Dealing with problems related to professionalism shouldn’t require a superhero. Making professionalism a shared responsibility moves it to a more human level. This article offers three tools to do that by “harnessing the power of the community.”

 

KEY WORDS: professionalism, definition, decision-making, collegiality, disruptive behaviour, compassion

 

The burden on individual physician leaders to “fix problems” can be immense. You need to be a superhero, or at least it feels like it. “Fixing” professionalism issues is no exception. The discourse is most often negative — a compendium of stories about disruptive physicians. Leaders are expected to step in and solve egregious behavioural issues often with little support from their colleagues. Although institutional supports for leaders do exist (see appendix) the support of the profession is necessary. What we need is a different approach to professionalism, one that doesn’t rely on non-existent super power. We need a “human” vision of professionalism. Top

 

Making professionalism a shared responsibility — and not simply a problem for leaders to fix — is a way to move from superhero to human. Three tools are key to harnessing the power of the community:

 

1. A definition of professionalism that is attainable and desirable
2. A shared way of discerningright professional behaviour
3. A commitment to  compassionate collegial conversations

 

With these three tools, physician leaders can begin to create environments where professionalism is likely to flourish. A human vision of professionalism acknowledges that our professionalism is both an individual and a community responsibility.1 Without this shared responsibility and accountability, the burden on individual leaders to be superheroes can be immense. Top

 

A human definition of professionalism

 

How do we currently “see” professionalism? An agreed on definition does not exist. Perhaps the most common and widely referenced definition is described in the Physician Charter:

Professionalism is the basis of medicine’s contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health.2

 

In addition, the charter goes on to list commitments: to professional competence, honesty with patients, patient confidentiality, maintaining appropriate relations with patients, improving quality of care, just distribution of finite resources, scientific knowledge, maintaining trust by managing conflicts of interest, and professional responsibilities of self-regulation. Top

 

As physicians, we need and want to express our sincere desire to be of service. If we set the bar too high, it becomes unattainable and, therefore, demotivating. It may also make our lapses too threatening to our self-image as a “good doctor.”3 As Parker Palmer, renowned educator, points out: “If we approach it as a problem to be solved by ‘raising the ethical bar’ — exhorting each other to jump higher and meting out tougher penalties to those who fall short — we may feel more virtuous for a while, but we will not address the problem at its source.”4 The “problem” of course is that we are human beings and not superheroes.

 

The other challenge with this definition is that it gives no guidance for right action. Perhaps, if we simply make rules and regulations and policies for every conceivable situation, we can agree on right action. Although agreed-on norms of behaviour are very important, they do not account for context or how we do things. Top

 

The Royal College of Physicians of London uses a definition that points toward how we might judge actions. Professionalism is “a set of values, behaviours and relationships that underpin the trust the public has in doctors.”5 So perhaps an action can be judged on the basis of the trust it engenders in the public. Is this enough clarity?

 

I propose that a human vision of professionalism include a definition that is attainable and moves beyond individual ideas about right action. We can view professionalism as a dynamic and responsive process.6 Professionalism is the ability to aspire to ideal professional values, to identify when reality does not conform to this ideal, and to actively commit to narrowing the gap.

 

The heart of this definition is “to actively commit to narrowing the gap.” This is not about perfection but rather moving toward continuous quality improvement. It also normalizes the gap between real and ideal. As Mary Gentile, author of Giving Voices to Values, explains: “Instead of normalizing the loss of our values, we can normalize the fact that we will be called upon to preserve them in the face of predictable challenge….[and] then those who present these conflicts don’t have to be seen as villains.”7

 

Without such honesty about the predictable challenges of being a physician, our learners and colleagues believe that those of us who speak about professionalism are naïve at best, ignorant at worst. I also suspect that without this normalization, we become jaded and lose our initial enthusiasm about our work if it doesn’t live up to our ideals. Top

 

Professionalism decision-making

 

A human vision of professionalism also needs to support clarity about right professional behaviour. Ideas about appropriate professional behaviour change over time. Consider how we now approach truth-telling about a terminal illness, disclosure of medical error, right relationship with industry, and the concept of privilege — and our approach 20 years ago. Do individual physicians have their own “opinions” about right behaviour? Should leaders simply impose their idea of right action? If, however, leaders can offer a reproducible method of discerning why an action in a given context is “professional,” it is more likely that consensus can be reached.

