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August 16, 2016

Introducing JAMA Professionalism

Author Affiliations
  • 1Deputy Editor, JAMA
  • 2University of Texas Southwestern Medical School, Houston
  • 3Northwestern University, Evanston, Illinois
  • 4Wilson Centre for Research in Education, University of Toronto, Toronto, Ontario, Canada
  • 5St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada

Copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA. 2016;316(7):720-721. doi:10.1001/jama.2016.9854

This issue of JAMA marks the introduction of a new department: JAMA Professionalism. The goal of the articles in this section is to help physicians fulfill required competencies on this topic. According to the American Board of Medical Specialties definition, professionalism is “…a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations.”1 Taking responsibility for executing professional responsibility seems intuitive enough. But what does it mean to adhere to ethical principles? How are the ethical principles defined? Recently, the American Medical Association issued an update to its Code of Medical Ethics stating that in order to conduct themselves ethically, physicians should “uphold the standards of professionalism.”2 These definitions create an apparent dilemma—being ethical means exhibiting professionalism and professionalism is defined, in part, by being ethical.

“Perhaps the difficulty with teaching medical professionalism is that there seems to be no agreement on what the term actually means” noted DeAngelis in a 2015 JAMA theme issue on professionalism.3 In the same issue, Naylor and colleagues indicated that in both the United States and Canada, expectations for postgraduate medical education include 3 major tenets: knowledge, skills, and professionalism.4 In this context, professionalism is the application of knowledge and skills to deliver medical care and is difficult to define because professionalism represents almost everything a physician does while practicing medicine.

The varied ideas of what should be considered medical professionalism emerged in JAMA’s professionalism theme issue. The nonmedical public view of medical professionalism is that physicians display good behavior, high values, and positive attitudes.3 Another view from the public perspective is that professionalism is manifested by the public entrusting physicians with autonomy and the ability to self-regulate in exchange for physicians being competent, altruistic, and moral while addressing the health care needs of society.5 Other definitions included physicians being resilient, adaptable, and good communicators and have the ability to work well in teams.6 Professionalism can also be expressed by a physician’s commitment to continuously self-assess and improve the quality of the care provided7 or that physicians follow standards the profession defines for itself without the need for government-imposed regulation of practice standards.8

The articles in the JAMA Professionalism section will reflect the multifaceted nature of this fundamental aspect of being a physician and practicing medicine. Each article will present individual cases of actual medical scenarios in which professionalism is required to address important issues and solve difficult problems. For instance, how should a resident physician solve the dilemma regarding the need to adhere to work hour restrictions vs spending more time with a patient? How should physicians respond when they have observed or participated in a medical error that is undisclosed to the patient? How do clinicians address disrespectful communication between physicians and nurses? How should clinicians deal with conflicts with administrators about resource allocation in the health care system?

These scenarios will touch on the many aspects of how professionalism factors into medical decision making. The scenarios will be explored using the following logic. Consider the situation in which a resident must decide between complying with regulations when those regulations are in conflict with the delivery of patient care. How are the priorities established? How does the trainee approach supervisors who are charged with resolving these conflicts and who, exactly, should the trainee talk to? When physicians witness conflicts between personnel in the health care environment, what is their responsibility to intervene? From where does the authority flow should they decide to get involved? If the action is reportable, who is responsible for receiving the information? When physicians observe inadequate clinical care because of poor administrative decisions, what should they do about it? The examination of these scenarios and explanation of potential solutions will help physicians better understand how professionalism helps guide their actions and learn from the experience of the physicians who were involved in the cases.

