Professionalism

Introduction

Trust between the patient and clinician is central to the therapeutic relationship. Without this requisite level of trust, patients will not reveal information about themselves nor will they follow treatment recommendations. Trust builds from the belief that the clinician possesses expert knowledge (which will be applied to the benefit of individuals and society) and will avoid self-interest while acting on behalf of those served. Growing from that public trust, a level of autonomy to self-regulate is afforded to medicine; however, the autonomy extended to the profession must be in balance with medicine’s priority of advancing the public welfare. This combination of commitment to service, the possession of a specialized body of knowledge, and the ability to self-regulate are the key components of professionalism.

Some have questioned whether the shared body of medical knowledge and participation in a supervised practice qualifies physician assistants (PAs) for consideration as professionals. Others have clearly demonstrated that PAs should be considered professionals. Soon after PAs began to practice, Tworek applied the standards of professionalism to PAs and concluded that those in the occupation had become professionalized. Picking up on that distinction later, Gianola concluded that the evolution to the modern role of PAs has resulted in our becoming a full profession.

Thus, when the four leading PA organizations adopted the Competencies for the Physician Assistant Profession, they followed the lead of our physician colleagues and included professionalism as one of the six “general competencies.” The importance of professionalism for PAs was again emphasized by the work of the 2017 Physician Assistant Education Association (PAEA) Presidents Commission. They pointed to a growing body of research that called for increased attention to be paid to noncognitive attributes of health professionals, including professionalism. Their report confirmed that professionalism is one of the top 10 noncognitive attributes that needs to be fostered by PAs. This is the result of changes in the health care system and a consequence of the move to competency-based education. Recognition as a profession brings with it opportunities and responsibilities. In recent years, a variety of pressures resulting from changes in the health care delivery system have made it more difficult for medicine to live up to those responsibilities. As a result, the professional tenets of medicine have been called into question. ^, A return to professionalism depends on clearly defining the term and identifying ways to foster and assess it. Lessons for PAs can be learned from the physician experience.

Understanding its importance

Early in the history of medicine, the promises of the Hippocratic Oath grounded medicine and instilled in physicians a strong commitment to service. As attention later shifted to the science of medicine, the specialized knowledge associated with medicine became the central focus. Consequently, the understanding of and commitment to the service responsibilities diminished with significant consequences to the overall impression of physicians as professionals.

Compounding the consequences of that shift in focus, the business aspects of medicine also began to affect medicine’s image. Some have suggested that medicine used its significant knowledge base to find ways to manipulate the market to increase the demand for services, dramatically increasing costs for health care. In this scenario, physicians were thought to have put their own economic interests above the needs of patients and society—an action that goes against the precepts of professionalism. ^,

As health care costs escalated, government and insurer involvement in health care increased, with resulting tighter controls over medicine. Precertification and utilization review efforts by the government and insurers reduced the ability of health professionals to make autonomous medical decisions. Credentialing efforts by insurers that evaluated the performance of health professionals adversely impacted self-regulation efforts. As constraints over decision making and self-regulation have increased, the influence of medicine has decreased and the image of physicians as professionals has been affected. ^,

With changes in the health care system challenging the professionalism associated with medicine, today’s clinicians must understand what it means to be a professional and must be willing to abide by the expectations that result. Nevertheless, questions have been raised concerning the uniform existence of that understanding of and commitment to professionalism. Despite a commitment to teaching clinicians in training about professionalism, those efforts have been hampered by a lack of universal agreement on the definition of professionalism. ^,

The goal of teaching professionalism is to assist students with developing a professional identity. The process requires a dual focus on exploring through explicit curricula the definition of professionalism and the traits associated with professional behavior and teaching students to participate in experiential learning activities that include a component of reflection on professional behaviors.

After 2 years of observations during medical school interviews, as well as class discussions and exercises, Hafferty voiced concerns about the existence of the core values central to professionalism. He noted that medical students might feel less of an obligation to be bound by the expectations set forth in a code of ethics. He also suggested that they might not feel a need to ascribe to the values outlined in professional oaths that are generally part of most medical school graduations. In addition, he observed that even white coat ceremonies, despite all their symbolism, seem to fail to remind medical students of the values and obligations of professionals.

Reinforcing the tenets of professionalism during medical education is critical because there is a strong link between what is learned about professionalism in medical school and what one exhibits later in practice. In a landmark study, Papadakis and colleagues at the University of California–San Francisco School of Medicine conducted a case-control study that compared medical school graduates who were disciplined by the Medical Board of California with controls matched by medical school graduation year and specialty. Of those graduate physicians disciplined by the Medical Board, 95% experienced a violation associated with a professionalism lapse. Compared with controls, the physicians who experienced professionalism lapses during medical school were twice as likely to later experience an adverse medical board action while in practice. Recognizing the importance of responding to those early lapses, many strategies for dealing with professionalism lapses have evolved, including remediation assignments; remediation contracts; professionalism mentoring; stress management or mental health intervention; and community service.

Elements of the PA competency of professionalism

Recent efforts to define professionalism have shifted from the sociologic definition to a focus on values associated with professionals. The most commonly appearing elements identified in a recent literature search included a number of ill-defined concepts, such as “altruism, accountability, respect, integrity, ethic[ism], lifelong learn[ing], honesty, compassion, excellence, self-regulating, service,” that provide little guidance to the clinician who aspires to professionalism.

Van de Camp and colleagues provide an understandable overarching structure that brings together key values with service delivery concepts. The latest model includes four areas of professional behavior: toward the patient, toward other professionals, toward the public, and toward oneself. The authors note that their behavior-based focus intentionally avoided the use of vaguely understood elements that have been associated with professionalism. Another improvement in the recent model is that it included elements that grew from the models of competency developed by the Accreditation Council on Graduate Medical Education in conjunction with the American Board of Medical Specialties. ^,

The Competencies for the PA Profession incorporate nearly all of the top 10 constituent elements of professionalism mentioned most frequently in the literature and fit well into the structure outlined by Van de Camp and colleagues ( Box 35.1 ). In addition, a number of other, less frequently mentioned elements are included.

Behavior toward the patient