The ways of thinking about professionalism and their implications

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From Luke’s Journal Jan 2023  |  Vol.28 No.1  |  Evolving Professionals

Professionalism can be a controversial topic for health professionals and Christians. It is poorly defined, difficult to teach and even harder to assess. Disagreement on the meaning of professionalism creates the risk and mistake of Christians minimising it or even ignoring it altogether. Thinking clearly about professionalism offers an opportunity for Christians to lead the way in bringing Christ-like values into our workplaces. I will outline two main ways of thinking about professionalism and highlight some implications of these perspectives for those trying to live as salt and light (Matthew 5:12-16) in the healthcare setting.

Why does it matter?

Medical educators in modern times have recognised the importance of students’ professionalism. A significant reason for this has been that unprofessional students go on to be unprofessional doctors¹, causing harm to patients and the community. Professionalism has therefore moved from the hidden curriculum to the stated curriculum², and in many universities it may have a whole department of its own³. Some helpful research⁴ has articulated the main areas that medical students show a lack of professionalism:

Interaction (rude/disrespectful behaviour, discrimination, poor communication, lack of empathy)

Involvement (poor engagement: e.g. being late/missing classes, low initiative, avoiding patient contact)

Insight (low self-awareness: e.g. not willing/able to accept feedback, blaming external factors rather than taking personal responsibility)

Integrity (copying other’s assignments, lying, cheating in exams, falsifying data, plagiarism)

I am saddened by the fact that, in my experience, students who identify themselves as Christians seem no more immune to engaging in these negative behaviours than other students. The Biblical story clearly speaks to why all of these behaviours are not in line with the way of Christ. You can see how even if some of the above unprofessional behaviours are not blatantly contravening God’s stated commandments (i.e. the commands not to lie or steal), they are still destructive to our relationships with patients, peers, colleagues and employers. Conversely, when Christians live and behave according to Jesus’ call to love God and love others, many aspects of professionalism result naturally. When we live out of love we will interact with others well, engage with our work, be humble about our own humanity and limitations, and have integrity. We will become willing to improve along the pathways of our personal and professional lives.

What is Professionalism?

A major problem with Professionalism is the various ways that it is defined: Is it a value? Trait? Behaviour? Moral? Role? Identity? Social contract?⁵ Professional bodies within medicine cannot achieve a consensus on what it means, making it tempting to ignore the conversations about it altogether. The word ‘profess’ simply means to publicly commit to a set of values.  Interestingly, the first written record of its use was within the healthcare setting, in a book of prescriptions in the court of the Roman emperor Claudius⁶. Since then, the word has been commonly linked to non-cognitive virtues such as compassion and mercy – in other words, professionalism is not so much about what you believe but about how you behave.

Defining professionalism

I have found that people in healthcare have varied thoughts about what professionalism means. In this article, I will explore two common perceptions. A professional may be thought of as a person who is:

1. Paid to do their job (versus an Amateur)

2. An Expert/skilled worker (versus a Novice)

Let’s look at each of these in turn.

Professional as Paid

In many settings, professionals are defined as such because it is how they earn their livelihood. A professional athlete gets paid to play their sport, while an amateur needs to earn money some other way. This way of thinking about professionalism in medicine can cause some discomfort. William Osler in the early 1900s stated “the practice of medicine is not a business, and never can be one….Our fellow creatures cannot be dealt with as man deals in corn and coal”⁷. While there is no such thing as an amateur doctor, there can be doctors who give more or less attention to the role that finances have in the provision of healthcare.

Most doctors, regardless of their faith or background, would deny finances as being the main reason they practise medicine (and in fact it doesn’t take long for medical students to work out that medicine is not as lucrative as many other careers that have less arduous training and lower expectations). Most continue in medical practice for reasons other than money, and find a balance between serving patients and being adequately remunerated, which is not always compatible⁸.  Many Christians have found it helpful to consider what St Paul wrote to Timothy: “For the Scripture says, ‘Do not muzzle an ox while it is treading out the grain’ and ‘The worker deserves his wages’” (1 Timothy 5:18), hence giving permission to receive legitimate payment for work done.