 

A method of discerning professional action is using the concepts of intention and impact (Figure1). Intention refers to what we hope to accomplish in a given situation and impact refers to the expected outcome. These two broad concepts map easily to rules-based and outcome-based ethical decision-making. The clarity comes from considering our responsibilities in important professional relationships: with ourselves and our values, with our patients, with our colleagues, with our community. Top

 

As a current example, the intention and impact tool can be used in deciding on and justifying our anticipated involvement with medical assistance in dying (MAiD). Our own personal values must be considered first. If, for example, those values do not allow us to be actively involved in MAiD, we still need to consider our patients, who may make a request for information or more assistance, and not abandon them. How we do this will depend on our colleagues and how we support each other’s conscience — our colleagues who consciously object and our colleagues who consciously participate. We need also to consider our particular community of practice, as options and expectations may vary if one is working in a faith-based institution or rural community, for example. We cannot make these decisions in isolation. This is a shared responsibility, as are all such decisions.

 

Using this process moves professionalism from individual opinion to justifiable course of action. Often, serious lapses in professionalism are associated with an inability to appreciate the impact of our actions on others. Deliberately widening our perspective to include patients, colleagues, and our community offers the possibility of moving beyond personal impact and personal opinion. As leaders, we can begin to articulate our reasoning process and engage others in discussions about right behaviour. Top

 

Committing to “collegial conversations”

 

This concept of shared responsibility is key to effective and sustainable professionalism. It manifests when we observe behaviours of concern in our colleagues and we decide whether to get involved. Using intention and impact helps to guide our choice. Imagine observing a physician shouting in a threatening way to a nurse. If we begin with ourselves, we could imagine that we would prefer to deal with a colleague rather than have the issue escalated or we could be a learner and feel vulnerable. We do know that such conflict interferes with patient care and safety. The particular relationship we have with our colleague may influence our decision, or we may have an understanding in our group that support in the moment is the ideal.

 

Without a doubt, a member of the public would expect that this less than ideal situation be dealt with in an effective way. If we choose not to engage, we need to justify why. We also need to share in the responsibility for a pattern of behaviour that may develop in our colleague and, in time, become disruptive. If a community of practice chooses to commit to collegial conversations, many unhealthy behaviours will never develop into patterns and the burden does not rest solely on leaders to correct behaviour. If we do choose to engage — with our colleague or with another professional — how do we do that if we have a human vision of professionalism? We have a collegial conversation. Collegial means in a spirit of friendliness.

 

Often the decision is made not to engage in a collegial conversation. Alternatives include silence, talking about the situation/person to others, blaming people higher in authority for not “fixing the problem” without being willing to come forward, pretending it isn’t a problem and “working around it,” or even aggressively “confronting” someone. None of these alternatives is effective. All of these choices have consequences that leaders are often left to “fix” with little sense of shared responsibility. However, as a leader, you are in a position to initiate discussions about the preferred way to deal with these situations and move toward group agreement. Top

 

Why is the decision to engage with a colleague so difficult? At an individual level, many barriers exist: fear of upsetting a colleague, lack of communications skills, belief that someone else will deal with the issue, belief that behaviour will not change, or even feeling sorry for the colleague.10 At a systems level, there is a basic confusion over our responsibilities and relationship to our colleagues. Are our colleagues simply co-workers, competitors, peers, friends, or something different? If professionalism is a shared responsibility, do we have a responsibility for the behaviour and well-being of a colleague?

 

Compassionate accountability

 

A human vision of professionalism includes a sense of compassion toward our colleagues. Compassion includes an affective component — trying to understand empathetically and generously where a colleague may be coming from — and a cognitive component — what skillful action is called for. Top

 

Often a collegial conversation can be a compassionate response. Daniel Goleman, author of Emotional Intelligence, points out that compassion is not so easy. One of the biggest barriers to feeling compassion is fear.11 When we are feeling rushed, when we have not taken care of our own needs, when we are unclear about our responsibilities, and when we do not feel that our colleagues “have our back,” it is difficult to feel compassion for others. A leader who exhibits good self-care, who talks about our responsibilities to each other, and who shares our personal struggles models this compassion.

 

If we, as individual physicians and a profession, embrace a human vision of professionalism, we see things in a different light. With a human vision, professionalism lapses are seen as errors. We are seen as humans and not villains. Just culture principles apply, and a root cause analysis is explored. The intention is to understand, mitigate harm, and prevent further lapses. A learning and supportive response makes sense, and a clear line exists where a more formal remediation or punitive response is indicated. In a root cause analysis, individual factors as well as institutional factors are explored. Top

 

So as a physician leader are you expected to be a superhero or a real human being? You can add three new tools to your practice:

 

• An operational definition of professionalism to actively work to narrow the gap between ideal and real behaviour
• A process to clarify and justify professional behaviour that is grounded in intention and impact on our professional relationships
• An agreement among colleagues to engage compassionately in collegial conversations

 

