Aspects of Professionalism

Summary

As the consumption of health care and commoditization of care providers is on the rise, the need for health care organizations to emphasize the creation of professional environments that foster patient and provider well-being becomes evident. Health care organizations play a pivotal role in establishing and leading the culture that their care providers embrace. This culture can affect patient safety1,2, quality of care3,4, and levels of burnout3,5,6. The Charter on professionalism for Health Care Organizations outlines four domains of a model organization that include Patient Partnerships, Organization Culture, Community Partnerships, and Operations and Business Practices. The role of health care organizations is becoming greater and they act as leaders as they drive the overall mission that their providers seek to accomplish.

Key Articles:

  • Dupree E, Anderson R, McEvoy MD, Brodman M. Professionalism: a necessary ingredient in a culture of safety. Jt Comm J Qual Patient Saf. 2011;37(10):447-455. doi:10.1016/s1553-7250(11)37057-2
  • McKenzie L, Shaw L, Jordan JE, et al. Factors Influencing the Implementation of a Hospitalwide Intervention to Promote Professionalism and Build a Safety Culture: A Qualitative Study. Jt Comm J Qual Patient Saf. 2019;45(10):694-705. doi:10.1016/j.jcjq.2019.07.005
  • Williams ES, Manwell LB, Konrad TR, Linzer M. The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Health Care Manage Rev. 2007;32(3):203-212. doi:10.1097/01.HMR.0000281626.28363.59
  • Angerer P, Weigl M. Physicians’ Psychosocial Work Conditions and Quality of Care: A Literature Review. Prof Prof. 2015;5(1). doi:10.7577/pp.960
  • Shanafelt T, Trockel M, Ripp J, Murphy ML, Sandborg C, Bohman B. Building a Program on Well-Being: Key Design Considerations to Meet the Unique Needs of Each Organization. Acad Med J Assoc Am Med Coll. 2019;94(2):156-161. doi:10.1097/ACM.0000000000002415
  • Swensen S, Kabcenell A, Shanafelt T. Physician-Organization Collaboration Reduces Physician Burnout and Promotes Engagement: The Mayo Clinic Experience. J Healthc Manag Am Coll Healthc Exec. 2016;61(2):105-127.

Summary

Physicians enjoy a large degree of self-regulation as they are designated as experts in their fields. Unfortunately, this self-regulation can lead to problems such as an unwillingness to callout colleagues for inappropriate or unprofessional behavior. This issue often stems from failures in medical school and residency and can ultimately lead to damages in the social contract between society and physicians. Other topics, such as advocation for social justice, the role of the physician in creating value in health care, health equity, and recommendations on clinical topics, are also highly debated in medical ethics. In a society with increasing polarity in beliefs, addressing questions of medical ethics is becoming more complex and of utmost importance to ensure the best care is provided to patients.

Key Articles

Summary

A sizeable body of writing on professionalism has studied the ‘contract’ implicitly granted by society to physicians over the years. It is a theoretical paradigm that aligns physicians and the rest of society as two stakeholders in a long-term partnership. The theory argues that society asks physicians to be altruistic in their care, advocate for their patients, keep up to date on medical knowledge, adhere to certain standards, and—more recently—consider the social determinants of their patients’ health. In return, it suggests that physicians have been allowed to remain largely separate in terms of professional regulation and educational standard-setting. More recent writings argue that this perspective on medical professionalism is heterogeneous geographically and temporally, more so than early thinkers believed. It is not without its critics; there are some who argue it has little basis in practicality and history. More than anything, the social contract is characterized as an important lens through which physicians and researchers can examine medical professionalism.

Key Ideas

  • There is a dialogue between medicine and society on the nature of their relationship, which always has and will continue to take place.
  • As health systems and policy continue to change, understanding of the social contract between the medical profession and society can help facilitate meaningful discussion and planning.
  • The social contract is theoretical; further study is needed to establish practical understandings of the topic.

