cares for
socially disadvantaged (e.g.,
homeless, alcoholic)
Attentive to his/her own
family needs
Follows-up on promises to
patients
Tells the truth
Makes certain that patients
understand them
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Accountable to society
Accountable to the
profession
Commitment to excellence
Commitment to
professional development
Commitment to ethical
principles regarding
providing care
Commitment to ethical
principles regarding
withholding care
Confidentiality of patient
information
Obtains informed consent
Ethical Business practices
Sensitive and responsive to
patient’s culture
Sensitive and responsive to
patient’s age
Sensitive and responsive to
patient’s gender
Personal life reflects moral
integrity
Supports a balance in
personal and professional
activity for peers and
subordinates
Dresses appropriately
Professional appearance
(avoids tattoos, piercing
etc.)
Uses neat hand-writing
Does not cut corners
Sets own goals
Committed to reading core
material in discipline
Masters techniques and
technologies of learning
Self critical
Tells patients what is going
to happen to them
Clarifies CODE status
Family (appropriately)
involved in patient care
decisions
Does not talk about patients
beyond the patient care
area
Provides sufficient
information for decision
making
Does not incorrectly
document
Does not discuss patient
insurance status
Adheres to HIPAA
guidelines
Does not shout slowly to
non-English speaking
patients
Demonstrates tolerance to
various sexual orientations
Does not call elderly
patients by heir first name
Avoids sexists remarks,
jokes, etc.
Avoids unflattering terms
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 for men and women

Sensitive and responsive to Actions assist care of the

patient’s disabilities blind and deaf
Asks for help when needed

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 Ingham Regional Medical Center
Professionalism Evaluation Exercise
Interns will be directed that the purpose of this exercise is to watch how they provide feedback and patient
education on a newly diagnosed, mildly retarded 60 y/o female patient. Intern is limited to 20 minutes for
the history taking visit.

Professionalism Evaluation Exercise

Intern name________________________ Date___________ Pre ______ Post _____

Interns are told that the purpose of the exercise is to watch how they gather a medical
history. They will be time limited (20 minutes).

Setting; direct admit patient with Type II diabetes, showing signs of peripheral
neuropathy. The patient is a 60 something year-old female, mildly retarded and is hard of
hearing. Her female “partner” is in the waiting room.

(Describe scoring 0-1 unsatisfactory; 2-3 satisfactory; 4-5 very good to excellent)

Item Score

1. The intern introduces him/herself and uses pt. name 01/23/45

2. The intern touches the patient (e.g., shakes hands) 01/23/45

3. The intern looks at the patient while talking to them 01/23/45

4. The intern refers to the patient by their last name 01/23/45

5. The intern does not interrupt quickly (count seconds) 01/23/45

6. The intern redirects history with expressing

interest (or avoiding disaffirmation) 01/23/45

7. The intern explains what will happen next

(e.g., lab tests, etc.) 01/23/45

8. Acknowledges patient’s pain 01/23/45

9. Acknowledges patient’s fear 01/23/45

10. Respect and equality with gender issues 01/23/45

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Scoring guidelines defined;

#1 0 = Does not do
1 = Does introduce self but not so pt. can hear or acknowledge
2 = During introduction and one other time
3 = Introduction and two more
4 = Introduction and three more
5 = Introduction and four or more times

#2 0 = Does not do
1 = Only during introduction
2 = During introduction and one other time
3 = Twice
4 = Three times
5 = Introduction and several more with empathy

#3 0 = Does not do
1 = Only during introduction
2 = During introduction and one other time
3 = Twice
4 = Introduction and several more with empathy
5 = During entire discussion, keeps discussion at level of pt. understanding

#4 0 = Never
1 = Only during introduction
2 = During introduction and one other time
3 = Introduction and two more
4 = Introduction and three more
5 = Introduction and four or more times

#5 0 = Interrupts 3 or more times, no wait time

1 = Interrupts, waits 2-5 seconds
2 = Does not interrupt, but appears to not listen, does not respond appropriately to
pt. questions, waits 5-30 seconds
3 = Listens, waits for pt. to finish, allows the pt. time to complete their
thought/question
4 = Listens, responds appropriately to pt. statement
5 = Listens attentively

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#6 0 = Disaffirms, “Oh you don’t mean that”, etc.
1 = Does not direct history, pt. rambles, interns shows little interest in process
2 = Follows form, gets lost without prompts
3 = Follows form, helps pt. stay on track
4 = Makes statements; eg, I’m sorry to hear that
5 = Makes statements and asks for clarification, eg, when did you first notice it?

#7 0 = Does not appear to know what to suggest is next step

1 = Does not include pt. in decision making
2 = Gives broad overview of what may happen, not at pt. level of understanding
3 = Gives some detail, attempts to explain at pt. level
4 = Gives detail, doesn’t answer questions appropriately or give pt. opportunity to
ask
5 = Gives detail, waits for response from pt., answers all questions appropriately

#8 0 = Never
1 = non-verbal recognition, eg., makes eye contact when pt. discusses
2 = Repeats what pt. has stated
3 = Verbally acknowledges, eg, “oh, you have a pain right there?”
4 = Repeats, acknowledges, asks for description
5 = Repeats, acknowledges, asks for description, gives idea for control

#9 0 = Never
1 = non-verbal recognition, eg., makes eye contact when pt. discusses
2 = Repeats what pt. has stated
3 = Verbally acknowledges, eg, “oh, having ‘sugar’ is scary to you?”
4 = Repeats, acknowledges, asks for description of fear
5 = Repeats, acknowledges, asks for description, gives idea for control

#10 0 = No, disrespectful

1 = non-verbal but makes eye contact when pt. discusses problems
2 = Repeats what pt. has stated in non-threatening, equality manner
3 = Verbally acknowledges that symptoms may be different for genders
4 = Verbally acknowledges that symptoms may be different for genders but we’ll
work together
5 = Gives pt. autonomy in decision making process

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Full text:

The Charter on Medical Professionalism

Physicians today are experiencing frustration as changes in the health care delivery
systems in virtually all industrialized countries threaten the very nature and values of
medical professionalism. Meetings among the European Federation of Internal
Medicine, the American College of Physicians-American Society of Internal Medicine
(ACP-ASIM), and the American Board of Internal Medicine (ABIM) have confirmed that
physician views on professionalism are similar in quite diverse systems of health care
delivery. We share the view that medicine's commitment to the patient is being
challenged by external forces of change within our societies.

Recently, voices from many countries have begun calling for a renewed sense of
professionalism, one that is activist in reforming health care systems. Responding to
this challenge, the European Federation of Internal Medicine, the ACP-ASIM
Foundation, and the ABIM Foundation combined efforts to launch the Medical
Professionalism Project (www.professionalism.org) in late 1999. These three
organizations designated members to develop a "charter" to encompass a set of
principles to which all medical professionals can and should aspire. The charter
supports physicians' efforts to ensure that the health care systems and the
physicians working within them remain committed both to patient welfare and to the
basic tenets of social justice. Moreover, the charter is intended to be applicable to
different cultures and political systems.

Preamble

Professionalism is the basis of medicine's contract with society. It demands placing

the interests of patients above those of the physician, setting and maintaining
standards of competence and integrity, and providing expert advice to society on
matters of health. The principles and responsibilities of medical professionalism must
be clearly understood by both the profession and society. Essential to this contract is
public trust in physicians, which depends on the integrity of both individual
physicians and the whole profession.

At present, the medical profession is confronted by an explosion of technology,

changing market forces, problems in health care delivery, bioterrorism, and
globalization. As a result, physicians find it increasingly difficult to meet their
responsibilities to patients and society. In these circumstances, reaffirming the
fundamental and universal principles and values of medical professionalism, which
remain ideals to be pursued by all physicians, becomes all the more important.

The medical profession everywhere is embedded in diverse cultures and national

traditions, but its members share the role of healer, which has roots extending back
to Hippocrates. Indeed, the medical profession must contend with complicated
political, legal, and market forces. Moreover, there are wide variations in medical
delivery and practice through which any general principles may be expressed in both
complex and subtle ways. Despite these differences, common themes emerge and
form the basis of this charter in the form of three fundamental principles and as a set
of definitive professional responsibilities.

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Fundamental Principles

Principle of primacy of patient welfare. This principle is based on a dedication to

serving the interest of the patient. Altruism contributes to the trust that is central to
the physician-patient relationship. Market forces, societal pressures, and
administrative exigencies must not compromise this principle.

Principle of patient autonomy. Physicians must have respect for patient autonomy.
Physicians must be honest with their patients and empower them to make informed
decisions about their treatment. Patients' decisions about their care must be
paramount, as long as those decisions are in keeping with ethical practice and do not
lead to demands for inappropriate care.

Principle of social justice. The medical profession must promote justice in the health
care system, including the fair distribution of health care resources. Physicians should
work actively to eliminate discrimination in health care, whether based on race,
gender, socioeconomic status, ethnicity, religion, or any other social category.

A Set of Professional Responsibilities

Commitment to professional competence. Physicians must be committed to lifelong

learning and be responsible for maintaining the medical knowledge and clinical and
team skills necessary for the provision of quality care. More broadly, the profession as
a whole must strive to see that all of its members are competent and must ensure
that appropriate mechanisms are available for physicians to accomplish this goal.

Commitment to honesty with patients. Physicians must ensure that patients are
completely and honestly informed before the patient has consented to treatment and
after treatment has occurred. This expectation does not mean that patients should be
involved in every minute decision about medical care; rather, they must be
empowered to decide on the course of therapy. Physicians should also acknowledge
that in health care, medical errors that injure patients do sometimes occur. Whenever
patients are injured as a consequence of medical care, patients should be informed
promptly because failure to do so seriously compromises patient and societal trust.
Reporting and analyzing medical mistakes provide the basis for appropriate
prevention and improvement strategies and for appropriate compensation to injured
parties.

Commitment to patient confidentiality. Earning the trust and confidence of patients

requires that appropriate confidentiality safeguards be applied to disclosure of
patient information. This commitment extends to discussions with persons acting on
a patient's behalf when obtaining the patient's own consent is not feasible. Fulfilling
the commitment to confidentiality is more pressing now than ever before, given the
widespread use of electronic information systems for compiling patient data and an
increasing availability of genetic information. Physicians recognize, however, that
their commitment to patient confidentiality must occasionally yield to overriding
considerations in the public interest (for example, when patients endanger others).

