Keywords

Professionalism; Health care; Health professionals; Training

Introduction

Professionalism, an indispensable element between society and any profession, is essential in medical profession too, for patient care, training and above all trust which has to be inherent part of medical profession. Resurgence of interest in professionalism does not go back to many decades. It was only some years back when health maintenance organizations were formed and proprietary influences in health care increased. Professionalism provides an implicit grounding for appropriate public health practice.

Medical professionalism refers to attributes, values, behaviors, responsibilities and commitments of physicians, congruent with public’s expectations. Currently medical profession is facing the challenges which include its perceived status and physician satisfaction/dissatisfaction, behavior and its relation to quality education, quality health care and patient safety. Individual medical schools are reporting on educational institute efforts to promote professionalism in the curricula. Professionalism, based on trust, an indispensable element between the medical profession and society, is essential for putting the needs of patients above all other considerations and so is essential to learn by the health professionals [1].

Objective

To have information about professionalism in health care and health professionals’ training.

Literature Review

Literature search was done with various available search engines, for looking into clinical studies and reviews in relation to professionalism in health systems, health care as well as health professionals training institute. Opinions and selfexperiences were also added. There was no specific inclusion or exclusion criteria for studies. Whatever literature, studies, reviews and opinions were available were looked into [2].

A number of formal definitions of professionalism have been proposed. All include the word ‘trust’. At Mayo clinic, professionalism was defined as ‘engendering trust by doing the right things, for the right reasons, in the right way and at the right time’. It is believed that definition incorporated all the key attitudes and behaviors. Allied elements included well developed interpersonal and communication skills which are required to overcome the discrepancy in knowledge and expertise between highly trained doctors and the lay public. Such discrepancies add to the sense of patient vulnerability that is constantly present with sickness and ill health. Professionalism, defined according to Merriam-Webster’s Learner’s dictionary, means ‘the skill, good judgment and polite behavior that is expected from a person who is trained to do a job well’ [3].

The Association of Schools of Public Health (ASPH) has identified professionalism as ‘an ability to demonstrate ethical choices, values and practices in decision-making and to commit to the practice of personal and professional values as one of the cross-cutting or interdisciplinary competencies necessary for graduate education in public health’.

Brennan, reported that it was only in 1980s when health maintenance organizations were formed and proprietary influences in health care increased. Literature search revealed that professionalism is one of the six core competencies mandated by the Accreditation Council for Graduate Medical Education in the USA. The American college of physicians has stated in its ethics manual that ‘any discrimination violated the principles of professionalism’. Others reported that in clinical settings, professionalism was simplistically and narrowly defined as a ‘technical problem’. Most solutions offered were prescriptive, mechanical and rule-bound. Monrouxe reported gender differences in observations of professionalism which could be because of respondents acting according to gendered expectations, like males downplaying distress because they were expected to appear tough. Habituation to dilemmas suggested that students balanced patient autonomy and right to dignity with their own needs to learn for future patient benefit. This leads to the notion that students become less empathic as times passed. Future research might examine the strategies that students use to manage their distress, to understand how this impacted them in issues such as burnout and/or leaving the profession. Rees, et al., reported in their study, the most common themes across all narratives students gave were dilemmas that related patient care, consent and intimate examinations, actions of health care professionals or students or student abuse. In the study it was revealed that around 41% such experiences had occurred over 6 months and around 80% of them had taken place in hospital settings. Wiggleton, reported that medical students frequently experienced moral distress in their learning environment. Students at extremes of moral distress were at the risk of burnout or erosion of professionalism. The study by Medline search for peer-reviewed, English language articles published between 1990 and 2015 reporting on burnout among trainees, revealed high prevalence of burn out, much higher than in the general population [4].

Brennan, et al, has reported that the literature does reveal the role that health care organizations could play in establishing environments that were conducive to the consistent expression of professionalism by individuals and health care teams. Studies of health care effectiveness and outcomes, revealed that the organizational and individual professionalism were associated with a wide range of benefits to patients and the organizations. It has been identified as actionable organizational strategies and approaches that, if adopted, in health care systems can foster and promote combined organizational and individual actions. In doing so, trust in the medical profession and its institutions can be enhanced, which in turn will reconfirm a commitment to the social compact. The medical profession enjoys certain rights and privileges that are granted by the society and its representatives and agencies but they bring with them many duties too. However there are many problems, especially because in the modern era the trust in medical profession has been eroded badly. Krishnan has written that ‘the physician Danielle Ofri, suggested that in the era of medical corporatization, physicians unwavering commitment to their patients can become a paradoxical cause of burnout as physicians “do the right things for their patients “even at a high personal cost’ [5].

