The terms, profession, professional, professional identity, and professionalism, are quoted many times in medical student teaching, and often used interchangeably. This can lead to confusion as to what the concepts really are, and we therefore need to be careful what we mean when we quote them, and more importantly what we understand about how they relate to our personal clinical practice. Medical students are constantly being told in lectures, tutorials, and workshops, that they need to demonstrate professionalism in their future careers, so what is vital in their professional development is that they understand not only how everybody else defines professionalism, but most importantly what it means to them, that they have got it right, and that they keep getting it right throughout their careers.
The American philosopher Mortimer J. Adler defined a professional as “a man or woman who does skilled work to achieve a useful social goal. In other words, the essential characteristic of a profession is the dedication of its members to the service they perform [1].” So, if professionals belong to a profession, what does it take to be part of one? In the early 20th century E. P. Scarlett defined what he believed were the seven pillars of a profession: (1) technical skill and craftsmanship, renewed by continuing education; (2) a sense of social responsibility; (3) a knowledge of history; (4) a knowledge of literature and the arts; (5) personal integrity; (6) faith in the meaning and value of life; and (7) the grace of humility [2]. This ‘list’ of attributes, as to what defines a person or a concept has become common amongst modern society, and just as humans have a ‘tick-box’ of what they may desire in a future partner, healthcare organisations have ‘tick-boxes’ as to what they expect of their members. For example, the Accreditation Council for Graduate Medical Education (ACGME) in another seven-point list defined the core competencies of a doctor as respect, compassion, integrity, responsiveness to needs, altruism, accountability, commitment to excellence, sound ethics, and sensitivity to culture, age, gender, and disabilities [3]. We can see that professionalism is an expected attribute for a member of the medical profession, but it also seems to align with old-fashioned values considered to be core properties of a profession, and the people who define these pillars are not just the profession themselves, but society as well. The profession has a contract with society, that society grants them self-determination and awards them an elevated status, in return for civic responsibility, community leadership, and this professionalism.
So, what is the connection between professional identity and professionalism? Burke states that “identities are the meanings that individuals hold for themselves, what it means to be who they are. These identities have bases in being members of groups (social identity), having certain roles (role identities) or being the unique biological entities that they are (personal identities) [4].” This is important for medical students as they develop their identity during their time at medical school. Tajfel and Turner [5] proposed that people tend to categorise themselves into one or more in-groups, deriving their identity from the group and forming boundaries with other groups. This group identification promotes self-esteem within the group and leads to greater commitment to the group, even if the group’s status is low. They believed the three major components of social identity are: (1) categorisation: putting others or ourselves into categories, labelling the person as a way of defining the person; (2) identification: the way in which we define our self-image through association with a group, in-groups being the ones with which we identify and out-groups those which we do not; and (3) comparison: we compare our own groups to others and create favourable biases towards our own. This process is very strong within people’s minds and leads to stereotyping. If doctors are stereotyped as being caring, altruistic individuals by one person, they may now be stereotyped in another person’s mind as greedy and arrogant. Ultimately, once these stereotypes are formed they can become rigid.
Coulehan [6] distinguishes three types of professional identity in medicine: (1) technical identity: the doctor abandons traditional values, becoming cynical about duty and integrity, and narrows the sphere of responsibility to the technical arena; (2) non-reflective identity: the doctor espouses and consciously adheres to traditional medical values whilst subconsciously basing behaviour, or some of it, on opposing values, thus being self-deluded and detached; and (3) compassionate and responsive identity: the doctor overcomes conflicts between tacit and explicit socialisation, internalises the virtues and values professed, and manifests these in behaviour. What is worrying is that Coulehan [6] demonstrated that a large percentage of medical graduates can be classed as having a non-reflective professional identity, maintaining that this outcome is most likely where there are conflicting values in the learning environment. The inability to reflect appropriately was demonstrated by the participants when there were deficits in their clinical reasoning, and this highlighted the need for expert facilitation and education. With poor supervision and mentorship, new doctors may internalise beliefs that certain ‘unvirtuous’ behaviours are virtuous, since that is ‘the way things are in medicine’; that is to say, it is the cultural norm. However, the development of a person’s professional identity is strongly influenced by another concept, the notion of ‘belongingness’. Belongingness is the human emotional need to be an accepted member of a group. Whether it is family, friends, co-workers, or a sports team, humans have an inherent desire to belong, and be an important part of something greater than themselves. This implies a relationship that is greater than simple acquaintance or familiarity. The need to belong is the need to give and receive affection from others [7]. Without belonging, a person cannot identify oneself as clearly, thus having difficulties communicating with and relating to one’s surroundings. This implies that belongingness is related to identity. However, there is a danger with belongingness in that the desire to belong can lead to conformity, which can lead to lack of self-regulation. And this is what brings us back to the notion of professionalism.
