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Abstract

Professionalism refers to the set of skills and values that, in the case of medicine, characterize the essence of humanism in professional work. Professionalism, ethics, and bioethics are closely linked. Within the framework of global bioethics, professionalism provides a comprehensive picture of the medical profession and its relationship with the major social challenges worldwide in the areas of health and education.

Introduction

In recent years, the world has witnessed signiﬁcant changes in the medical ﬁeld, not only in the areas of scientiﬁc and clinical knowledge, in the understanding of diseases, or in the development of new drugs and therapeutic treatments but also in the physician-patient relationship, the management of healthcare systems, and the general approach to health, welfare, and disease management. In practically all of these areas, the changes have been accompanied by a comprehensive approach to health. As might be expected, all these elements involve a signiﬁcant ethical component that is of special interest for bioethics.

Basic Concepts

In the area of healthcare, and of medicine in particular, professional work cannot be conceived outside the framework that includes the relationship among health, welfare, and disease. Health has a biological dimension that can be measured using biomarkers (i.e., functional imaging with PET/CT or MRI, tumor markers), but it also has a psychosocial dimension that can often only be perceived (only allowing qualitative analyses of the subjective components).

In its deﬁnition of health and welfare, the World Health Organization tacitly recognizes this fact (WHO 1989). Consequently, together with the professional duties related to disease treatment, the duties directly related to patients’ welfare should also be taken into account. There may be diseases that cannot be cured or even treated, but this by no means frees physicians from their professional duty of caring for the patient. While the ability to identify and use physical, clinical, and analytic facts is relevant in the patients’ treatment, there are other elements that should be considered in the assessment of professional practice. These elements, such as how the healthcare professionals interact with patients or how professionals address their roles in healthcare, are also an important piece of their professional practice. Unfortunately, either the rapid spread of new technologies, especially in the most developed countries, or the over demand of patients, in the majority of developing countries, has caused that any source of knowledge (i.e., knowledge derived from better understanding of patients’ concern) outside of the exact sciences falls in practice into oblivion. This leads to the need for training to provide physicians with the necessary tools to treat patients from a comprehensive approach based on adapting management to the particular situation of the patient, as in, for example, linguistic, social, and cultural differences. With this aim, the development of skills focused mostly on the technical part of medical and clinical aspects involved in the diagnosis and treatment of disease is not enough. It is also essential to design a model of professional behavior which should include communication and analysis skills in professional physician-patient interaction, teamwork skills to optimize the services provided by multidisciplinary healthcare teams, and, ﬁnally, information retrieval and analysis skills and competence in the application of different types of information and professional knowledge. These elements, set within a clear framework of ethical and legal action, are the source of professionalism in the context of medical practice.

History And Development

Despite professionalism as a concept used to describe the core elements of the medical practice, which can be traced back at least around 400 BC with the Hippocratic Oath, the use of this term in the medical literature is not longer than a century ago (DeAngelis 2015). According to some authors (Hu et al. 2000), behind the use of the term of medical professionalism, there are at least three common elements that medical doctors from different cultural backgrounds recognize as core part of their profession (Hu et al. 2000): (i) the existence of common ethical principles such as conﬁdentiality, truthfulness, informed consent, respect, justice, and commitment to preventive medicine, (ii) the need for medical education based on fostering good practice, and (iii) the requirement for professional practice to comply with moral codes of good practice. These elements, which are common to the different medical traditions, are in the basis on which professionalism is built.

The concept of professionalism arises as an articulated body made up of professional traits and skills that constitute physicians’ professional work, regardless of the geographical, social, or cultural settings where it is carried out.

According to David Stern (2006), the core values of medical professionalism derive from the universality of disease and begin with caring or compassion. Caring over time creates the value of responsibility. The shared responsibility for care, between physicians and patients, engenders trust and respect in both parts. The maintenance of trust demands integrity and conﬁdentiality. In these terms, human values, traditionally viewed as central to medical practice, have a biological basis on the very nature of the human bonds established among people by the experience of disease. This human core is present in all medical traditions to date and in all the existing perspectives of professionalism. Some of these values are autonomy, service, maintenance of competence, and accountability. And these professional values, as such, are common to all professions and not only to medicine.

However, a brief historical introduction will contribute to the understanding of how human and professional values are the two main elements that lead to the birth and further development of professionalism in the medical ﬁeld.