Commitment to maintaining appropriate relations with patients. Given the inherent

vulnerability and dependency of patients, certain relationships between physicians
and patients must be avoided. In particular, physicians should never exploit patients
for any sexual advantage, personal financial gain, or other private purpose.

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Commitment to improving quality of care. Physicians must be dedicated to
continuous improvement in the quality of health care. This commitment entails not
only maintaining clinical competence but also working collaboratively with other
professionals to reduce medical error, increase patient safety, minimize overuse of
health care resources, and optimize the outcomes of care. Physicians must actively
participate in the development of better measures of quality of care and the
application of quality measures to assess routinely the performance of all individuals,
institutions, and systems responsible for health care delivery. Physicians, both
individually and through their professional associations, must take responsibility for
assisting in the creation and implementation of mechanisms designed to encourage
continuous improvement in the quality of care.

Commitment to improving access to care. Medical professionalism demands that the

objective of all health care systems be the availability of a uniform and adequate
standard of care. Physicians must individually and collectively strive to reduce
barriers to equitable health care. Within each system, the physician should work to
eliminate barriers to access based on education, laws, finances, geography, and
social discrimination. A commitment to equity entails the promotion of public health
and preventive medicine, as well as public advocacy on the part of each physician,
without concern for the self-interest of the physician or the profession.

Commitment to a just distribution of finite resources. While meeting the needs of

individual patients, physicians are required to provide health care that is based on
the wise and cost-effective management of limited clinical resources. They should be
committed to working with other physicians, hospitals, and payers to develop
guidelines for cost-effective care. The physician's professional responsibility for
appropriate allocation of resources requires scrupulous avoidance of superfluous
tests and procedures. The provision of unnecessary services not only exposes one's
patients to avoidable harm and expense but also diminishes the resources available
for others.

Commitment to scientific knowledge. Much of medicine's contract with society is

based on the integrity and appropriate use of scientific knowledge and technology.
Physicians have a duty to uphold scientific standards, to promote research, and to
create new knowledge and ensure its appropriate use. The profession is responsible
for the integrity of this knowledge, which is based on scientific evidence and
physician experience.

Commitment to maintaining trust by managing conflicts of interest. Medical

professionals and their organizations have many opportunities to compromise their
professional responsibilities by pursuing private gain or personal advantage. Such
compromises are especially threatening in the pursuit of personal or organizational
interactions with for-profit industries, including medical equipment manufacturers,
insurance companies, and pharmaceutical firms. Physicians have an obligation to
recognize, disclose to the general public, and deal with conflicts of interest that arise
in the course of their professional duties and activities. Relationships between
industry and opinion leaders should be disclosed, especially when the latter
determine the criteria for conducting and reporting clinical trials, writing editorials or
therapeutic guidelines, or serving as editors of scientific journals.

Commitment to professional responsibilities. As members of a profession, physicians

are expected to work collaboratively to maximize patient care, be respectful of one
another, and participate in the processes of self-regulation, including remediation and
discipline of members who have failed to meet professional standards. The profession

19
should also define and organize the educational and standard-setting process for
current and future members. Physicians have both individual and collective
obligations to participate in these processes. These obligations include engaging in
internal assessment and accepting external scrutiny of all aspects of their
professional performance.

Summary

The practice of medicine in the modern era is beset with unprecedented challenges
in virtually all cultures and societies. These challenges center on increasing
disparities among the legitimate needs of patients, the available resources to meet
those needs, the increasing dependence on market forces to transform health care
systems, and the temptation for physicians to forsake their traditional commitment to
the primacy of patients' interests. To maintain the fidelity of medicine's social
contract during this turbulent time, we believe that physicians must reaffirm their
active dedication to the principles of professionalism, which entails not only their
personal commitment to the welfare of their patients but also collective efforts to
improve the health care system for the welfare of society. This Charter on Medical
Professionalism is intended to encourage such dedication and to promote an action
agenda for the profession of medicine that is universal in scope and purpose.

Source: "Medical Professionalism in the New Millennium: A Physician Charter", Annals of Internal
Medicine, 5 Feb 2002, 136:3, pp 243-246.

A Curmudgeon’s View

20
For convenience, for the rest of this article I shall refer to these as the
"Oath" (Hippocratic Oath) and the "Charter" (The Charter on Medical
Professionalism) .

Small but amusing points

1. Hippocrates comes across as rather humble. He appeals to the gods to help him
live up to his oath. A bit later he says that all medical students should adhere to "a
stipulation and oath", but does not specify that all must follow his oath. While I
presume he would not support an oath containing contradictory principles, he
seems quite willing to accept the idea that his might not be the final word. On the
other hand, the Annals of Internal Medicine article introduces the Charter with the
assertion that "we will look back upon its publication as a watershed event in
medicine" and "everyone who is involved with medical care should read the
charter and ponder its meaning".
2. The Charter is very socially conscious, indeed quite "politically correct" at points.
Shortly after making the rather pretentious statement about how all the doctors in
the world should "ponder [the] meaning" of this Charter, the editors themselves
ponder if doctors from non-Western cultures might not have different standards,
and suggest a "dialogue" on the subject. The Charter attacks "market forces" as a
threat to good medicine that must be overcome, and frets about the impact of
"globalization". They have a lot to say about "social justice" and discrimination.
The Oath, on the other hand, makes no reference to larger social or political
issues: it speaks only of what the individual doctor should and should not do.

More substantive issues

Similarities
1. Both say that a doctor should always put what is best for the patient above his
own personal gain.
2. Both say that a doctor should not divulge private information about his patients.
(The Charter adds an exception in cases of "overriding ... public interest", such as
when a patient endangers others.)
3. Both prohibit taking sexual advantage of patients.

Differences
1. The Oath is very specific. For the most part, if someone claimed that a doctor had
violated the Oath, the only thing to debate would be the facts: did he really
commit the claimed violation or not? For example, the Oath prohibits a doctor
from participating in physician-assisted suicide or performing abortions. These
are specific acts: the doctor did one of these things or he didn't.

The Charter is much more vague. It tells doctors to "promote

justice in the health care system", to be "dedicated to continuous
improvement in the quality of health care", and to "provide

21
 health care that is based on the wise and cost-effective
management of limited clinical resources". Even if you knew
exactly what a doctor did every minute of every day, it could still
be quite difficult to say whether or not he had lived up to this
Charter. Exactly what is an individual doctor supposed to do to
improve the quality of health care ... "continuously"? How do we
determine whether a given treatment plan is "wise" and "cost-
effective"? There's lots of room for interpretation and judgement
calls here.

As an editorial in World magazine put it (March 9, 2002),

"Whereas the Hippocratic oath is a succinct 364 words (in the
English translation), the Charter is 1,445 words that say much
less".

2. The meaning and goals of the Oath are plain: Hippocrates opposed specific
practices that other doctors engaged in or that he feared they might engage in, and
he spells them out: euthanasia, abortion, sexual relations with patients, violating
patient confidentiality, and failing to refer to a specialist. (That last one strikes me
as being of a different character from the rest. I guess that he feared that a doctor,
through arrogance and/or greed, might attempt procedures that he was not
qualified to perform, with obvious potential harm to the patient.) (A tangential
thought: I am, of course, referring back to the Oath as I write this to get the list
right, and as I do so it suddenly occurs to me that the issues that concerned
Hippocrates are almost all issues that are still in the news regularly today. Perhaps
things haven't changed so much in 2,500 years after all.)

The Charter, on the other hand, plays word games that leave us
guessing what they really mean. The example of this that I find
the most puzzling, perhaps disturbing: There is a section on
respecting a patient's right to make decisions about his own care
that concludes, "Patients' decisions about their care must be
paramount, as long as those decisions are in keeping with ethical
practice and do not lead to demands for inappropriate care".
What in the world is "inappropriate care"? If we just take the
ordinary, literal English meaning of these words, I guess it would
mean, "treatment that is not a good idea". But then what are we
left with? Something like: Doctors should not try to make medical
decisions for a patient, but should give the patient whatever
treatment he asks for ... unless the doctor thinks that the
patient's decision is wrong, in which case the doctor should
ignore the patient's wishes and do what he thinks is best. But
then, how is that different from the doctor just doing what he
thinks is best all the time? I'd be happy to promise anyone that I
would obey every order he gives me as ... long as I agree that it's
a good idea and it's what I would have done anyway. Thus, I can't

22
help but suspect that "inappropriate care" is a code word. I
notice a couple of other similarly vague statements that I can't
help but wonder might be related, namely: Another section talks
about "wise and cost-effective" health care and a "just
distribution of finite resources". And in two places they warn of
the danger that "market forces" might pressure a doctor to
"compromise" his "principles". Put this all together and -- and I
freely admit that I am speculating here, but it seems to fit -- I
think what they mean is this: If a patient asks for life-saving
treatment and the doctor decides that this patient is not worth
saving, that his quality-of-life is too poor, or that further care is
too expensive, then the patient's wishes should be ignored and
he should be left to die. That would be "wise and cost-effective".
The fact that the patient has insurance or personal financial
resources to pay for treatment is irrelevant, because that would
be allowing "market forces" to pressure the doctor into
"compromising his principles". I'm not making this up out of
whole cloth: the idea of rationing medical care -- with decisions
made either by government officials or hospital ethics
committees -- has been floated a number of times in the last few
decades, perhaps most dramatically in the "Clinton health care
plan" proposed in the US in the early 90's that would have made
it a federal crime for a doctor to give a patient treatment that
was not approved by the government. (The proposal labeled this
"graft and corruption in medical care".) If you have another idea
what this might mean, I'm happy to hear it.

23
 Medical Professionalism — Focusing on the Real
Issues
The New England Journal of Medicine
David J. Rothman, Ph.D.
April 27, 2000, Number 17

There is considerable interest in reinvigorating medical professionalism. 1,2,3,4,5,6 This

interest reflects a profound unease with the seeming primacy of economic factors
among those currently affecting medical practice in the United States. There is
general agreement that patients' interests must take precedence over physicians'
financial self-interest and that professionalism also entails service to vulnerable
populations and civic engagement. But as commentators focus on managed care and
other issues of the moment, many considerations are entirely overlooked. These
omissions may well subvert the effort to make professionalism relevant to
contemporary medicine.

Because the focus on the threats from managed care is so intense, the thorny
question of whether professionalism is more or less vibrant or effective today than it
was under fee-for-service medicine has been slighted. Commentators do not consider
whether professionalism has to be revived or, more dauntingly, created. Why is there
such steadfast inattention to the past? Perhaps the reason is that an analysis of the
historical record would severely complicate the agenda, forcing a shift of attention
from managed care to the more fundamental problem of professionalism in American
medicine.