Ironically, despite the term ‘professional’ being associated with people being paid to do their job, commercialism is a well-recognised challenge to professionalism in medicine⁹. It is tempting for doctors to prioritise income or to justify non-financial incentives (like gifts or holidays). These things can take their focus away from what should be their core goal, which is to care for their patients. To protect the community from unscrupulous doctors, various codes of conduct and standards have been brought in around the world, and there has been increasing scrutiny of doctors’ interaction with financial entities, especially pharma and device companies. However, the failure of the law to constrain human selfishness is clearly recognised – as Irvine says, “No regulatory system can ever substitute for a doctor’s personal professionalism¹⁰”(p1175)  and “Local medical regulation and clinical governance will not themselves be sufficient to assure the good practice of all doctors¹⁰”(p1176).

Christians are not immune to temptation and need wisdom and accountability to navigate this. CMDFA recently put out some helpful guidance on receiving incentives, and like any guidance this should be viewed as a tool and not a rule. However helpful this may be, no amount of laws, codes of ethics or guidelines will be sufficient to ensure that every Christian doctor behaves in an honest way. One of the key points that St Paul makes in his letters to the Romans and the Galatians is that we are all unable to live according to the perfect law of God. Consequently, we receive our terrible diagnosis: we are dead (Romans 3:23). However, recognising that we are unable to follow God’s law is also the basis of Paul’s incredible prognosis: we can be brought to life again! (Romans 4:17; Galatians 2:21). This life, however, is no longer a life under the law, but under the grace of God, embedded in Christ Jesus (Romans 6:23; Galatians 2:21).  Rather than giving us licence to do whatever we like (Romans 6:1-2; Galatians 5:16), we now live according to a new set of laws – those where loving God and loving others trump everything else. Our lives need to be brought under the tutorship of God so that we can start to live His way (Romans 12:2). This is something we do in community, where we deliberately humble ourselves and become accountable (Galatians 6:1).  I believe that this is the truest way of developing professionalism in our lives. I also believe that when Christians practising medicine nurture, instruct and discipline each other well, the benefits resulting from these relationships become a witness to our colleagues and patients (John 13:34).

“The bottom line for Christians should always be that money in the healthcare system is there to serve people, not the other way around.”

The reality of medical care in the 21st century is that it is expensive, and costs continue to rise – in part because of the plethora of medications, devices, and lines of support that we can potentially offer to patients. None of us has bottomless finances and deciding where money should be spent (or not) is a challenge in all areas of medical care. There will always be a struggle to find the balance between care and cost. Jesus is very clear that we cannot serve both God and money (Matthew 6:24). Part of professionalism is about being above reproof in the way we receive and spend money. The bottom line for Christians should always be that money in the healthcare system is there to serve people, not the other way around.

Professional as Expert

This is the way that most perceive professionalism. In fact “expertise” is considered one of the three pillars of medical professionalism¹¹, along with “ethics” and “service”. Who would not want their doctor to have expertise? A risk with taking this view, however, is in thinking that professionalism/expertise is something you achieve and then you ‘have it’. Yet even the very word we give to what we do (i.e. we ‘practise’ medicine), underscores the need to continually develop. We cannot rest on our laurels when we master an aspect of care, because our skills, knowledge and application will become outdated over time. This is one reason that continuing professional development (CPD) is mandatory and should be something we take seriously if we in the medical world want to provide safe and effective care for our patients.

Many people, often unconsciously, jump from thinking about professionalism as being about expertise to being about people who are experts. In common vernacular this is certainly the case – if someone is labelled as being ‘pro’ at a skill, it invariably means they are excellent at it. So, it concerns me that when we tell medical students and junior doctors to act professionally, it may sound as if we are asking them to behave as if they are already experts. This in turn may put pressure on them to reach an unrealistic level of practice that is beyond their ability (especially when they are young and inexperienced). I was shocked to once hear this being explicitly outlined to hundreds of medical students when a well-meaning educator was giving them advice on how to be a professional in the hospital setting: “Fake it until you make it”. Seriously?! Is that really what we want our so-called ‘professionals’ to do?