However there are positive examples too. The limitation of the foundation for medical excellence is a nonprofit organization that relies on grants and donations for educational programs, consulting and other initiatives to improve the quality of health care and advance sound health policies. The charter has 4 areas of focus. Patient partnerships, organizational culture, community partnerships and operations and business practices. The atmosphere in any organization affects professionalism and the actions of health professionals. Health care organizations pressuring the physicians to compromise the patients’ interests for those of the organizations are detrimental to the health system, health care as well as training professionalism in health. They are the major cause of dilemmas and mental distress amongst students and to some extent health providers too. Mason, reported that health care organizations are under enormous pressure for improving people’s experiences with the care being provided, for improving population health, reducing health care cost and also fostering professionalism satisfaction among health providers [6].

Medical school curricula, are traditionally and historically dominated by science. Recent concerns have led to discussions about the specific role and contribution of literature and stories in putting more of human aspects. Thoughtful scholars have considered the modalities of teaching professionalism effectively and meaningfully. Questions have arisen about the role of stories, essays, first person narratives and poetry in facilitating the professional identity formation of medical students. Those who argued affirmatively, implied that exposing students to literature inculcated professionalism virtues and attributes. Those who did not believe in it asserted that the study of literature had goals and purposes unrelated to professionalism in health system. In terms of professionalism specifically, attempting to inculcate values and virtues, often struck both learners and educators as threatening and potentially implying character defects in students. Further curricula should never be divorced from culture. Professionalism in health education programs are commonly transported into different cultures without sufficient considerations of students acceptance or local impact. In the era of globalization medical students needed to seek worldwide learning experiences.

Batalden, reported that professionalism needed to become one of the six essential core competencies in medical education amongst those described by the ‘outcome project 2001’. Six essential care competences included. Even as professionalism became identified as an area of medical competence some medical educators’ reflections on the professionalism continued to reveal a discomfort with behavioral pedagogical approaches, instead advocating for developing, reinforcing and sustaining deeply held attitudes and values. Hanna, et al and others advocated that medical students must learn how to “be good doctors”, rather than acting like good doctors’. Others have also suggested that behavioral professionalism tempted students to behave in the ways that fulfilled society’s expectations of work with professionalism without actually believing in the virtues or principles that underpin need of such behavior. This resulted in an emphasis on surface impression management. A complex pattern was found across countries for Hofstede dimensions. Krupat reported that assessment of the understanding of professionalism that students learned from literature would have been better achieved through qualitative, narrative means and needed to be done. Studies are being done [7]. Professionalism, an ability to demonstrate ethical choice, values and practices in decision making, to commit to the practice of personal and professional values as one of the cross cutting or interdisciplinary competencies necessary for graduate education in public health.

According to Association of Schools of Public Health (ASPH), such interdisciplinary competencies are considered cross-cutting because they are integrated throughout the core public health disciplines like biostatistics, environmental health sciences, epidemiology, health policy management and social and behavioral sciences. Four themes or concepts that apply to health care organizations activities have been suggested, first model health care organizations needed to emphasize the primacy of obligations to patients and ensure that all members of the organization reflected this priority in their day-to-day work. Second model health care organizations promoted the goal of broad access to health care. Third model health care organizations were good stewards of resources invested in health care and finally, model health care organizations were learning organizations which continually transformed themselves to perform their core mission better and to take on new roles as the health system [8].

Discussion

The decisions of leaders of hospitals and other health care organizations can facilitate or impede health professionals’ living up to their own profession’s code of conduct, to learn professionalism and behave with professionalism. Large, prospective studies are needed to identify, cause-effect relationships and the best approaches for improving the trainees experiences, especially because medical training is a stressful time. An organization needs to demonstrate a commitment to engaging patients and families in shared decision making, addressing the health and the wellbeing of the patient as a whole, rather than just disease, ensuring continuum of care through coordination and collaboration within and across organizations and measuring what matters to the patients and society. Health care organizations must invest in addressing social determinants of health in collaboration with the communities they serve. This included shaping policies that affected a community’s environment, socioeconomic well-being and social service. An individual clinician’s behavior is intertwined with the culture, policies and behavior of the organization in which he or she works. As a result, principles of professionalism in health care organizations need to be at the top of the agenda of health care training institutes [9]. To treat someone with dignity is to treat him/her as being worth, in a way that is respectful of as valued individual. Dignity is affected by the physical environment, organizational culture; by the attitudes and behavior of the health care teams and the way in which health care activities are carried out. If people feel in control confident, comfortable are best valued and are able to make decisions for themselves, it may be called dignified treatment. If dignity is absent people feel devalued, lack control and comfort. They may feel humiliated, embarrassed or ashamed. They lost confidence and so are unable to make decisions for themselves. The health care teams should treat everyone, at any setting and at any health facility with dignity, dignified care must continue during and after death too. Licensures to institutes are granted on the understanding that the doctors will use their knowledge and skills to meet the needs of their patients and in doing so place the needs of patients ahead of any other consideration. Essential levels of trust can be achieved and sustained through consistent expression of professionalism, right attitudes, behaviors, integrity, accountability, motivation, empathy and the pursuit of excellence through lifelong learning. The teaching of professionalism and the experiences of professionals enrich each other and foster the critical link between education and practice. Challenges in the delivery of health care, be it prevention of disease, promotion of health and development of health policy continue to increase in complexity and scope. New diseases and technologies are emerging and reemerging. Globalization is faster. A growing gap between rich and poor, prompt professionals for the right things to be done and in making decisions that affect the health of communities, over all public's health. Egener, reported that the professional competencies and behaviors that organizations can leverage to create an environment that promoted professional behavior throughout the organization developed by administrators, physicians, nurses and patients, the charter was a multidisciplinary effort that melded the aspirations of all involved to provide such an outcome. The downside to this vagary is that it allows for the weaponization of professionalism, leaving space for “professionals” to reject certain approaches in health care [10,11].