Take the question of how well physicians met the demands of professionalism during
the period from 1910 to 1980. Did they put their patients' interests first? That some
physicians did is clear, but given the compelling evidence of overtreatment of
patients and such practices as self-referral and fee splitting, it would be difficult to
conclude that before managed care was introduced the profession as a whole
unequivocally gave precedence to the interests of patients.7 At least since the
inception of Medicare, which led to the extraordinary rise in physicians' incomes,
some (perhaps many) physicians acted in ways that were designed to enhance their
financial positions.

Thus, to the degree that managed care does not pose the initial or exclusive
challenge to the precept of putting the interests of patients first, it is necessary to
examine the internal, not the external, factors that have weakened professionalism.
The problem involves medical norms and practices more than reimbursement
formulas under managed care. The most pressing question is not how to redraft
contracts between physicians and health maintenance organizations (HMOs) but how
to reduce physicians' financial interests and better monitor their behavior. Concepts
of professionalism are particularly relevant to this task, as a charge to physicians to
make their financial compensation secondary to the welfare of their patients. In fact,
professionalism may well require some financial sacrifices.

Discussions about professionalism before the introduction of managed care involved

other issues, such as technical expertise and self-regulation of medical practice.
These considerations, as formulated by Talcott Parsons in the 1920s and 1930s, were
once understood as the foundation of professionalism. In fact, the goal of maintaining

24
technical expertise among physicians has been exceptionally well met. Board
certification has proved so effective a mechanism that problems involving technical
expertise have almost disappeared from discussions of professionalism.

However, the record on self-regulation, particularly with respect to incompetence and

impairment, is replete with failures.8 Professional societies, with only a few
exceptions, have not effectively disciplined their members. By-laws may provide for
reprimand, probation, suspension, and expulsion of errant physicians. But most
organizations do not publish records of their disciplinary actions. By all accounts,
complaints against members are few and rarely result in disciplinary action. The
inadequacies of self-regulation make it clear that an examination of professionalism
must go beyond questions of money and managed care. To the extent that self-
regulation is the focus, professionalism today has to be invented, not restored.

This proposition is even more true of the current effort to make civic and social
obligations central to medical professionalism. Over the past century, physicians have
been extraordinarily reluctant to enter the public arena. A few exceptions aside, most
physicians have not taken part in national politics (even when health care reform was
debated), let alone in state or local politics (e.g., serving on school boards). If the
historical record of civic engagement is so bleak, how can it be changed? Why expect
doctors to engage in public service now if they have rarely done so in the past?

Just as the recent literature on professionalism ignores history, it slights the structural
barriers, apart from managed care, to the accomplishment of the principles of
professionalism. Most of the authors, for example, pay little attention to the
interactions between pharmaceutical companies and physicians or the influence of
such companies on undergraduate medical education and residency training. Despite
the evidence that this influence is far-reaching, the few analysts who do remark on
the issue fail to convey its importance. Pellegrino and Relman, 1 for example, assert
that contributions from pharmaceutical companies should not dominate the budgets
of professional associations. But they do not cite the data showing how extensive
these contributions are or discuss what the associations might have to do to survive
without them.

To select one example from an organization that specifies in its budget reports the
contributions of pharmaceutical companies, all 21 major donors to the American
Academy of Family Physicians in 1995 were drug companies.9 If more professional
societies divulged information about such contributions, this example might be
multiplied many times over. There is also substantial evidence that gifts from
pharmaceutical companies (such as subsidies for meetings and travel) influence the
prescribing practices and formulary choices of physicians.10 A discussion of threats to
professionalism that does not address the influence of pharmaceutical companies
omits a critical consideration, one that, unlike managed care, is largely subject to the
control of physicians.

Perhaps the most important omission from the recent discussions of professionalism
is the question of how to implement and enforce professional standards. There are
calls to expand the teaching of professionalism in medical schools and in residency
programs and to have professional societies become more explicit about the norms
they espouse. But the limitations of these two approaches are apparent. Ludmerer
observes that lectures in the preclinical curriculum are no match for the rough-and-
tumble lessons of clinical training.3 The rhetoric on respect for patients is too easily
undercut by the reality of exhausted residents teaching medical students how to
avoid a "hit." But Ludmerer does not suggest how to implement a change. He is eager

25
"to make the internal culture of academic medical health centers less commercial and
more service oriented," but he has no more specific strategy for accomplishing this
goal than to appeal to the "courage" of medical leaders.

Nor is it completely satisfactory to depend on a public declaration of norms, whether

through new oaths or ceremonies in which first-year medical students are given white
coats. Take, for example, the call for greater social engagement through the provision
of care to underserved populations or greater civic participation. Professional
resolutions favoring such practices might have some effect on individual behavior,
but it is doubtful that they would have a substantial collective impact. Lofty phrases
generally do not change customary ways of doing things. To put it another way, the
burden is surely on those who would rely on such strategies to demonstrate that they
would be successful.

In what other ways might professionalism be promoted and implemented? There are
a range of possible strategies, many requiring fundamental departures from current
procedures. First, professional and board-certifying societies could require rather than
recommend standards of behavior, including service. One could imagine that, like
continuing medical education, service to vulnerable groups of people would be
required to maintain certification. A number of community organizations already
attempt to meet the medical needs of uninsured patients by coaxing physicians, more
or less successfully, to provide care to such patients without charging fees. A minimal
requirement to render free care might improve the health of poor patients and
promote medical practice that exemplifies the precepts of professionalism. The
controversy that would greet such a proposal cannot be underestimated, especially
since physicians are under pressure to see larger numbers of insured patients. But
controversy may be the price that has to be paid for taking professionalism seriously.

Second, professional associations could form alliances with consumer groups to

accomplish goals that neither can realize separately.11 Sullivan suggests that
medicine might wish to "go public" and become "much more of a partner to other
fields and social interests."4 This approach informs at least one program, Medicare as
a Profession (I chair the program's advisory board). Part of the Open Society Institute,
it funds joint efforts by consumer groups and medical groups to improve the quality of
care, implement professional standards, and provide care to underserved
populations. Although physicians have traditionally refrained from joining forces with
consumer groups, the need for such alliances may break the tradition.

Third, the medical school and residency curriculum should be altered, not only by
including lectures on professionalism but also by inculcating the skills necessary to
promote it. To the degree that the profession accepts a commitment to social
engagement, the curriculum should teach advocacy skills along with diagnostic skills.
Once again, this would constitute a startling break with established patterns. Medical
school faculty would have to include persons trained in advocacy and community
organization. The clash of cultures would be great, but so would the benefits.

Fourth, medicine in its organized capacity must encourage and protect whistle-
blowers, so that the profession is not so dependent on outsiders to identify and
publicize problems. Whether the problem is specific instances of conflict of interest or
abuses by managed-care companies, journalists and government officials have taken
the lead in uncovering abuses and providing remedies. Thus, when HMOs imposed
restrictions on the length of hospital stays for new mothers and women recovering
from mastectomy, the press — not organizations representing obstetricians or
oncologists — spearheaded the protests and brought about corrective legislation.12

26
Journalists have been especially active in ferreting out instances of conflict of interest.
To be sure, many medical journals have reported on the overall dimensions of the
problem, and universities and medical schools have established useful oversight
procedures. But it is the press that continues to highlight the failures of the existing
system to control the behavior of physicians. A recent article in the New York Times
on the development and testing of new cardiac devices is a telling case in point.13

Fifth, professional organizations must be persuaded to expand the agenda for which
they lobby and advocate. Nearly all these organizations engage in extensive
lobbying, with many spending over $500,000 annually on such activities.14 Through
lobbying firms or their own staff, they attempt to influence legislation on various
matters, including health insurance, drug regulation, managed care, antitrust
violations, and liability reform. But in most, if not all, cases, these efforts conform to
the special interests of the organization's members.

Thus, the American Academy of Dermatology has fought to maintain direct access to
specialists because it is the "most efficient and cost-effective method of providing
quality dermatologic services."15 By the same token, the American Academy of
Ophthalmology has strongly opposed the creation of "centers of excellence as they
apply to cataract surgery," as well as "single surgery payment provisions,"16
apparently because they would reduce earnings for ophthalmologists. And when
Medicare benefits were being debated by Congress, the American College of
Gastroenterology lobbied to include screening for colorectal cancer as a benefit. 17

Imagine what could have happened if these societies had advocated for the well-
being of patients without regard for their own special interests. Support by
dermatologists and ophthalmologists for colorectal-cancer screening would carry
great weight in the debate over whether to include it as a benefit. Again, the barriers
to such activities are formidable. Members of professional organizations do not want
their dues spent on advancing the other fellow's specialty, and they may believe that
only subspecialists can determine what patients need. But think of how the public
might respond to advocacy that was driven not by narrow self-interest but by a
broader professional vision of patients' welfare.

Sixth, professional societies, medical schools, and teaching hospitals should adopt
policies to minimize the influence of pharmaceutical companies and their
representatives. If professional societies raised annual membership dues and
registration fees for meetings, they would reduce their dependence on underwriting
and advertising by drug companies. At the very least, these organizations should
refrain from such practices as identifying drug-company donors in programs for
meetings according to the level of support (platinum, gold, silver, and so forth); this
suggests a degree of venality that is inconsistent with professionalism. 18 Societies
may not wish to ban drug-company booths from annual meetings on the grounds that
such a restriction might hamper the spread of new information, but no educational
purpose is served by allowing the booths to dispense such "brand reminders" as pens,
note pads, briefcases, flashlights, and golf balls.19

In the same spirit, medical schools should adopt formal rules that prohibit all gifts
from drug companies to students, whether books, stethoscopes, or meals. Medical
training should not include acquiring a sense of entitlement to the largesse of drug
companies. Finally, teaching hospitals should enforce these same restrictions,
proscribing drug-company sponsorship of lunches, conferences, and travel for house
staff, and should also make it clear that accepting birthday presents, Christmas gifts,

27
or food and drink off the premises from drug-company representatives violates the
ethical norms of the profession.

However fanciful, impractical, or misguided these suggestions may seem, they make
it clear that physicians have avoided the admittedly tough question of how
professionalism is to become more central to their thinking and behavior. A general
call to embrace the ethic may be appealing and may even exert some influence in the
long run, but it is not sufficient to bring about substantial change in the near future.
Professionalism is too important for an exclusive reliance on such tactics. An infusion
of strength and relevance is needed. By one means or another, professionalism must
become a vital part of American medicine today.