Instead, it is essential that we have a more nuanced understanding of what ‘being an expert’ means, which should always incorporate the concepts of ethics and service. Part of expertise is knowing our limits and being willing to ask for help. This fits well with the Christian understanding of humility, a trait which is being increasingly recognised by the broader medical education community as being an important aspect of professional behaviour¹².

“Part of expertise is knowing our limits and being willing to ask for help.”

As a medical educator, I am acutely aware of how challenging it is to teach and assess professionalism in our students. Professionalism is difficult to teach and even harder to assess. Simply putting classes into the curriculum is insufficient. I have known students who have scored highly in the ‘professionalism’ stream of our course, who have demonstrated unprofessional behaviours in my classes – for example faking signatures, lying about their reasons for non-attendance, and copying classmates’ projects. Attempts to examine professionalism as a separate area of expertise are being made e.g. via OSCE stations¹³, and in measures of conscientiousness through the term/semester ¹⁴.  However, we still have a long way to go.

For Christians, our desire to be professional should be less about satisfying government, employment or university requirements, or even excelling at a skill, and more about living the life we have been created for (Ephesians 2:10), knowing that we are accountable to the God who knows, sees and cares for all – remembering that ultimately it is Christ we are serving (Colossians 3:23; Matthew 25:34-46).

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References

1. Papadakis M, Hodgson C, Teherani A, Kohatsu N. Unprofessional Behavior in Medical School Is Associated with Subsequent Disciplinary Action by a State Medical Board. Academic medicine : journal of the Association of American Medical Colleges. 04/01 2004;79:244-9. doi:10.1097/00001888-200403000-00011
2. Hafferty FW. Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med. Apr 1998;73(4):403-7. doi:10.1097/00001888-199804000-00013
3. Hatem CJ. Teaching approaches that reflect and promote professionalism. Acad Med. Jul 2003;78(7):709-13. doi:10.1097/00001888-200307000-00010
4. Mak-van der Vossen M, van Mook W, van der Burgt S, et al. Descriptors for unprofessional behaviours of medical students: a systematic review and categorisation. BMC Medical Education. 2017/09/15 2017;17(1):164. doi:10.1186/s12909-017-0997-x
5. Frye V, Camacho-Rivera M, Salas-Ramirez K, et al. Professionalism: The Wrong Tool to Solve the Right Problem? Academic Medicine. 2020;95(6):860-863. doi:10.1097/acm.0000000000003266
6. Pellegrino ED, Pellegrino AA. Humanism and Ethics in Roman Medicine: Translation and Commentary on a Text of Scribonius Largus. Literature and medicine. 1988;7(1):22-38. doi:10.1353/lm.2011.0164
7. Osler W. On the Educational Value of the Medical Society. The Boston Medical and Surgical Journal. 1903;148(11):275-279. doi:10.1056/NEJM190303121481101
8. Muula AS. Medicine and money: friends or foe? Mens Sana Monogr. Jan 2006;4(1):78-88. doi:10.4103/0973-1229.27607
9. Stern DT. Measuring medical professionalism. Oxford University Press; 2006.
10. Irvine D. The performance of doctors: the new professionalism. The Lancet (British edition). 1999;353(9159):1174-1177. doi:10.1016/S0140-6736(99)91160-1
11. Stern DT. Measuring Medical Professionalism. Oxford University Press, Incorporated; 2005.
12. ten Cate O, Chen HC. The ingredients of a rich entrustment decision. Medical Teacher. 2020/12/01 2020;42(12):1413-1420. doi:10.1080/0142159X.2020.1817348
13. Dearman SaA, Jennifer Alice and Swann, Alan and Armer, Martin Lee. How well does objective examination of professionalism discriminate medical students practice commensurate with regulatory expectations? Association for the Study of Medical Education. 2018;2018-07-112018-07-13
14. McLachlan J. Measuring conscientiousness and professionalism in undergraduate medical students. The Clinical Teacher. 2010/03 2010;7(1):37-40. doi:10.1111/j.1743-498x.2009.00338.x