Professionalism has always provided an implicit grounding for public health practice. New graduates needed the abilities and skills necessary to effectively manage their careers. Educators responsibility is to prepare competent healthcare professionals by facilitating their learning experiences for the best of understanding and integrate the multiple perspectives of healthcare teams [12,13].

Conclusion

People entrusted to deliver care needed to be steered by ethical commitments and social accountability which are the essence of professionalism. The development of competencies for professionalism in public health coincide with the emergence of public health ethics, with its population-based focus, as a specialty area, distinct from bioethics, with its individual-based focus. Because the best methods for teaching the knowledge, skills and behaviors included under the professionalism competencies can be elusive, a variety of methods and philosophical viewpoints will emerge as schools and programs move forward to ensure that curricula included mechanisms for meeting professionalism. In many medical schools, a portion of the curriculum is dedicated to the intricacies of medical professionalism. Professionalism, as a necessity in health care setting is an important precedent of excellence and respect towards peers and patients.

References

1. Brennan MD (2016) The role of professionalism in clinical practice, medical education, biomedical research and health care administration. J Transl Intern Med 4: 64-65.

   [Crossref] [Google Scholar] [PubMed]

2. Brennan MD, Monson V (2014) Professionalism: Good for patients and health care organizations. Mayo Clin Proc 89: 644-652.

   [Crossref] [Google Scholar] [PubMed]

3. Snyder L (2012) American college of physicians ethics manual. Ann Intern Med 156: 73-104.

   [Crossref] [Google Scholar] [PubMed]

4. Lucey C, Souba W (2020) Perspective: The problem with the problem of professionalism. Acad Med 85: 1018-1024.

   [Crossref] [Google Scholar] [PubMed]

5. Monrouxe LV, Rees CE, Dennis I, Wells SE (2015) Professionalism dilemmas, moral distress and the healthcare student: Insights from two online UK-wide questionnaire studies. BMJ Open 5: e007518.

   [Crossref] [Google Scholar] [PubMed]

6. Rees CE, Monrouxe LV, McDonald LA (2013) Narrative, emotion and action: Analysing ‘most memorable’professionalism dilemmas. Med Edu 47: 80-96.

   [Crossref] [Google Scholar] [PubMed]

7. Wiggleton C, Petrusa E, Loomis K, Tarpley J, Tarpley M, et al. (2010) Medical students' experiences of moral distress: Development of a web-based survey. Acad Med 85: 111-117.

   [Crossref] [Google Scholar] [PubMed]

8. Dyrbye L, Shanafelt T (2016) A narrative review on burnout experienced by medical students and residents. Med Edu 50: 132-149.

   [Crossref] [Google Scholar] [PubMed]

9. Krishnan L, Marchalik D (2019) Physicians, oaths and vampires. Lancet 394: 1001.

   [Crossref] [Google Scholar] [PubMed]

10. Mason DJ (2017) Professionalism in health care organizations. Jama 317: 1203-1204.

    [Crossref] [Google Scholar] [PubMed]

11. Holmgren L, Fuks A, Boudreau D, Sparks T, Kreiswirth M (2011) Terminology and praxis: Clarifying the scope of narrative in medicine. Lit Med 29: 246-273.

    [Crossref] [Google Scholar] [PubMed]

12. Bishop JP (2008) Rejecting medical humanism: Medical humanities and the metaphysics of medicine. J Med Human 29: 15-25.

    [Crossref] [Google Scholar] [PubMed]

13. Batalden P, Leach D, Swing S, Dreyfus H, Dreyfus S (2002) General competencies and accreditation in graduate medical education. Health Aff 21: 103-111.

    [Crossref] [Google Scholar] [PubMed]