David J. Rothman, Ph.D.

Columbia University College of Physicians and Surgeons
New York, NY 10032

References

1. Pellegrino ED, Relman AS. Professional medical associations: ethical and practical guidelines.
JAMA 1999;282:984-986.[Full Text]
1. Swick HM, Szenas P, Danoff D, Whitcomb ME. Teaching professionalism in undergraduate
medical education. JAMA 1999;282:830-832.[Abstract/Full Text]
1. Ludmerer KM. Instilling professionalism in medical education. JAMA 1999;282:881-882.
[Full Text]
1. Sullivan WM. What is left of professionalism after managed care? Hastings Cent Rep 1999;29:7-
23.[Medline]
1. Wynia MK, Latham SR, Kao AC, Berg JW, Emanuel LL. Medical professionalism in society. N
Engl J Med 1998;341:1612-1616.[Full Text]
1. Casalino LP. The unintended consequences of measuring quality on the quality of medical care. N
Engl J Med 1999;341:1147-1150.[Full Text]
1. Rodwin MA. Medicine, money, and morals: physicians' conflicts of interest. New York: Oxford
University Press, 1993.
1. Derbyshire RC. How effective is medical self-regulation? Law Hum Behav 1983;7:193-202.
1. AAFP Foundation corporate members. Bull Am Acad Fam Physicians 1995;10:4.
1. Chren MM, Landefeld CS. Physicians' behavior and their interactions with drug companies: a
controlled study of physicians who requested additions to a hospital drug formulary. JAMA
1994;271:684-689.[Abstract]
1. Cleary PD, Edgman-Levitan S. Health care quality: incorporating consumer perspectives. JAMA
1997;278:1608-1612.[Abstract]
1. Kassirer JP. Our endangered integrity -- it can only get worse. N Engl J Med 1997;336:1666-1667.
[Full Text]
1. Eichenwald K, Kolata G. Hidden interests — a special report: when physicians double as
entrepreneurs. New York Times. November 30, 1999:A1.
1. Washington Representatives (a directory of lobbyists and organizations) 1996, pursuant to 1995
Lobbying Disclosure Act (Public Law 104-65). The Center for Responsive Politics maintains a file
on each organization. (Or see: http://opensecrets.org/lobbyists/98lookup.htm.)
1. American Academy of Dermatology Web site. (See: http://www. aad.org.)

55336. American Academy of Ophthalmology Web site. (See: http://www. eyenet.org.)

1. American Academy of Gastroenterology Web site. (See: http://www. acg.gi.org.)

28
1. Program and abstracts of the 32nd Annual Meeting of the American Society of Nephrology.
Washington, D.C.: American Society of Nephrology, 1999.

1. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA
2000;283:373-380.[Abstract/Full Text]

29
Selected Professionalism References
Anonymous. Medical professionalism in the new millennium: a physicians' charter*.
Clin-Med. 2002 Mar-Apr; 2(2): 116-8.
The practice of medicine in the modern era is beset with unprecedented challenges in virtually all
cultures and societies. These challenges centre on increasing disparities between the legitimate
needs of patients, the available resources to meet those needs, the increasing dependence on
market forces to transform healthcare systems, and the temptation for physicians to forsake their
traditional commitment to the primacy of patients' interests. To maintain the fidelity of medicine's
social contract during this turbulent time, we believe that physicians must reaffirm their active
dedication to the principles of professionalism, which entails not only their personal commitment
to the welfare of their patients but also collective efforts to improve the healthcare system for the
welfare of society. This Charter on Medical Professionalism is intended to encourage such
dedication and to promote an action agenda for the profession of medicine that is universal in
scope and purpose.

Anonymous. Issues in medical ethics. Understanding professionalism and its

implications for medical education. Proceedings of a conference. New York City, New
York, USA. November 3, 2000. Mt-Sinai-J-Med. 2002 Nov; 69(6): 354-420.

Arnold,-L. Assessing professional behavior: yesterday, today, and tomorrow. Acad-

Med. 2002 Jun; 77(6): 502-15.
PURPOSE: The author interprets the state of the art of assessing professional behavior. She
defines the concept of professionalism, reviews the psychometric properties of key approaches to
assessing professionalism, conveys major findings that these approaches produced, and
discusses recommendations to improve the assessment of professionalism. METHOD: The author
reviewed professionalism literature from the last 30 years that had been identified through
database searches; included in conference proceedings, bibliographies, and reference lists; and
suggested by experts. The cited literature largely came from peer-reviewed journals, represented
themes or novel approaches, reported qualitative or quantitative data about measurement
instruments, or described pragmatic or theoretical approaches to assessing professionalism.
RESULTS: A circumscribed concept of professionalism is available to serve as a foundation for
next steps in assessing professional behavior. The current array of assessment tools is rich.
However, their measurement properties should be strengthened. Accordingly, future research
should explore rigorous qualitative techniques; refine quantitative assessments of competence,
for example, through OSCEs; and evaluate separate elements of professionalism. It should test
the hypothesis that assessment tools will be better if they define professionalism as behaviors
expressive of value conflicts, investigate the resolution of these conflicts, and recognize the
contextual nature of professional behaviors. Whether measurement tools should be tailored to
the stage of a medical career and how the environment can support or sabotage the assessment
of professional behavior are central issues. FINAL THOUGHT: Without solid assessment tools,
questions about the efficacy of approaches to educating learners about professional behavior will
not be effectively answered.

Ber,-R; Alroy,-G. Teaching professionalism with the aid of trigger films. Med-Teach.
2002 Sep; 24(5): 528-31.
Medical professionalism includes expert knowledge, self-regulation and fiduciary responsibility to
place the needs of patients ahead of the self-interest of physicians. In teaching medical
professionalism to our medical students only the behavioural elements are dealt with. One of the
challenges facing medical educators today is how medical professionalism can be taught. At the
authors' faculty of medicine brief videotapes (trigger films) of amateur actor physician-patient
encounters in various clinical settings (taken from genuine encounters) are used as a stimulus for

30
discussion and instruction of medical professionalism. A series of 16 trigger films has been
produced that raise many medical professional issues. The films and the issues raised are
described in brief. These trigger films are viewed by small groups of medical students together
with a physician tutor facilitator at various stages of their studies. It is noteworthy how fast the
transition occurs in students, from observing the trigger films in their pre-clinical stage as a
client, to observing them in their clinical years from the angle of a provider; from identifying with
the patient's concerns to identifying with the physicians' behaviour; from being a critical person
to becoming a person who accepts the rules and regulations of the guild. Most probably the
power of the teaching of ethical and professional rules is overruled by the power of everyday
clinical experience during their clinical clerkships. It is planned to run a series of trigger film
sessions with senior and junior physicians of the major clerkships, in an attempt to promote an
institutional environment/atmosphere/culture of professional behaviour.

Bloom,-S-W. Professionalism in the practice of medicine. Mt-Sinai-J-Med. 2002 Nov;

69(6): 398-403.
Although medicine is universally recognized as the archetype of the professions, it can only be
understood as part of the modern medical center, a dynamic social system consisting of the
university, the hospital, the medical center and, most recently, corporate managed care. Such a
view results in a portrait of medicine as a profession transformed, driven by huge and growing
health care markets, its fate tied not only to state bureaucracies, but also to the dynamics of
both health and non-health care businesses. The question asked here is how does such a radical
change in medical practice affect medical education?. Using methods of historical analysis, it
appears that medical educators operate as though the educational process itself determines the
values, and therefore the present and future behavior of their students. In other words, at the
end of their formal education, doctors are fully formed professionals. However, from the analysis
of this paper it can be concluded that the physician as an individual cannot function
independently of the structure of the society and its general conception of the world. In the
structure of medicine s present situation, the ethical standards of professionalism, as they are
classically defined, cannot survive. Instead, modern medical graduates, much like their teachers
and professional mentors, will be forced to adapt to a situation that is contradictory to the best
traditions of medicine. How to stop this process is the urgent question. Three answers are
presented.

Chervenak,-F-A; McCullough,-L-B. Professionalism and justice: ethical management

guidelines for leaders of academic medical centers. Acad-Med. 2002;77(1): 45-7.
Academic health centers (AHCs) exist for the sake of pursuit of excellence in their missions of
patient care, teaching, and research. Survival should be a means to these goals and not an end
unto itself. Because of the fiscal crisis in health care, leaders of AHCs face the possible diminution
or even extinction of their centers. When preventing such a fate becomes the governing concern
of these leaders, power concentrates in their hands and can be used to force cooperation among
competing faculty members and groups for the sake of mutual survival. The ethical concepts of
professionalism and justice can be used to create a vital, practical, alternative vision for the
leadership of AHCs, in which their missions once again become central to their organizational
culture. Creating a morally sustainable organizational culture of professionalism and justice
should rely not on forced cooperation, but on voluntary cooperation of all stakeholders in the
pursuit of a common goal-professional excellence in patient care, teaching, and research-with
survival understood to be a means to this goal. To achieve this alternative vision, the authors
propose five management guidelines. For example, all faculty should be made accountable not
only for maximizing the good of the organization's professionalism but also for fostering financial
viability.

31
Chisholm,-C-D; Whenmouth,-L-F; Daly,-E-A; Brizendine,-E-J; Cordell,-W-H. A
comparison of faculty contact time with emergency medicine residents in different
teaching venues. Acad-Emerg-Med. 2003 May; 10(5): 472.
AB: OBJECTIVE: Emergency Medicine (EM) residencies must implement the 6 ACGME core
competencies by 2006. EM educators recommend direct observation (DO) as the optimal
evaluation tool for 4 of the 6 core competencies (Patient Care, Systems-Based Practice,
Interpersonal and Communication Skills, and Professionalism). The 24/7 faculty presence in the
Emergency Department (ED) is believed to facilitate DO as an assessment technique. METHODS:
Observational study of faculty contact in 2 EDs, 2 trauma services, inpatient medicine, adult &
pediatric ICUs, and a pediatric outpatient clinic (UVC). Faculty contact was categorized as DO of
patient care, indirect patient care, or non-patient care activities using a priori definitions. EM
residents were shadowed for 2-hour intervals. Subjects were blinded to the nature of the study
and data gathering was encrypted. RESULTS: 270 observation periods of 2 hours each were
conducted, sampling 32 EM R1, 33 EM R2-3, 41 EM and 38 non-EM faculty. Total faculty contact
time ranged from a maximum of 30% (95% CI = 20, 41) in the pediatric ICU to a minimum of
10% (3, 16) on internal medicine wards. Overall ED faculty contact was 20% (18, 22). DO by
faculty ranged from a high of 5% (3, 8) in the pediatric UVC to a low of 1% (0, 2) on internal
medicine wards. Overall ED DO was 3.6% (2.6, 4.7). ED DO did not vary across EMR level or by
site. DO varied by treatment area within the ED with the critical area being substantially higher
(6%) when compared with the non-critical care areas (1%). CONCLUSIONS: Direct observation
of EM residents was low in all training venues studied. Overall DO was the highest in ED critical
care areas and lowest on medicine ward rotations. EM faculty who are already involved in routine
teaching, supervision, and patient care rarely performed DO in spite of their immediate physical
presence 24/7. This suggests that alternative strategies may be required to assess core
competencies through direct observation in the Emergency Department.

