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Professionalism is in fashion at the moment. Articles on the subject are appearing in journals almost every week. Academics are writing books about it, and medical schools are running courses for students in how to be professional. In the UK, the Royal College of Physicians and the King's Fund are running a series of road shows inviting students to come and talk about how they understand professionalism and what matters to them about it.1 In spite of all this activity, professionalism is far from being a straightforward concept. Although its meaning seems obvious at first, it tends to slip through your fingers as soon as you try to define it. You may well have your own concept of what it is, but if you check it out with others you may find they have entirely different ones.
How people see professionalism seems to depend very much on who they are and what they do.2 For doctors, professionalism is often a badge of honour and a token of their independence. It signifies everything that differentiates them from others with more humble callings (although there is probably no reason to believe that hairdressers, taxi drivers or dry cleaners cannot also behave professionally). Governments and managers, by contrast, usually prefer to see professionalism in terms of doctors doing what they are told—including following official guidelines and policies. These two views of the concept are in sharp contrast to each other. They are also in contrast to those of patients, who may care very little about either doctors' sense of special status or their compliance with external directives. They are far more likely to put a premium on things like courtesy, attentiveness and a willingness to share their power in the consultation.
Different interests
There are many circumstances where one person's construction of professionalism is entirely at odds with someone else's. If a particular surgeon ignores a directive to fill in a lengthy questionnaire sent by his chief executive, is he being professional because his time can be better spent seeing patients, or bloody minded for thwarting the organisation in its aims? If the questionnaire is going to help the hospital to decide whether to continue doing varicose vein surgery or to reallocate the funds to its paediatric department, how would patients with varicose veins regard his actions, and what would parents of local children think of it? Essentially, all these people are likely to see professionalism according to their own interests and perspectives.
One of the controversies surrounding professionalism is whether or not it can be taught and assessed. Some writers on the subject believe it can be broken down into specific competences that can be measured in the same way as any other aptitude, such as reasoning or dexterity.3 If you equate professionalism with specific behaviour like punctuality or being conscientious about writing up clinical notes, there is little doubt that you can teach about it and measure it. On the other hand, if you regard professionalism as something far more complex involving choices where the answers may not always be black and white, you will probably think it is more difficult to teach, at least in the formal sense, and more or less impossible to assess.4 While you can instruct students and practitioners how to behave in a range of circumstances and offer them vignettes with a range of possible actions to choose from, there is no guarantee that they will behave with decency in real life situations that put their professionalism to the test. For example, it isn't hard to imagine why someone who turned up punctually to every meeting might be highly unprofessional because it meant never being willing to take more time with a patient who needed it.
Working environment
Another controversy is whether you can consider professionalism to be an individual attribute or whether is largely or entirely determined by the working environment.5 Self evidently, most of us are capable both of honourable actions and of lapses. How much we demonstrate one type of behaviour rather than the other may depend on all sorts of factors including our level of team support, the level of pressure in our work, the culture of our organisation, and quite simple things like the amount of sleep we have had.
For that reason, many people now put an emphasis on the effect of the so-called ‘informal curriculum’ in promoting professionalism, arguing that the behaviour of medical students and trainees is affected far more by what they see modelled by those around them than by what they are explicitly taught.6 There are innumerable examples of how teams, institutions and whole nations have declined into brutality, and it would be hard for any of us to say we have never behaved unprofessionally when under intolerable stress in the work setting. It would be even harder to claim that we would never do so in future if our working conditions deteriorated to the point where we cared more for our own survival than anything else.
Preparing for the patient
Given all this fuzziness surrounding the word, is the idea of professionalism worth retaining at all? I would argue that it is, provided one avoids offering lists of arbitrary qualities based on personal preference, and states instead exactly what aspect of professionalism is being discussed, and with what evidence. A good starting point in this respect could be an arresting finding from a recent study in the USA showing that nearly 80% of patients regarded ‘preparing before seeing the patient’ as an important attribute of professionalism in doctors.7 This is probably not the aspect of professionalism that might occur first of all to most doctors, but it makes an enormous amount of sense from the patient's point of view. However highly we may view our other more complex qualities, it seems that our patients judge our level of professionalism by quite simple things such as whether we are able to make eye contact from the moment they enter the room rather than shuffling through bits of paper or staring at the computer screen, and whether we can engage in conversation with them in a way that demonstrates we know who they are and have considered some of the issues that are likely to be bothering them.
What is striking about this particular notion of professionalism is that it does not relate solely to the internal qualities of the doctor, nor necessarily to the strengths of the organisation, but to the nature of the relationship. One might characterise it as ‘interactional professionalism’, or an ability to move into another's world not just from the moment of the encounter but even before it.
Accepting other views
It would of course be easy to contest this particular angle on professionalism and many doctors might be tempted to do so. We all know, for example, that the clinical notes are sometimes unavailable for reasons outside our control, or we are so ridiculously busy that it seems impossible to take time before each consultation to read the notes. These objections are understandable, but they entirely miss the point. What patients want, it seems, is not for us to set the terms of engagement ourselves, but to alter them in their favour. Thus, they might well prefer us to keep them waiting while we move heaven and earth to track down the notes (especially if we explain this is happening), and might even accept a shorter consultation with us if the quality of the time they do have is enhanced by full intellectual and emotional engagement on our part.
What this evidence teaches us is that professionalism may not be about looking inwards but outwards. In fact, a core feature of professionalism, however defined, might be to consider favourably the views of others, even if they don't happen to coincide with our own. Professionalism may mean rising to the challenges that others set for us, rather the ones we set for ourselves.
Footnotes
Competing interests None declared.
Provenance and peer review Commissioned; not externally peer reviewed.