When you look at the definitions of medical professionalism, there are numerous differing statements. For example, the University of Ottawa states that professionalism embodies the relationship between medicine and society as it forms the basis of patient-physician trust [8]. It attempts to make tangible certain attitudes, behaviours, and characteristics that are desirable among the medical profession [8]. The Medical Protection Society in the UK has a whole page on it, but does not give a definition [9]. The Australian Medical Association (AMA) makes a statement on it: “while the expression medical professionalism is used in different ways, for the purposes of this position statement we are using it to refer to the values and skills that the profession and society expects of doctors, encapsulating both the individual doctor-patient relationship and the wider social ‘contract’ between the profession and society [10].” Despite this, professionalism remains very vague as a concept.
The previous discussion and statements suggest that professional identity is constructed at the level of the individual, whereas professionalism is constructed by the community and medical profession as a whole. These community and societal ideals are articulated in professional codes, institutional frameworks, and formal medical curricula, which may or may not reflect reality. However, professional identity is a reality that might not correspond to the ideal, for reasons that can be valid or not. It is based on one’s beliefs about what it means to be professional, and a doctor’s beliefs may differ from those of the community or other health professionals. It therefore follows that a responsive and reflective professional identity is more likely to develop where there is alignment between the understandings and expectations of others, self-identity and personal values, the social identity of the professional group, and the cultural milieu of the working environment. Since identity implies values and goals, it will also determine motivation; thus it has important educational implications for self-regulated learning. This means that professionalism must be defined by the individual, and they have to ensure that their personal beliefs and concept of what professionalism means resonates with the organisations and society in which they operate.
Ensuring that you define professionalism to yourself in the correct manner necessitates critical reflection. Reflection can occur at either a superficial, moderate, or deep level [11], and it is this deeper level of reflection that makes it critical. Superficial reflection is purely descriptive, and whilst it might make reference to existing knowledge it does not critique it. With moderate reflection, often called dialogic reflection, the person takes a step back and starts to explore thoughts, feeling, assumptions, and gaps in knowledge. The reflector makes sense of what has been learnt from the experience, and what future action might need to take place. Deep or critical reflection leads to a change due to the experience. To achieve this, the learner needs to be aware of the relevance of multiple perspectives from contexts beyond the chosen incident, and how the learning from the chosen incident will impact on other situations.
So how does this translate to me, a practicing clinician? After all, if I am to suggest that you should practice in a certain manner, then I should lead by example. Professionalism as defined by myself to myself is based on ‘3 rights’: (1) I know what the patient has a right to; (2) I know what the right thing to do is, and I will do it; and (3) I know the right manner to do it in. This conveniently for me encompasses the legal, ethical, and moral aspects of my clinical practice, and I believe it is summarised by the concept of integrity: integrity for me is what defines professionalism. To translate this into a clinical concept, consider the delivery of open disclosure. I know the patient has a right to an apology, I am aware of need to apologise, and I want to apologise. To ensure that I hopefully continue to practice in this way, I reflect with the right people, at the right time, in the right manner, meaning I don’t seek out those who will always agree with me, and I ask them for them an opinion before I state my beliefs, whilst I am ready to listen to their suggestions.
Over the next few years of your careers, you will hear it repeated many times from senior clinicians that as your career progresses the knowledge becomes fairly straightforward. This is not entirely true as new advances and techniques are continually being developed, however understanding yourself and those around you to a greater depth is the best piece of armamentarium you can acquire as you begin to forge your medical careers. Your curriculum is extremely busy and you will probably not relish the thought of further background reading, however this will not change throughout your career, so make time to see medicine beyond the facts. Consider concepts such as intellectual humility, growth mindset, situational awareness, and the competency matrix, concepts beyond your basic curriculum, as this will ensure your career is as successful and fulfilling as possible.
References
[1] Manning PR, DeBakey L. Preserving the passion in the 21st century. 2nd ed. New York: Springer; 2003.
[2] Scarlett EP. The medical jackdaw. Patrick Lewis Papers 1949-1987. Johannesburg: Historical Papers Research Archive; 2016.
[3] Accreditation Council for Graduate Medical Education (ACGME). Outcome Project [Internet]. 2007 [cited 2017 Apr 10].
[4] Burke P. Identities and social structure: the 2003 Cooley-Mead Award address. Soc Psychol Q. 2004;67:5-15.
[5] Tajfel H, Turner J. The social identity theory of intergroup behaviour. In: Worchel S, Austin W. Psychology of intergroup relations. Chicago: Nelson-Hall; 1986.
[6] Coulehan J, Williams P. Conflicting professional values in medical education. Camb Q Healthc Ethics. 2013;12:7-20.
[7] Fiske ST. Social beings: a core motives approach to social psychology. New Jersey: Wiley; 2003.
[8] What is professionalism in medicine? [Internet]. Canada: University of Ottawa [cited 2017 Apr 10]. Available from:
[9] The Medical Protection Society. Chapter 1: Medical professionalism – what do we mean? [Internet]. 2017 [cited 2017 Apr 10].
[10] Medical Professionalism [Internet]. Australian Medical Association; 2010 [updated 2015 Oct; cited 2017 Apr 10].
[11] Reflective practice in health: models of reflection [Internet]. La Trobe University [updated 2017 Apr; cited 2017 Apr 10].