Connelly,-J-E. The other side of professionalism: doctor-to-doctor. Camb-Q-Healthc-

Ethics. 2003 Spring; 12(2): 178-83.

Cruess,-S-R; Johnston,-S; Cruess,-R-L. Professionalism for medicine: opportunities

and obligations. Med-J-Aust. 2002 Aug 19; 177(4): 208-11.
Physicians' dual roles - as healer and professional - are linked by codes of ethics governing
behaviour and are empowered by science. Being part of a profession entails a societal contract.
The profession is granted a monopoly over the use of a body of knowledge and the privilege of
self-regulation and, in return, guarantees society professional competence, integrity and the
provision of altruistic service. Societal attitudes to professionalism have changed from supportive
to increasingly critical - with physicians being criticised for pursuing their own financial interests,
and failing to self-regulate in a way that guarantees competence. Professional values are also
threatened by many other factors. The most important are the changes in healthcare delivery in
the developed world, with control shifting from the profession to the State and/or the corporate
sector. For the ideal of professionalism to survive, physicians must understand it and its role in
the social contract. They must meet the obligations necessary to sustain professionalism and
ensure that healthcare systems support, rather than subvert, behaviour that is compatible with
professionalism's values.

Davis,-M-H. OSCE: the Dundee experience. Med-Teach. 2003 May; 25(3): 255-61.
The Dundee Medical School has bean running OSCEs since 1977. In 1995, an integrated systems-
based spiral curriculum on the core and options model was introduced. In 1997, outcome-based
education was introduced as the basis for instruction, with a task-based educational strategy
employed for students in years 4 and 5. This blend of educational strategies was considered in
the design of the student assessment process. Assessment instruments, appropriate for use at
each of the four levels of Miller's pyramid, were identified and included in the assessment
process. The OSCE was used for summative assessment of students at the level of 'shows how'

32
or simulation in years 2, 3 and 4. A year 2 OSCE is described here. Features of the Dundee OSCE
are identified, relating to number and length of individual stations, practicalities or assessing a
year group of students without student contamination with examination information and the
blueprints used to design the examinations. Suggestions made for future development of the
OSCE include the OSSE, the Objective Structured Selection Examination, and an exploration of
the potential of the OSCE to assess attitudes, personal attributes and professionalism. The need
is identified for a platform to debate issues such as should individual medical schools attempt to
achieve national test centre standards with their examinations.

Epstein,-R-M; Hundert,-E-M. Defining and assessing professional competence. JAMA.

2002 Jan 9; 287(2): 226-35.
CONTEXT: Current assessment formats for physicians and trainees reliably test core knowledge
and basic skills. However, they may underemphasize some important domains of professional
medical practice, including interpersonal skills, lifelong learning, professionalism, and integration
of core knowledge into clinical practice. OBJECTIVES: To propose a definition of professional
competence, to review current means for assessing it, and to suggest new approaches to
assessment. DATA SOURCES: We searched the MEDLINE database from 1966 to 2001 and
reference lists of relevant articles for English-language studies of reliability or validity of measures
of competence of physicians, medical students, and residents. STUDY SELECTION: We excluded
articles of a purely descriptive nature, duplicate reports, reviews, and opinions and position
statements, which yielded 195 relevant citations. DATA EXTRACTION: Data were abstracted by 1
of us (R.M.E.). Quality criteria for inclusion were broad, given the heterogeneity of interventions,
complexity of outcome measures, and paucity of randomized or longitudinal study designs. DATA
SYNTHESIS: We generated an inclusive definition of competence: the habitual and judicious use
of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection
in daily practice for the benefit of the individual and the community being served. Aside from
protecting the public and limiting access to advanced training, assessments should foster habits
of learning and self-reflection and drive institutional change. Subjective, multiple-choice, and
standardized patient assessments, although reliable, underemphasize important domains of
professional competence: integration of knowledge and skills, context of care, information
management, teamwork, health systems, and patient-physician relationships. Few assessments
observe trainees in real-life situations, incorporate the perspectives of peers and patients, or use
measures that predict clinical outcomes. CONCLUSIONS: In addition to assessments of basic
skills, new formats that assess clinical reasoning, expert judgment, management of ambiguity,
professionalism, time management, learning strategies, and teamwork promise a
multidimensional assessment while maintaining adequate reliability and validity. Institutional
support, reflection, and mentoring must accompany the development of assessment programs.

Fins,-J-J; Gentilesco,-B-J; Carver,-A; Lister,-P; Acres,-C-A; Payne,-R; Storey-Johnson,-

C. Reflective practice and palliative care education: a clerkship responds to the
informal and hidden curricula. Acad-Med. 2003 Mar; 78(3): 307-12.
The authors discuss the damaging influence of informal and hidden curricula on medical students
and describe a two-week clerkship in palliative care and clinical ethics at their school (Weill
Medical College of Cornell University). This required clerkship, begun in 1999, uses reflective
practice and a special pedagogic technique, participant observation, to counteract the influences
of the informal and hidden curricula. This technique seeks to immerse the participant observer in
the context of care. In their role as participant observers, students are relieved of any direct
clinical responsibilities for two weeks so they have time for the careful observation and reflection
required and also can consider the humanistic dimensions of practice, which are often displaced
by the need to master diagnostic and therapeutic skills. Course objectives include identifying
psychosocial and contextual factors that influence care, principles of pain and symptom
management, and ethical and legal issues at the end of life. Students are expected to learn how
to apply ethical norms to patient care, describe methods of pain and symptom management,

33
communicate in an effective and humanistic manner, and articulate models of patient-centered
advocacy. The clerkship fosters professionalism in patient care, appreciation of cultural diversity,
and the student's ability to assume responsibility for developing competency in these areas.
Although it is too early to know whether this clerkship will ultimately affect the practice patterns
of students who experience it, short-term evaluation has been very favorable.

Ginsburg,-S; Regehr,-G; Stern,-D; Lingard,-L. The anatomy of the professional lapse:

bridging the gap between traditional frameworks and students' perceptions. Acad-
Med. 2002 Jun; 77(6): 516-22.
PURPOSE: To support students' developing professionalism, it is necessary to understand the
professional challenges and dilemmas they perceive in the clinical setting. This study
systematically documented and catalogued students' reports of professional lapses. METHOD: Six
focus groups were conducted with senior medical students (n = 29) at three universities. Using a
grounded-theory approach, three researchers analyzed the students' reports of specific lapses in
professionalism for recurrent themes. The resulting coding structure was applied using NVivo
qualitative data analysis software. RESULTS: A total of 120 pages of text yielded 48 specific
incidents of professional lapses, which were analyzed by three researchers using grounded
theory. Most incidents were witnessed (n = 34) or known about (n = 4), as opposed to self-
reported (n = 10). Six critical "issues" emerged: communicative violations (to or about patients or
other health care professionals); role resistance (individuals chafing against constraints or
expectations of their perceived roles); objectification of patients (ignoring patients or treating
patients as vehicles for learning); accountability (to colleagues or patients, including avoiding
patients, failing to disclose information, or failing to treat appropriately); physical harm (to
patients or others); and crossfire (being put in the middle of a struggle between superiors).
CONCLUSIONS: This study explored how students experienced and operationalized
professionalism in clinical settings at a variety of universities. Interestingly, the critical issues they
reported as salient did not map easily onto standard, abstract definitions of professionalism. This
incongruence suggested that the development of effective curricula in this domain must bridge
the gap between traditional taxonomies and students' perceptions of professionalism.

Glannon,-W; Ross,-L-F. Are doctors altruistic? J-Med-Ethics. 2002 Apr; 28(2): 68-9;
discussion 74-6.
There is a growing belief in the US that medicine is an altruistic profession, and that physicians
display altruism in their daily work. We argue that one of the most fundamental features of
medical professionalism is a fiduciary responsibility to patients, which implies a duty or obligation
to act in patients' best medical interests. The term that best captures this sense of obligation is
"beneficence", which contrasts with "altruism" because the latter act is supererogatory and is
beyond obligation. On the other hand, we offer several examples in which patients act
altruistically. If it is patients and not the doctors who are altruistic, then the patients are the gift-
bearers and to that extent doctors owe them gratitude and respect for their many contributions
to medicine. Recognizing this might help us better understand the moral significance of the
doctor-patient relationship in modern medicine.

Gordon,-J. Assessing students' personal and professional development using

portfolios and interviews. Med-Educ. 2003 Apr; 37(4): 335-40.
BACKGROUND AND PURPOSE: Medical schools are placing more emphasis on students' personal
and professional development (PPD) and are seeking ways of assessing student progress towards
meeting outcome goals in relation to professionalism. The Faculty of Medicine at the University of
Sydney sought an assessment method that would demonstrate the value of reflection in attaining
PPD, provide feedback and encourage students to take responsibility for setting and achieving
high standards of performance. METHODS: The instruments used to assess Year 1 students in
PPD are a portfolio and interview. This assessment format encourages students to explore ideas

34
and values that are important to them and relevant to the PPD theme. A confidential interview,
based on the PPD goals, is held with a faculty member who has read the student's portfolio.
RESULTS: In 1997/98, 96% of students agreed that they had engaged in useful reflection on
their approach to the course and 91% agreed that the experience was worthwhile. A further 76%
of students agreed that they could see opportunities to modify their approach in some ways as
result of this exercise. CONCLUSION: Sustained PPD is essential in equipping doctors for the
varied stresses of careers in medicine. Despite, or perhaps because of, the latitude in the Year 1
assessment, both students and faculty members found the process of value. This form of
assessment acknowledges that the most valid assessment formats cannot always be made
reliable and that in some parts of the curriculum it is more important to demonstrate trust in
students' own motivation to become competent and mindful practitioners. The fact that the
portfolio and interview are the only summative assessments in the first year emphasises the
importance that the Faculty places on PPD.

