The Unbearable Vagueness of Medical ‘Professionalism’

When Joel Bervell thought of professionalism as a student, he thought of “Grey’s Anatomy.” In particular, he reflected on what the show’s residents were expected to be, even though they often weren’t: on time, prepared for their case, and respectful of everyone around them.

“That was the only benchmark I had for what it meant to be a doctor – especially someone like me, who doesn’t come from a family of doctors,” said Mr. Bervell, 28, a fourth-year medical student at Washington State University. Mr. Bervell, a Ghanaian American, is one of the first black medical students at the medical college, which opened in 2017.

From the moment students set foot in medical school, they are imbued with the concept of medical professionalism: their sacred responsibility to conduct themselves according to the values ​​of a profession that automatically gains trust in society. “It’s the first thing they tell you: you’re literally a medical professional now,” Mr Bervell said.

The same metric can be used to determine whether a medical student becomes a doctor at all.

Beginning in their third year, Mr. Bervell learned that he and his classmates would be graded regularly professional behavior, along with other characteristics such as communication skills. Faculty, staff and other students could also report specific concerns about an individual’s professionalism, resulting in writings whose contents could be attached to their permanent records and tracked as scarlet letters.

The problem, as many medical students have also learned, is that where “professional” is vague, “unprofessional” is even more so. Depending on who is calling, there may be unprofessional behavior cuddle your program director, where ua show bra strapwear braidsputting on one swimsuit during the weekend or with a “Black lives matter” sweatshirt in the emergency room

As a result, professionalism exists on two levels: both as an elevated standard of behavior and as asometimes literally) list of do’s and don’ts that cloud ethics and appearance. That second meaning can be particularly damaging to residents of color, says Dr. Adaira Landry, a consultant at Harvard Medical School and co-author of a study on recent magazine article about the “over-policing” of black residents.

The article, published in The New England Journal of Medicine, adds to the growing literature documenting what residents of color are like disciplined or expressed of medicine. In 2015-2016 20 per cent of trainees discharged from their residencies were black, even though black students make up just 5 percent of residents, according to unpublished data from the Accreditation Council for Graduate Medical Education, or ACGME

For students who didn’t grow up in the culture of medicine or don’t resemble an outdated idea of ​​what a doctor should look like (white, male, elite), these opaque rules can be a minefield. “The environment is so restrictive on what is allowed that if you act, look or speak differently, it feels like it’s unprofessional,” said Dr. Landry.

Among the minority students with whom Dr. Landry works and when faced with probation or dismissal, she has seen a common thread. “I’ve never had a student tell me he was being expelled because of an academic grade,” she said. “The overwhelming theme is that they are interpersonal conflicts, labeled as professional challenges.”

From ethical code to dress code

The lofty ideals Mr. Bervell encountered on his first day are more consistent with the way professionalism was originally conceived, said Dr. David C. Leach, who served as executive director of the ACGME from 1997 to 2007.

Medicine was at a crossroads at the time. Giant corporations took over individual practices and turned them into for-profit companies. Doctors saw their time with patients decrease and patients saw their quality of care decline.

“There was an increasing public perception that doctors were just like everyone else: they just want to make money,” says Dr. Matthew Wynia, a medical ethicist who studies the ethics of managed care during this period. “The fear was that our sense of professionalism would be lost.”

In response, the council has defined a series of general powers: measurable results that a resident had to demonstrate before continuing on the journey to becoming a physician.

Of the six competencies that the council ultimately identified, professionalism came closest to the core of what it meant to be a doctor. “It is a series of promises about the reliability of both the profession as a whole and the individuals who practice it.” Dr. Leach wrote in 2014. Many believed that professionalism was the key to helping medicine recover its values ​​as an ethics-based altruistic profession – one committed to the patient and not the bottom line.

Professionalism was also the vaguest competency on the list. The 1999 definition characterized professionalism as “a commitment to carrying out professional responsibilities, adhering to ethical principles, and sensitivity to a diverse patient population.” Doctors were also expected to demonstrate a set of attributes in every interaction, including compassion, respect, humility, integrity and responsibility.

Residency directors complained that, compared to things like patient care and medical knowledge, professionalism was weak and difficult to measure. The concerns boiled down to, “I’m very busy with program directors, so what the heck am I supposed to do?” reminded Dr. Leach yourself.

The vagueness problem never went away, says Dr. Deborah Powell, former director of the University of Kansas School of Medicine, who served on the ACGME board at the time. In the 2000s, conversations about what professionalism meant often focused on how doctors should dress. “You shouldn’t have beards, you shouldn’t have long hair, and women should wear skirts,” said Dr. Powell. “It was crazy. We went overboard.”

Those conversations are still happening today. Dr. Londyn Robinson, now a resident at Duke University, learned the second definition of professionalism in 2020. While looking for tips on applying for residencies, she came across an article in the journal Vascular Surgery titled “Prevalence of Unprofessional Social Media Content Among Young Vascular Surgeons.”

The authors had searched the social media accounts of 500 surgical trainees without their knowledge and rated them on professionalism. According to the authors’ definition, potentially unprofessional content included photos of residents holding alcoholic beverages, wearing Halloween costumes, or “posing provocatively in bikinis/swimwear.”

For Dr. Robinson, who is the first in her family to earn a medical degree, the article revealed that for some, professionalism had been reduced to superficial traits rather than ethical behavior with patients. “They actually said the quiet part out loud,” she said.

A new ideal

Like Dr. Robinson has learned, professionalism now radiates beyond the clinic or classroom. Mr. Bervell’s instructors had warned him about the consequences of social media: Because medical students always represented the profession, they said, being a professional meant thinking twice before talking about politics or current issues like abortion online.

Mr. Bervell didn’t exactly heed that warning. During the Covid-19 pandemic, he began making TikTok videos pointing out racial bias in medical devices like the pulse oximeter And pulmonary function tests. (Both are less accurate for non-white patients, research has shown), earning him the nickname “medical mythbuster.” His videos have been added to medical school syllabi and have received critical acclaim of the American Medical Association And earned him a seat on the White House Roundtable on Healthcare Leaders in Social Media.

By the standards of his own school, Mr. Bervell, his activism on social media could be considered unprofessional. But, he added, he saw that challenging the gaping racial disparities in health care is part of his role in changing medicine — and perhaps by giving doctors something better than “Grey’s Anatomy” as a model for how to can be a professional.

The vagueness of professionalism can be challenging not only for students of color, but for anyone who falls outside the historical stereotype of a physician. Dr. Robinson noted that the people judged by their swimwear in the Vascular Surgery paper were more likely to be women than men.

In 2020, outraged by the newspaper, she posted a photo of herself in a bikini top and shorts on X, formerly known as Twitter, with the hashtag #MedBikini. “I’ll say it: I wear bikinis. I’m going to be a doctor,” wrote Dr. Robinson. The next day, her post had gone viraland the article was formally retracted.

As an apologythe journal’s editors recognized that “professionalism has historically been defined by and for white, heterosexual men and does not always reflect the diversity of our workforce or our patients.”

As the face of medicine changes and platforms like TikTok and Twitter transform the way medical knowledge is shared, the original architects of professionalism still believe that the term’s core principles will remain central to medicine.

For Dr. Leach’s definition is simple. ‘Do you have discernment and do you speak the truth? Do you put the patient’s interests above your own? And do you develop practical wisdom that can combine the best science with the particularities of this particular patient to make a creative clinical decision? he said. “If you do these three things, you are a professional.”

He added: “And a dress code is so far removed from those three things.”