Further Reading

  • Cruess RL, Cruess SR. Expectations and Obligations: Professionalism and Medicine’s Social Contract with Society. Perspectives in Biology and Medicine. 2008. doi:10.1353/pbm.0.0045
  • Newton W, Conry C, Bortz B, Baxley EG. The Social Contract, Professionalism, and its Assessment: The Strategy of the ABFM Going Forward. Ann Fam Med. 2020. doi:10.1370/afm.2506
  • Cruess SR, Cruess RL. Professionalism as a Social Construct: The Evolution of a Concept. J Grad Med Educ. 2016. doi:10.4300/JGME-D-16-00102.1

Summary

One of the most important ways in which medicine has changed in recent decades is in how it focuses care. Transitioning to models of patient-centered care has fundamentally changed the way patients are treated in some respects. It is a perspective that makes patients the drivers of the decision-making process in evaluation and treatment. Changes to health care delivery now include patient representation and input. Going forward, health systems need to find more and better ways to engage patients beyond feedback and complaints. Professionalism literature on patient-centered care highlights these needs. While much writing highlights ways in which patient-centeredness can positively change, some papers also provides some critique, noting when this concept can be taken too far.

Key Points

  • Patient-centered health care places the patient and their interests at the heart of the decision-making process in medicine. Care teams are led by them, in this view.
  • New ways to evaluate patient involvement in care are needed.
  • Modern quality improvement relies on patient input.

Further Reading

  • Haverfield MC, Tierney A, Scwartz R, et al. Can Patient-Provider Interpersonal Interventions Achieve the Quadruple Aim of Healthcare? A Systematic Review. J Gen Intern Med. 2020. doi.org/10.1007/s11606-019-05525-2
  • Nahai F. Embracing Patient-Centered Professionalism. Aesthetic Surgery Journal. 2011. doi.org/10.1177/1090820X11420689
  • Wynia M, Von Kohorn I, Mitchell PH. Challenges at the intersection of team-based and patient-centered health care. JAMA. 2012.

Summary

The intersection of medical professionalism and medical education is an important facet of the field that should not be overlooked. In order for professionalism to achieve greater cultural dissemination, researchers and policymakers should devote more resources to examining ways in which undergraduate and graduate medical education can help learners adopt professional schema. Education can be one efficient way of bringing social contract into wider discourse. Discussions of professional pedagogy also examine medicine’s hidden curricula. Overall, there is an understanding that teaching professionalism to students and trainees is an important step in identity formation and integration into the medical community.

Key Points

  • Teaching professionalism to students and trainees facilitates earlier and deeper integration into the health care community.
  • The “hidden curriculum” in medicine is a complex concept that is not wholly negative.
  • Revising curricula on professional development may help disseminate less tangible concepts like the social contract.

Further Reading

  • Berger AS, Niedra E, Brooks SG, Ahmed WS, Ginsburg S. Teaching Professionalism in Postgraduate Medical Education. Academic Medicine. 2019. Doi:10.1097/ACM.0000000000002987.
  • Lawrence C, Mhlaba T, Stewart KA, Moletsane R, Gaede B, Moshabela M, et al. The Hidden Curricula of Medical Education: A Scoping Review. Academic Medicine. 2018. doi:10.1097/ACM.0000000000002004

Summary

One of the greater challenges to medical professionalism has been increasing commoditization of health care and medical work. Shifts to business incentives and the increasingly for-profit nature of health care complicate the goals of the profession and may impact patient care. Greater regulation has challenged professionalism and facilitated the spread of burnout. Literature on the subject examine how to preserve medical culture as we know it. This topic focuses not only on the exploitation of physicians but also nurses and other medical professionals. This is an ongoing area of investigation, and recommendations are sparse.

Key Points

  • Changes to the structure of medical practice are putting physicians’ professional responsibilities in conflict with financial and organizational motives.
  • Medical professionals are suffering from burnout related to increasing regulation and shifts of focus to profit incentives.
  • Better measures of commoditization are needed before rigorous policy recommendations can be formulated.