Hatem,-C-J Teaching approaches that reflect and promote professionalism. Acad-

Med. 2003 Jul; 78(7): 709-13.
The teaching and cultivation of professionalism have long been part of medical education and
have had recent special emphasis because professionalism has been identified as a core
competency by the Accreditation Council for Graduate Medical Education. The author focuses on
two complementary teaching initiatives that contribute to the development of professionalism in
the academic environment: a resident-as-teacher program and an approach to faculty bedside
teaching that mirrors and extends the lessons of the resident-as-teacher effort. These have been
implemented and refined over the previous 15 years by the author and his colleagues at Mount
Auburn Hospital in Cambridge, Massachusetts. The commitment to the development and
refinement of residents' teaching skills serves to promulgate the fundamental elements of
professionalism, with emphasis on caring and the educational well-being of the team. The author
describes the elements and benefits of these approaches and shows how they can foster the
development of professionalism in graduate medical education.

Heard,-J-K; Allen,-R-M; Clardy,-J. Assessing the needs of residency program

directors to meet the ACGME general competencies. Acad-Med. 2002 Jul; 77(7): 750.
OBJECTIVE: New accreditation requirements for residency training programs require residents to
have educational experiences that allow them to demonstrate competency in the following areas:
(1) patient care, (2) medical knowledge, (3) practice-based learning and improvement, (4)
interpersonal and communication skills, (5) professionalism, and (6) systems-based practice.
Residents' competence must be assessed with dependable measures. Residency training program
directors (PDs) need assistance in complying with these new requirements. DESCRIPTION: Using
a survey modified from Michigan State University, we asked PDs to rate their current
understanding of and preparation for the general competencies and to provide written
comments. PDs of the 47 ACGME-accredited programs received e-mailed instructions to complete
the Web-based survey. Twenty-four PDs (51%) complied by the deadline. The mean ratings were
calculated from a five-point scale (1 = strongly disagree, major impediment or least useful, 5 =
strongly agree, not an impediment, or most useful). PDs felt they were informed (3.45) and
understood (3.67) the requirements, but they were not well prepared to meet them (2.95). The
perceived impediments to implementation included amount of PD time (2.27), amount of
residents' protected time for the curriculum (2.30), amount of residency support staff (2.73), lack
of expertise in curriculum development (2.73) and evaluation (2.41), and lack of funding for
resources other than personnel (2.91). PDs rated types of assistance that would be helpful:
developing workshops or presentations on curriculum development and evaluation techniques
(3.82), developing curricula (4.14), providing one-on-one consultation (4.23), receiving examples
of materials, methods, and ideas from other programs (4.41), and describing evaluation
methods/instruments (4.50). Written comments stated that time to concentrate on the topic,
release time from clinical responsibilities, and technical computer support would be helpful. Of

35
the six competency areas, PDs were most interested in receiving assistance in developing
curricular materials for the competencies of systems-based practice (4.50), professionalism
(4.36), and practice-based learning and improvement (4.27). PDs were most interested in
receiving assistance in developing evaluations for practice-based learning and improvement
(4.59), professionalism (4.59), interpersonal and communication skills (4.45), and systems-based
practice (4.36). PDs responded that they currently use written faculty evaluations to assess all six
general competency areas. DISCUSSION: Results of the survey indicate that PDs require
assistance to comply with the new ACGME requirements. Curricular materials and valid and
reliable evaluation methods need to be developed. In order to assist PDs, the following activities
are under way: (1) PDs are members of a listserve for sharing ideas and examples of curricular
and evaluation materials; (2) PDs attend a monthly seminar series that provides practical
information for curricular material development and specific evaluation methods, including
indications for use and feasibility; (3) educators from our Office of Educational Development
provide individual consultations with each PD; (4) PDs participate in an eight hour workshop with
practical sessions for developing curricular materials and evaluations; and (5) two institution-wide
assessments are being developed: a patient-satisfaction survey and a 360-degree evaluation to
assess communication skills and professionalism.

Heru,-A-M. Using role playing to increase residents' awareness of medical student

mistreatment. Acad-Med. 2003 Jan; 78(1): 35-8.
The teacher-learner relationship is subject to both internal and external influences that may lead
to mistreatment and harassment of the student. The student who is mistreated may mistreat
students when he or she becomes a teacher. The author describes an experiential program for
residents at Brown Medical School from 1999 to 2002 in which residents, through role playing,
helped produce teaching videotapes on medical student mistreatment. Fourteen residents had
participated in the program to date. They reported that they had benefited from an increased
awareness of the effects of student mistreatment and had learned how to handle mistreatment
more effectively. They also reported increased sensitivity to others and improved self-awareness,
qualities that they planned to incorporate into their professional identities and that should help
them avoid mistreatment of students and residents later in their careers. Because preventing
mistreatment from being transmitted to the next generation is an important way to increase
medical professionalism, the author recommends that role-playing exercises dealing with
mistreatment be a part of all residency education.

Klein,-E-J; Jackson,-J-C; Kratz,-L; Marcuse,-E-K; McPhillips,-H-A; Shugerman,-R-P;

Watkins,-S; Stapleton,-F-B. Teaching professionalism to residents. Acad-Med. 2003
Jan; 78(1): 26-34.
The need to teach professionalism during residency has been affirmed by the Accreditation
Council for Graduate Medical Education, which will require documentation of education and
evaluation of professionalism by 2007. Recently the American Academy of Pediatrics has
proposed the following components of professionalism be taught and measured:
honesty/integrity, reliability/responsibility, respect for others, compassion/empathy, self-
improvement, self-awareness/knowledge of limits, communication/collaboration, and
altruism/advocacy. The authors describe a curriculum for introducing the above principles of
professionalism into a pediatrics residency that could serve as a model for other programs. The
curriculum is taught at an annual five-day retreat for interns, with 11 mandatory sessions
devoted to addressing key professionalism issues. The authors also explain how the retreat is
evaluated and how the retreat's topics are revisited during the residency, and discuss general
issues of teaching and evaluating professionalism.

36
Larkin,-G-L; Binder,-L; Houry,-D; Adams,-J. Defining and evaluating professionalism:
a core competency for graduate emergency medicine education. Acad-Emerg-Med.
2002 Nov; 9(11): 1249-56.
Professionalism, long a consideration for physicians and their patients, is coming to the forefront
as an essential element of graduate medical education as one of the six new core competency
requirements of the Accreditation Council for Graduate Medical Education (ACGME).
Professionalism is also integral to the widely endorsed Model of the Clinical Practice of Emergency
Medicine (Model). Program directors have now been charged with implementing the new core
competencies in training programs and to assess the acquisition of these competencies in their
trainees. To assist emergency medicine (EM) program directors in this endeavor, the Council of
Emergency Medicine Residency Directors (CORD-EM) held a consensus conference in March
2002. A focused Consensus Group addressed the specific core competency of professionalism
during the course of this conference, and the results are highlighted in this article. The definition
and curricular requirements relating to professionalism are highlighted, specific techniques for
evaluating this core competency in EM are reviewed, and recommendations are provided
regarding the most appropriate assessment method for EM programs.

Larkin,-G-L; Marco,-C-A; Abbott,-J-T. Emergency determination of decision-making

capacity: balancing autonomy and beneficence in the emergency department. Acad-
Emerg-Med. 2001 Mar; 8(3): 282-4.
AB: The determination of decision-making capacity (DMC) is an essential component of securing
voluntary informed consent, for either treatment or refusal of care. Decision-making capacity
should be determined on some level during each patient encounter. Decision-making capacity
includes the ability to receive, process, and understand information, the ability to deliberate, the
ability to make choices, and the ability to communicate those preferences. For patients in whom
DMC may be uncertain, a more explicit approach to determination of DMC is recommended.
However, DMC determination must neither compromise patient safety nor delay needed care.
When DMC determination is challenging, or when the ramifications of a decision are serious, the
assistance of a third party (such as a surrogate, a consultant, or another clinician) may be
valuable in discerning the most appropriate action. In addition to the obvious clinical utility of
DMC assessment, the steps taken in the very establishment of DMC may promote patient trust,
professionalism, and humanistic clinical practice. While DMC may be conditional, the compassion
and respect we have for our patients must be unconditional.

Li,-S-F; Haber,-M; Birnbaum,-A. Patient satisfaction and physician dress in the

emergency department. Acad-Emerg-Med. 2003 May; 10(5): 550.
BACKGROUND: To determine if patients' evaluations of EM physicians are influenced by their
manner of dress. Past studies concerning patient responses to physicians' style of dress have
been limited to clinic/in-patient settings, or were limited to preference by photographs. There is
one study of patients' attitude toward ED physician attire, done in the UK, where patients did not
show any preference of dress. We wish to determine if patient preferences are influenced by
physicians' dress in our clinical setting, a U.S. urban hospital. METHODS: A cross-section,
convenience sample of patients. Physician dress was recorded. Patients were asked to determine
on a 100 mm VAS their evaluation of physician appearance, satisfaction, and professionalism.
Dress styles were recorded as scrubs, dress shirt/pants, or mixed. We estimated 56 patients were
needed to detect a 10% difference between groups based on an estimated mean of 75, sd of 10,
2-tailed alpha of.05, beta of.2. Comparison of scores between groups was done using one-way
ANOVA, or Kruskal-Wallis when variances were unequal. Comparison of variances was done using
the F test. Correlation between physician appearance and satisfaction or professionalism was
done using Pearson's rho. RESULTS: 117 patients were surveyed. Physician dress style was 56%
scrubs, 26% mixed, and 17% dress. There were no differences between patients' evaluation of
appearance, satisfaction, or professionalism between the three groups (Table 1). There was poor
correlation between ratings on dress and physician satisfaction (r(2) =.42) or professionalism

37
(r(2) =.32). CONCLUSIONS: Physicians' dress style in the ED does not affect patients' evaluations
of their performance.