The first article in the JAMA Professionalism series discusses the dilemma a physician encountered when he learned after he performed skin biopsy procedures that the instruments he used were not sterile.9 As a clinician, he first needed to determine what the risks of infection were and then disclose the error and those risks to the patients. He also had to consider risk management and any potential liability issues. He needed to consider how to interact with the quality improvement program to ensure the error was not repeated. Reflecting the multiplicity of definitions for professionalism, physicians assume a variety of roles and responsibilities when addressing professionalism issues. In this case, the physician needed to be compassionate and responsible by fully informing the patients of the error without needing external regulations telling him he needed to do so. He needed to be involved in the performance improvement group of his clinic to understand how the error occurred and he needed to be involved in administrative tasks to ensure that the clinic he worked in developed processes to ensure the error was not repeated.2

The cases presented in JAMA Professionalism articles will specify the challenge to professionalism. Where appropriate, the scenarios will discuss the reporting of and resolution of issues relating to deficiencies in professionalism, and they will address systems and organizational factors that may contribute to the problem. There is inherent subjectivity to identifying what is appropriate professional behavior and also what the best approach might be for addressing what is perceived as unprofessional behavior in a specific context or setting. Because of that uncertainty, suggestions in the article for addressing the situation in question will not necessarily be seen as correct or incorrect. Rather, a series of options will be discussed with the relative merits of each explained. There will be a summary of the case resolution and long-term follow-up if available. There will be a bottom line section with 2 or 3 brief take-home messages that summarize the main learning points of the article.

Each article in this series will be accompanied by an audio recording that may include an interview with the author of the article and/or relevant experts in the field. The intent of the audio feature is to provide a forum for much more in-depth discussions about professionalism than can be achieved in a printed article. The article and its related recording will include self-assessment CME. Inquiries regarding this series can be made by contacting Deputy Editor Edward Livingston (edward.livingston@jamanetwork.org).

Despite the various definitions and multifaceted nature of professionalism, at its core, professionalism can be thought of as a set of behaviors that must be learned and practiced like any other skill, and they should be developed and refined continuously over a physician’s practice lifetime.9 Much can be learned about professionalism by studying individual case scenarios in which clinicians faced situations they were not necessarily trained to address. In some cases, physicians may have responded well and in others, not so well. By studying these cases and how they evolved and were resolved in articles in the JAMA Professionalism series, physicians can learn more about how professionalism can guide them when they encounter challenging clinical situations, interpersonal issues, and ethical dilemmas for the first time or perhaps on a recurrent basis.

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Article Information

Corresponding Author: Edward H. Livingston, MD, Deputy Editor, JAMA, 330 N Wabash Ave, Chicago, IL 60611 (edward.livingston@jamanetwork.org).

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Board certification: based on core competencies. American Board of Medical Specialties website. http://www.abms.org/board-certification/a-trusted-credential/based-on-core-competencies/. Accessed July 24, 2016.
Brotherton  S, Kao  A, Crigger  BJ.  Professing the values of medicine: the modernized AMA Code of Medical Ethics.  JAMA. 2016. doi:10.1001/jama.2016.9752.PubMedGoogle Scholar
DeAngelis  CD.  Medical professionalism.  JAMA. 2015;313(18):1837-1838.PubMedGoogle ScholarCrossref
Naylor  CD, Gerace  R, Redelmeier  DA.  Maintaining physician competence and professionalism: Canada’s fine balance.  JAMA. 2015;313(18):1825-1826.PubMedGoogle ScholarCrossref
Cohen  JJ.  Tasking the “self” in the self-governance of medicine.  JAMA. 2015;313(18):1839-1840.PubMedGoogle ScholarCrossref
Kirch  DG, Gusic  ME, Ast  C.  Undergraduate medical education and the foundation of physician professionalism.  JAMA. 2015;313(18):1797-1798.PubMedGoogle ScholarCrossref
Chassin  MR, Baker  DW.  Aiming higher to enhance professionalism: beyond accreditation and certification.  JAMA. 2015;313(18):1795-1796.PubMedGoogle ScholarCrossref
Madara  JL, Burkhart  J.  Professionalism, self-regulation, and motivation: how did health care get this so wrong?  JAMA. 2015;313(18):1793-1794.PubMedGoogle ScholarCrossref
Levinson  W, Ginsburg  S, Hafferty  FW, Lucey  C.  Understanding Medical Professionalism. New York, NY: McGraw-Hill Professional; 2015.
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