Further Reading

  • Rothman DJ, Blumenthal D, Thibault. Medical Professionalism in an Organizational Age: Challenges and Opportunities. Health Affairs. 2020 doi.org/10.1377/hlthaff.2019.00186
  • Byyny R. Medical Professionalism in the Modern Era. The Pharos. 2018. alphaomegaalpha.org/pharos/PDFs/Winter/2018-1-Byyny.pdf
  • Komesaroff PA, Kerridge IH, Isaacs D, Brooks PM. (AUS) The scourge of managerialism and the Royal Australasian College of Physicians. Medical Journal of Australia. 2015. doi:10.5694/mja15.00170

Summary

Burnout is a type of moral, mental, emotional, and often physical exhaustion that can have negative impacts on the mental health, productivity, and quality of care provided by the health care professional. Burnout is also associated with feelings of dissatisfaction and demoralization as well as increased rates of medical error by health care providers. While burnout can stem from a wide array of factors, the Mayo Team has identified the following as the most prominent: lack of control at work, unclear expectations, dysfunctional work environments, lack of social support, and poor work-life balance1. With commoditization of physicians and other health care providers on the rise, the prevalence of burnout will likely increase if dramatic changes are not made to the health care system. The economic cost of burnout in the US alone is estimated at $4.6 billion annually2, although it is important to remember that burnout is a global problem. The Center for Professionalism and Value in Health Care is actively investigating root causes of burnout, interventions to curb burnout, and most importantly, changes to the health care environment that emphasizes quality care and provider emotional and physical well-being.

Key Articles:

  1. Know the signs of job burnout. Mayo Clinic. Accessed July 9, 2020. https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/burnout/art-20046642
  2. Han S, Shanafelt TD, Sinsky CA, et al. Estimating the Attributable Cost of Physician Burnout in the United States. Ann Intern Med. 2019;170(11):784-790. doi:10.7326/M18-1422
    • Olson KD. Physician Burnout—A Leading Indicator of Health System Performance? Mayo Clin Proc. 2017;92(11):1608-1611. doi:10.1016/j.mayocp.2017.09.008
    • Saultz J. Burnout. Family Medicine. doi:10.22454/FamMed.2020.598170
    • Shanafelt TD, Dyrbye LN, West CP, Sinsky CA. Potential Impact of Burnout on the US Physician Workforce. Mayo Clin Proc. 2016;91(11):1667-1668. doi:10.1016/j.mayocp.2016.08.016

Summary

This category of professionalism aims to investigate how patient care and provider satisfaction are affected by payment models and administrative tasks assigned to physicians and other primary care providers. This category also investigates how teamwork between providers, provider burnout, provider wellbeing, and the role that the individual provider plays in sustaining professionalism are affected by payment models and practice transformations. During this  transition period, it is important to emphasize high-value care and examine the changing nature of the patient-provider relationship.

Key Articles:

  • Erickson SM, Rockwern B, Koltov M, McLean RM. Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians. Ann Intern Med. 2017;166(9):659-661. doi:10.7326/M16-2697
  • American College of Physicians, Smith CD, Balatbat C, et al. Implementing Optimal Team-Based Care to Reduce Clinician Burnout. NAM Perspect. 2018;8(9). doi:10.31478/201809c
  • Friedberg MW, Chen PG, Van Busum KR, et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Rand Health Q. 2014;3(4). Accessed July 10, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5051918/

Summary

The primary goal of the medical provider should be to ensure the safety and well-being of their patients. This section seeks to highlight publications that link quality of care with professionalism in the medical environment. This includes addressing barriers that prevent team members from speaking up about unprofessional behavior in an effort to create an environment that emphasizes patient and provider well-being. In addition, the role of the health care organization, role of patient and family, interventions, and the “hidden curriculum” in medical education and how they affect patient safety are explored.

Key Articles:

  • Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout Among Health Care Professionals: A Call to Explore and Address This Under-recognized Threat to Safe, High-Quality Care. National Academy of Medicine, Washington DC. 2