Lie,-D; Rucker,-L; Cohn,-F. Using literature as the framework for a new course.
Acad-Med. 2002 Nov; 77(11): 1170.
OBJECTIVE: The award-winning book The Spirit Catches You and You Fall Down,(1) a true story
of the collision between two cultures (American and Hmong) with heartrending consequences for
the patient, the patient's family, and the medical professionals who care for them, has been
favorably reviewed(2) and used to stimulate teaching of cultural diversity, ethics, and
professionalism to students and residents. We used it as a required text for a new Patient Doctor
Society (PDS) course for 184 first- and second-year medical students. This report describes the
scope and contexts in which the book was used to meet specific course goals. DESCRIPTION:
PDS is a required 90-hour introduction to medical interviewing, which integrates ethics,
communication, clinical reasoning, cultural diversity, humanities, spirituality, integrative medicine,
nutrition, and behavioral science. To provide a common experience among these diverse topics,
faculty members were asked to use examples from the book to achieve their learning objectives.
A required faculty development session illustrated strategies for effectively using the text.
Focusing on chapter 13 ("Code X"), dramatic portrayals of differences in beliefs about end-of-life
care and clinician-family communication, facilitated the introduction of methods including point-
of-view writing, role-plays, and faculty-facilitated discussions as techniques for meeting course
objectives. At PDS orientation, we used the same chapter, and had faculty members lead small
groups of students using the teaching techniques they acquired. About 90% of students read the
book prior to orientation. Students favorably reviewed this three-hour session. For the ethics
session, unfacilitated small groups of students were asked to identify and discuss the ethical
issues in chapter 11 ("The Big One"), which describes a major turning point in the health care
provided to the text's central character, Lia. Each group presented its "moral diagnosis" and
ethical arguments for resolution. Class discussion then focused on the diverse views presented,
to emphasize the importance of justifying decisions and to practice using tools of ethical analysis.
In the communication skills workshop, we excerpted dramatic readings from the book. Faculty
members played the roles of the author, the patient's mother, and one of Lia's physicians. The
interaction became a dialogue to illustrate the points of view of the participants. The dialogue
was used to stimulate discussion about potential pitfalls in physician-patient communication and
understanding. In a medical humanities session, excerpts from the book were compared with
poetry explicating themes of physician arrogance and humility. DISCUSSION: The Spirit Catches
You and You Fall Down provides a context appropriate to teaching students how to listen to, and
learn from patient stories. The story will be reintroduced in the pediatrics clerkship. Caution will
be exercised to (1) avoid overexposure to the text, (2) counteract the potential to interpret the
story too narrowly, and (3) assure that faculty become familiar with the text and its uses. We
intend to track outcomes in knowledge, skills and attitudes for each content area, and observe
the degree that the book facilitates achievement of objectives. We will follow several cohorts of
students to verify longitudinally the learning effects observed.

Lockyer,-J. Multisource feedback in the assessment of physician competencies. J-

Contin-Educ-Health-Prof. 2003 Winter; 23(1): 4-12.
Multisource feedback (MSF), or 360-degree employee evaluation, is a questionnaire-based
assessment method in which rates are evaluated by peers, patients, and coworkers on key
performance behaviors. Although widely used in industrial settings to assess performance, the
method is gaining acceptance as a quality improvement method in health systems. This article
describes MSF, identifies the key aspects of MSF program design, summarizes some of the salient
empirical research in medicine, and discusses possible limitations for MSF as an assessment tool
in health care. In industry and in health care, experience suggests that MSF is most likely to
succeed andb2 result in changes in performance when attention is paid to structural and
psychometric aspects of program design and implementation. A carefully selected steering

38
committee ensures that the behaviors examined are appropriate, the communication package is
clear, and the threats posed to individuals are minimized. The instruments that are developed
must be tested to ensure that they are reliable, achieve a generalizability coefficient of Ep2 = .
70, have face and content validity, and examine variance in performance ratings to understand
whether ratings are attributable to how the physician performs and not to factors beyond the
physician's control (e.g., gender, age, or setting). Research shows that reliable data can be
generated with a reasonable number of respondents, and physicians will use the feedback to
contemplate and initiate changes in practice. Performance may be affected by familiarity between
rater and ratee and sociodemographic and continuing medical education characteristics;
however, little of the variance in performance is explained by factors outside the physician's
control. MSF is not a replacement for audit when clinical outcomes need to be assessed.
However, when interpersonal, communication, professionalism, or teamwork behaviors need to
be assessed and guidance given, it is one of the better tools that may be adopted and
implemented to provide feedback and guide performance.

Lynch,-D-C; Pugno,-P; Beebe,-D-K; Cullison,-S-W; Lin,-J-J. Family practice graduate

preparedness in the six ACGME competency areas: prequel. Fam-Med. 2003 May;
35(5): 324-9.
BACKGROUND AND OBJECTIVES: Since July 2002, family practice residency program
accreditation requires evidence of teaching and assessing residents in six competency areas. This
study was conducted to obtain baseline information about family practice graduates' perceptions
of the importance of specific competencies and the extent to which residency training prepared
them to perform skills representative of the six competency areas. METHODS: A national, cross-
sectional survey was conducted of family physicians who had graduated from residency programs
from 1998 to 2000. RESULTS: The response rate was 54% (n=1,228). Graduates reported the
most preparation in patient care skills, followed by interpersonal and communication skills and
then professionalism. The least preparation was reported for skills pertinent to practice-based
learning and improvement, systems-based practice, and some areas of professionalism.
CONCLUSIONS: Areas of residency education that appear to warrant improvement include
education about system aspects of care, practice-based learning and improvement, and selected
professionalism issues.

Lypson,-M-L; Hauser,-J-M. Talking medicine: a course in medical humanism--what do

third-year medical students think? Acad-Med. 2002 Nov; 77(11): 1169-70.
OBJECTIVE: The early 1990s sparked an interest in organized medicine to reclaim and re-
evaluate how it promotes professionalism among physicians. The American Board of Internal
Medicine (ABIM) launched Project Professionalism as a means to define and evaluate
professionalism as a component of clinical competence. The course "Talking Medicine" was
developed to create a series of small-group discussions on humanism and professionalism where
students can reflect on the process of becoming a physician and share personally or ethically
difficult and rewarding cases with each other. We asked students to define these concepts and
use these definitions to spark small-group discussion. DESCRIPTION: "Talking Medicine" is
predicated on the belief that humanism and professionalism come to students and others through
understanding a number of core concepts and relationships complemented by self-reflection.
"Talking Medicine" offers a consistent (every other week for ten weeks) opportunity to share
experiences in small groups (six to eight students), facilitated by two preceptors, in a format
driven by students' experiences. Although the focus is on students' experiences, readings are
provided on basic topics and contexts in humanism and professionalism (e.g., end-of-life care,
mistakes, spirituality in medicine, and boundaries between patients and doctors). Also, at the
beginning of each internal medicine clerkship we asked students to define humanism and
professionalism anonymously on sheets of paper to be handed to the preceptors. DISCUSSION:
"Talking Medicine" began in summer 2000. We hope to expand it to other institutions. We
surveyed students and found 94% felt "very" or "somewhat" comfortable in the course. Seventy-

39
three percent of students reported that the course increased their "connectedness" to
classmates, and 61% favored its occurring during all rotations. Fifty-nine percent reported that
their interest in caring for patients improved, and 53% reported their interest in internal medicine
as a field improved. Answers to open-ended questions highlighted the importance of "Talking
Medicine" as a forum to connect with others-both students and faculty. Despite this course's
focus during an internal medicine clerkship, students see a broader definition of professionalism
than the ABIM; the student's definitions were similar in many ways to the Group of Educational
Affairs definition of professionalism. Third-year medical students focus more on tolerance of
difference (e.g., race, socioeconomic status, and varying health beliefs), and the importance of
collegiality and collaboration in the new environment of patient care. Their vantage point early in
training allows them to look critically at the profession they are joining and view its shortcomings
and strengths. Future work is needed that focuses on how these definitions change as students'
progress through fourth year, into residency, and finally continuing medical education.
Nevertheless, we suggest that "Talking Medicine" may be most effective in helping classmates
connect to and learn from each other, thereby setting a foundation for changes in how they
interact with patients.

McLaughlin,-S-A; Doezema,-D; Sklar,-D-P. Human simulation in emergency medicine

training: a model curriculum. Acad-Emerg-Med. 2002 Nov; 9(11): 1310-8.
The authors propose a three-year curriculum for emergency medicine residents using human
simulation both to teach and to assess the Accreditation Council for Graduate Medical Education
(ACGME) core competencies. Human simulation refers to a variety of technologies that allow
residents to work through realistic patient problems so as to allow them to make mistakes, learn,
and be evaluated without exposing a real patient to risk. This curriculum incorporates 15
simulated patient encounters with gradually increasing difficulty, complexity, and realism into a
three-year emergency medicine residency. The core competencies are incorporated into each
case, focusing on the areas of patient care, interpersonal skills and communication,
professionalism, and practice based learning and improvement. Because of the limitations of
current assessment tools, the demonstration of resident competence is used only for formative
evaluations. Limitations of this proposal and difficulties in implementation are discussed, along
with a description of the organization and initiation of the simulation program.

Miles,-S-H. On a new charter to defend medical professionalism: whose profession is

it anyway? Hastings-Cent-Rep. 2002 May-Jun; 32(3): 46-8.

Norcini,-J-J; Blank,-L-L; Duffy,-F-D; Fortna,-G-S. The mini-CEX: a method for

assessing clinical skills. Ann-Intern-Med. 2003 Mar 18; 138(6): 476-81.
OBJECTIVE: To evaluate the mini-clinical evaluation exercise (mini-CEX), which assesses the
clinical skills of residents. DESIGN: Observational study and psychometric assessment of the
mini-CEX. SETTING: 21 internal medicine training programs. PARTICIPANTS: Data from 1228
mini-CEX encounters involving 421 residents and 316 evaluators. INTERVENTION: The
encounters were assessed for the type of visit, sex and complexity of the patient, when the
encounter occurred, length of the encounter, ratings provided, and the satisfaction of the
examiners. Using this information, we determined the overall average ratings for residents in all
categories, the reliability of the mini-CEX scores, and the effects of the characteristics of the
patients and encounters. MEASUREMENTS: Interviewing skills, physical examination,
professionalism, clinical judgment, counseling, organization and efficiency, and overall
competence were evaluated. RESULTS: Residents were assessed in various clinical settings with a
diverse set of patient problems. Residents received the lowest ratings in the physical examination
and the highest ratings in professionalism. Comparisons over the first year of training showed
statistically significant improvement in all aspects of competence, and the method generated
reliable ratings. CONCLUSIONS: The measurement characteristics of the mini-CEX are similar to
those of other performance assessments, such as standardized patients. Unlike these

40
assessments, the difficulty of the examination will vary with the patients that a resident
encounters. This effect is mitigated to a degree by the examiners, who slightly overcompensate
for patient difficulty, and by the fact that each resident interacts with several patients.
Furthermore, the mini-CEX has higher fidelity than these formats, permits evaluation based on a
much broader set of clinical settings and patient problems, and is administered on site.