These tools can help to engage our communities of practice in shifting professionalism from an individual responsibility to a shared one. As Edmund Pellegrino reminds us, the “burden is too heavy without the support of the whole profession.”12

 

Appendix: Institutional supports for promoting professionalism

 

As a leader, I use following institutional tools, allies and resources, or opportunities for improvement:

 

Institutional vision

• mission, vision, values
• supportive vision/definition of professionalism
• Clarity about desirable behaviour
• codes of conduct
• institutional policies that are prominent and understood, e.g., conflict of interest, confidentiality, disclosure of error, do not resuscitate

 

Ethics supports visible and known

• ethical and professionalism decision-making tool(s) available and consistently used
• ethics committee or ethics consultation services available
• ethics and professionalism education and resources available at all levels

 

Inclusive decision-making

• involving employees, patients, and appropriate stakeholders in institutional decisions
• processes for expressing opinions, including dissent: confidential lines, town halls, walk around, rounds

 

Openness

• rationales for decisions are shared
• rationales and decisions are connected to values/ethics
• expressions of concern, disagreement are welcomed without blame
• diversity of members in senior management Top

 

Consistency

• appreciating and rewarding ethical/professional behaviour is part of performance review for all
• leadership role-modeling of respectful behaviour

 

Monitoring

• process in place to monitor and track professionalism and ethical learning issues and successes
• ability to identify trends in behaviour or frequent ethical challenges from multiple sources
• faculty and learner assessment of professionalism
• miscommunication/professionalism component of medical error/near miss identified

 

Enforcement

• individual professionals accept responsibility for their colleagues’ behaviour  and are involved in accountability/conversations
• leaders have a step-wise approach to disruptive behaviour
• sanctioning undesirable behaviour occurs when appropriate

 

Preventive ethics/continuous quality improvement implemented

• formal relationship between ethics and quality/safety to identify trends in challenging behaviour/safety issues
• process for responding to patterns of unprofessional behaviour or frequent ethical challenges  with education or other interventions
• health professional health and wellness a quality indicator

 

Source: Adapted from Kaptein.13  Top

 

References

1.Lucey C, Souba W. Perspective: the problem with the problem of professionalism. Acad Med 2010;85(6):1018-24.

2.Medical professionalism in the new millenium: a physician charter. Philadelphia: American Board of Internal Medicine; 2005. Available: http://tinyurl.com/hedhlen (accessed 18 Dec. 2016).

3.Rees CE, Knight LV. The trouble with assessing students’ professionalism: theoretical insights from sociocognitive psychology. Acad Med 2007;82(1):46-50.

4.Palmer P. A hidden wholeness: the journey toward an undivided life. San Francisco: Wiley and Sons; 2004.

5.Working Party. Doctors in society: medical professional in a changing world. London: Royal College of Physicians of London; 2005.

6.Irby D, Hamstra S. Parting the clouds: three professionalism frameworks in medical education. Acad Med 2016;91(12):1606-11.

7.Gentile M. Giving voices to values. New Haven, Conn.: Yale University Press;, 2010.

8.Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med 2007;82(11):1040-8. Available: http://tinyurl.com/hurazwh (accessed Jan. 2017).

9.Webb LE, Dmochowski RR, Moore IN, Pichert JW, Catron TF, Troyer M, et al. Using coworker observations to promote accountability for disrespectful and unsafe behaviors by physicians and advanced practice professionals. Jt Comm J Qual Patient Saf 2016;42(4):149-61.

10.DesRoches CM, Rao SR, Fromson JA, Birnbaum RJ, Iezzoni L, Vogeli C, et al. Physicians’ perceptions, preparedness for reporting and experiences related to impaired and incompetent colleagues. JAMA 2010;304(2):187-93.

11.Goleman D. Why aren’t we more compassionate? TED Talks; 2007. Available: http://tinyurl.com/h93bnko (accessed Jan. 2017).

12.Pellegrino ED. The medical profession as a moral community. Bull N Y Acad Med 1990;66(3):221-32. Available: http://tinyurl.com/hnvk3k5 (accessed Jan. 2017).

13.Kaptein M. Why do good people sometimes do bad things? 52 reflections on ethics at work. Rotterdam, Netherlands: Rotterdam School of Management; 2012. Available: http://tinyurl.com/z6mwz5z (accessed Jan. 2017).

 

Author

Monica Branigan, MD, MHSc (Bioethics) is an associate professor at the University of Toronto and practises palliative care. She is on the faculty of the Physician Leadership Institute of the Joule inc., a CMA company, where she teaches “Professionalism and Ethics” and “Crucial Conversations.”

 

Correspondence to: Monica.branigan@utoronto.ca

 

This article has been reviewed by a panel of physician leaders.

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