Professionalism

NOTE: The UW Dept. of Bioethics & Humanities is in the process of updating all Ethics in Medicine articles for attentiveness to the issues of equity, diversity, and inclusion.  Please check back soon for updates!

Authors:

Albert R. Jonsen, PhD, Emeritus Professor (deceased), UW Dept. of Bioethics & Humanities

Clarence H. Braddock III, MD, MPH

Kelly A. Edwards, PhD, Affiliate Professor, UW Dept. of Bioethics & Humanities

Topics addressed:

• What does it mean to be a member of a profession?
• What is the difference between a profession and a business?
• What are the recognized obligations and values of a professional physician?
• Is professionalism compatible with the restrictions sometimes placed on physician's judgments in managed care?

Because medicine is a profession and physicians are professionals, it is important to have a clear understanding of what "professionalism" means. As a physician-in-training, you will be developing a personal sense of what it means to be a professional. This topic page outlines some common features. Please see the topic page on the Physician-Patient Relationship for further discussion of the professional responsibilities of physicians.

What does it mean to be a member of a profession?

The words "profession" and "professional" come from the Latin word "professio," which means a public declaration with the force of a promise. Professions are groups which declare in a public way that their members promise to act in certain ways and that the group and the society may discipline those who fail to do so. The profession presents itself to society as a social benefit and society accepts the profession, expecting it to serve some important social goal. The profession usually issues a code of ethics stating the standards by which its members can be judged. The traditional professions are medicine, law, education and clergy. 
The marks of a profession are:

1. Competence in a specialized body of knowledge and skill;
2. An acknowledgment of specific duties and responsibilities toward the individuals it serves and toward society;
3. The right to train, admit, discipline and dismiss its members for failure to sustain competence or observe the duties and responsibilities.

What is the difference between a profession and a business?

The line between a business and a profession is not entirely clear, since professionals may engage in business and make a living by it. However, one crucial difference distinguishes them: professionals have a fiduciary duty toward those they serve. This means that professionals have a particularly stringent duty to assure that their decisions and actions serve the welfare of their patients or clients, even at some cost to themselves. Professions have codes of ethics which specify the obligations arising from this fiduciary duty. Ethical problems often occur when there appears to be a conflict between these obligations or between fiduciary duties and personal goals.

What are the recognized obligations and values of a professional physician?

Professionalism requires that the practitioner strive for excellence in the following areas, which should be modeled by mentors and teachers and become part of the attitudes, behaviors, and skills integral to patient care:

• Altruism: A physician is obligated to attend to the best interest of patients, rather than self-interest.
• Accountability: Physicians are accountable to their patients, to society on issues of public health, and to their profession.
• Excellence: Physicians are obligated to make a commitment to life-long learning.
• Duty: A physician should be available and responsive when "on call," accepting a commitment to service within the profession and the community.
• Honor and integrity: Physicians should be committed to being fair, truthful and straightforward in their interactions with patients and the profession.
• Respect for others: A physician should demonstrate respect for patients and their families, other physicians and team members, medical students, residents and fellows.

These values should provide guidance for promoting professional behavior and for making difficult ethical decisions.
A Physician Charter: Medical Professionalism in the New Millennium was issued jointly by the American Board of Internal Medicine, the American College of Physicians and the European Federation of Internal Medicine in 2002. Subsequently, 90 professional associations, including most of the specialty and subspecialty groups in American medicine have endorsed the Charter. The fundamental principles of professionalism are stated as (1) the primacy of patient welfare; (2) patient autonomy; (3) social justice. Professional responsibilities that follow from these principles are commitment to competence, to honesty with patients, to confidentiality, to appropriate relationship with patients, to improving quality of care, to improving access to care, to a just distribution of finite resource, to scientific knowledge, to maintaining trust by managing conflicts of interests and to professional responsibilities.

Is professionalism compatible with the restrictions sometimes placed on physician's judgments in managed care?

One of the principal attributes of professionalism is independent judgment about technical matters relevant to the expertise of the profession. The purpose of this independent judgment is to assure that general technical knowledge is appropriately applied to particular cases. Today, many physicians work in managed care situations that require them to abide by policies and rules regarding forms of treatment, time spent with patients, use of pharmaceuticals, etc. In principle, such restrictions should be designed to enhance and improve professional judgment, not limit it. For example, requiring consultation is ethically obligatory in doubtful clinical situations; penalizing consultation for financial reasons would be ethically wrong. Also, requiring physicians to adhere to practice guidelines and to consult outcome studies may improve professional judgment; requiring blind adherence to those guidelines may be a barrier to the exercise of professional judgment. The presence of rules, policies and guidelines in managed care settings requires the physicians who work in these settings to make such judgments and to express their reasoned criticism of any that force the physician to violate the principles of professionalism.