Patenaude,-J; Niyonsenga,-T; Fafard,-D. Changes in students' moral development

during medical school: a cohort study. CMAJ. 2003 Apr 1; 168(7): 840-4.
INTRODUCTION: The requirements of professionalism and the expected qualities of medical
staff, including high moral character, motivate institutions to care about the ethical development
of students during their medical education. We assessed progress in moral reasoning in a cohort
of medical students over the first 3 years of their education. METHODS: We invited all 92 medical
students enrolled at the University of Sherbrooke, Que., to complete a questionnaire on moral
reasoning at the start of their first year of medical school and at the end of their third year. We
used the French version of Kohlberg's Moral Judgment Interview. Responses to the questionnaire
were coded by stage of moral development, and weighted average scores were assigned
according to frequency of use of each stage. RESULTS: Of the 92 medical students, 54 completed
the questionnaire in the fall of the first year and again at the end of their third year. The average
age of the students at the end of the third year was 21 years, and 79% of the students included
in the study were women. Over the 3-year period, the stage of moral development did not
change substantially (i.e., by more than half a stage) for 39 (72%) of the students, shifted to a
lower stage for 7 (13%) and shifted to a higher stage for 8 (15%). The overall mean change in
stage was not significant (from mean 3.46 in year 1 to 3.48 in year 3, p = 0.86); however, the
overall mean change in weighted average scores showed a significant decline in moral
development (p = 0.028). INTERPRETATION: Temporal variations in students' scores show a
levelling process of their moral reasoning. This finding prompts us to ask whether a hidden
curriculum exists in the structure of medical education that inhibits rather than facilitates the
development of moral reasoning.

Robins,-L-S; Braddock,-C-H 3rd; Fryer-Edwards,-K-A. Using the American Board of

Internal Medicine's "Elements of Professionalism" for undergraduate ethics
education. Acad-Med. 2002 Jun; 77(6): 523-31.
PURPOSE: To examine the feasibility of using the taxonomy of professional and unprofessional
behaviors presented in the American Board of Internal Medicine's (ABIM's) Project
Professionalism to categorize ethical issues that undergraduate medical students perceive to be
salient. METHOD: Beginning second-year medical students at the University of Washington
School of Medicine (n = 120) were asked to respond to three open-ended questions about
professional standards of conduct and peer evaluation. Two of the authors read and coded the
students' responses according to the ABIM's elements of professionalism (altruism,
accountability, excellence, duty, honor and integrity, and respect for others) and the challenges
to those elements (abuse of power, arrogance, greed, misrepresentation, impairment, lack of
conscientiousness, and conflict of interest). Coding disagreements were solved using review and
revision of the category definitions. New categories were created for students' responses that
described behaviors or issues that were not captured in the ABIM's categories. RESULTS: A total
of 114 students responded. The ABIM's professional code was adapted for students and teachers,
making it context- and learning-stage-specific. One new category of challenges, conflicts of
conscience, was added, and one category (abuse of power) was expanded to include abuse of
power/negotiating power asymmetries. CONCLUSIONS: Using the ABIM's taxonomy to name
professional and unprofessional behaviors was particularly useful for examining undergraduate
medical students' perceptions of the ethical climate for learning during the first year of medical
school, and it holds promise for research into changes in students' perceptions as they move into
clinical experiences. Using the framework, students can build a unified professional knowledge-
and-skills base.

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Siegler,-M. Training doctors for professionalism: some lessons from teaching clinical
medical ethics. Mt-Sinai-J-Med. 2002 Nov; 69(6): 404-9.
Medical professionalism encourages physicians to place their patients’ interests above self-
interest. In recent years, many medical organizations, including the American Board of Internal
Medicine (ABIM), Association of American Medical Colleges (AAMC), and the American Medical
Association (AMA), have developed initiatives to strengthen medical professionalism. By
emphasizing professionalism, supporters of these initiatives hope that medicine and physicians
may recapture professional autonomy, decrease public criticism of medicine and physicians, and
help physicians regain the moral high ground in the unending struggle with payers, both public
and private. One crucial question facing medical educators is whether the concepts of
professionalism can be taught to medical students and residents. This paper draws upon the
author s thirty years of experience in teaching clinical medical ethics to provide guidance on how
to teach the concepts of professionalism to students and residents.

Sklar,-D-P; Doezema,-D; McLaughlin,-S; Helitzer,-D. Teaching communications and

professionalism through writing and humanities: reflections of ten years of
experience. Acad-Emerg-Med. 2002 Nov; 9(11): 1360-4.
Both professionalism and interpersonal communication are core competencies for emergency
medicine residents as well as residents from other specialties. The authors describe a weekly,
small-group seminar lasting one year for emergency medicine residents that incorporates didactic
materials, case studies, narrative expression (stories and poems), and small-group discussion.
Examples of cases and narrative expressions are provided and a rationale for utilizing the format
is explained. A theoretical model for evaluation measures is also included.

Stephenson,-A; Higgs,-R; Sugarman,-J. Teaching professional development in

medical schools. Lancet. 2001 Mar 17; 357(9259): 867-70.
AB: Doctors must increasingly be aware of what they should be, as well as what they should
know. Professionalism, including a value system that supports the compassionate care of
patients, is a means of encapsulating and prioritising these competing responsibilities.
Accordingly, in this article, we assume that professionalism is an essential aspect of medical
practice that needs to be taught to those entering medicine. We first describe critiques of
professionalism and current challenges to it, in practice and in medical education. We then assess
the current efforts of curriculum reform to incorporate professionalism and the methods used to
teach it. Adopting and assessing such approaches to ensure that they are effective is of central
importance in the education of future clinicians.

Surdyk,-P-M. Educating for professionalism: what counts? Who's counting? Camb-Q-

Healthc-Ethics. 2003 Spring; 12(2): 155-60.

Wallach,-P-M; Roscoe,-L; Bowden,-R. The profession of medicine: an integrated

approach to basic principles. Acad-Med. 2002 Nov; 77(11): 1168-9.
OBJECTIVE: The University of South Florida College of Medicine developed and implemented an
innovative three-week course entitled, "The Profession of Medicine: An Integrated Approach to
Basic Principles" to introduce new medical students to topics and skills that are important to their
successful study of medicine. Demonstrating the clinical relevance of the basic sciences, the
importance of lifelong learning, and ethics and professionalism in medicine were emphasized.
Basic physical examination techniques, searching the medical literature and evidence-based
medicine, and study and computer skills were introduced in addition to traditional orientation
topics. DESCRIPTION: Four interdisciplinary "state of the art" presentations demonstrated the
importance of lifelong learning and the clinical relevance of basic science concepts. Lectures on
acute myocardial infarction, breast cancer, duodenal ulcer, and pulmonary prematurity were

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presented as if the lectures were being given in 1980. Students attended lectures on basic
science principles relevant to these topics, and then met in small groups with librarians, content
experts, and small-group facilitators to begin investigating an assigned topic. For example,
student groups researched the development of EMS and chest pain centers, thrombolysis and
percutaneous coronary intervention, and the psychological implications of acute myocardial
infarction for patients and families. Students were introduced to effective literature-searching
techniques, the tenets of evidence-based medicine, and effective computer skills in the context of
studying their assigned topics. Each group then selected a student presenter to deliver an eight-
minute PowerPoint presentation of its 2001 "state of the art" findings, making particular note of
scientific advances and new therapeutic protocols developed since 1980, such as the use of
artificial surfactant in premature babies, the role of H. pylori in duodenal ulcers, and the
discovery of the genetics of breast cancer. These projects as well as a series of small-group
educational programs enabled students and faculty to develop a strong sense of team-work and
cohesiveness. Students had opportunities to practice components of the history and physical
examination on standardized patients relevant to the four clinical topic areas, such as cardiac and
abdominal examinations with emphasis on anatomic principles. Basic ethical principles and their
application to cases that pertained to the four clinical topics were introduced, and students
participated in a small-group ethics case conference. Throughout the course, students and faculty
were required to wear specially designed nametags. By the time the course concluded with the
White Coat ceremony, the 75 participating faculty and 104 students knew one another, making
the ceremony particularly meaningful. DISCUSSION: The pace at which scientific findings
revolutionize the practice of medicine continues to accelerate. While it is important for
undergraduate medical students to master the basic and clinical science foundations of medical
practice, it may be even more important to teach students how to find and interpret medical
information, form professional relationships with mentors and peers, and make a commitment to
lifelong learning and professionalism. It is critical that students understand that the curricular
program at any college of medicine is only the beginning of a life of study.

Welling,-R-E; Boberg,-J-T. Professionalism: lifelong commitment for surgeons. Arch-

Surg. 2003 Mar; 138(3): 262-4; discussion 264.
Presently, there is a major initiative to rekindle the humanistic qualities in the practice of
medicine. Although there have been many suggestions on ways to rejuvenate this initiative, it
has not been a primary focus of graduate medical education until recently. Surgery residents are
expected to maintain a high standard of ethical behavior; demonstrate a commitment to
continuity of patient care; and demonstrate sensitivity to the age, gender, and culture of patients
and fellow health care professionals. We in surgical education must accept the responsibility for
the renewal in teaching and evaluating the professional and ethical principles of surgery
residents. This change will not happen quickly, but it should be done skillfully because future
generations will look back on this time of renewal in medicine and critique us on our ability or
inability to achieve this goal.

Yates,-S. Finding your funny bone. Incorporating humour into medical practice.
Aust-Fam-Physician. 2001 Jan; 30(1): 22-4.
BACKGROUND: Many people confuse seriousness with professionalism. Humour enables you to
separate who you are from the difficult work you do. OBJECTIVE: To illustrate ways humour and
fun can be incorporated into day to day working life. DISCUSSION: People are more productive,
cooperative and flexible when they have fun at work. Becoming a humour consumer of tapes,
jokes, TV shows, movies or funny books, strengthens your sense of humour, relieves stress and
improves relationships.

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