What is nowadays known as medicine is the product of countless sources of knowledge that have existed from the very origin of humankind.

Sumerian, Egyptian, Greek, Roman, and later Arabic culture, as well as providing the major bases of knowledge that have been used to study the diagnosis and treatment of disease, have left a rich body of doctrine on professional practice that has survived over time. Based on a similar worldview of the relationship between human beings and their environment, the Chinese, Indian, and pre-Columbian traditions have provided the bases for a holistic understanding of medicine. The concept of person introduced by Christianity was a turning point for medical practice. Attached to this concept is that of dignity, thanks to which health acquired universal value. The foundations of what would later be professional colleges were laid in the Middle Ages, as well as those for the creation of a professional medical body. The achievement of technical rigor and the necessary tools to acquire new knowledge, thanks to the scientiﬁc method, took place during the Renaissance and the subsequent evolution of modernity. Also in the modern era, the concept of profession becomes fully consolidated under a more formal structure that, in the case on medicine, has led to profound changes both in the physician-patient relationship and in the relationship between medicine and society.

Medical professionals are currently viewed as providers of a service based on the self-regulated and responsible application of knowledge earned through a learning process. Physicians’ professional activity is always carried out seeking the beneﬁt of others rather than their own. Nevertheless, because of the contractual nature of the job, physicians earn the right to a ﬁnancial reward for their work.

So far, a brief description of the historical background for the birth and development of professionalism has been provided. However, the history of how the term was originated and subsequently acquired the signiﬁcance it has nowadays in the ﬁelds of medical education and global bioethics is more recent. Toward the late 1970s, in the very early stages of bioethics, a ﬂourishing interest was starting around the term of medical professionalism to describe a renewed paradigm of medical practice. In the ﬁeld of medical education, there was an incipient interest in adapting teaching models to the needs of an increasingly globalized society (DeAngelis 2015). Within this context, the search for international performance standards necessarily entailed the need to focus reﬂection on the search for elements of global interest. However, it was not until the 1980s that the noncognitive attributes of physicians acquired their own space within this reﬂection. In 1983, the American Board of Internal Medicine (ABIM) took a ﬁrst step toward this by establishing respect, compassion, and integrity as dimensions of humanistic medicine. In the 1990s, the ABIM began to use the term “professionalism,” and, together with humanism, it explicitly included among its constituents the notions of altruism, duty and service, responsibility, and excellence (ABIM 1994). According to Stern (2006), in 2000, more than 60 medical colleges had already developed, or were in the process of developing, different types of tools for the assessment of their students’ professionalism. The turning point came in 2002, when the ABIM, in collaboration with the European Federation of Internal Medicine and several international authors, published “Medical Professionalism in the New Millennium: A Physician Charter” in Annals of Internal Medicine and in The Lancet. That same year, other journals of international relevance echoed this initiative by reproducing the document and publishing several articles and comments at the global level. In just a few years, the concept acquired its own space within specialized literature, becoming a reference both in the ﬁeld of medical training and in that of bioethics. In the latter, professionalism has taken on particular signiﬁcance through its inclusion in the Bioethics Core Curriculum, published by the UNESCO in 2008. The countless publications, conferences, events, and initiatives that from then until now have revolved around professionalism are proof of its signiﬁcant contribution both in the ﬁeld of medicine and in that of global bioethics. However, incorporating medical professionalism into the curriculum for many is still not feasible. Perhaps this difﬁculty is a consequence of a lack of global agreement on what to expect from the meaning of the term in different cultural contexts.

Conceptual Clarification

Despite that there is certain general agreement of the core elements of medical professionalism, having a deﬁnition offers important difﬁculties. These can appear due to the interdisciplinary framework around the term, or be derived from the important social disparities and cultural differences that accompany the medical practice in a global context.

One of the main referents of professionalism is undoubtedly the “Physician Charter” of 2002. In this document, professionalism is described as the basis of physicians’ contract with society. According to its text,

Professionalism demands placing the interests of patients above those of the physician, setting and maintaining the standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession.

This statement sets the bases for a deﬁnition without giving a closed deﬁnition of the concept. However, this document transmits the close relationship among professionalism, professional ethics, and bioethics. In agreement with this statement, it in 2008 the Bioethics Core Curriculum of the UNESCO included professionalism within the area of bioethics as the behavior, aims, and qualities that both professions and professionals should have.

The need for a clear, comprehensive, and concise deﬁnition of professionalism acquires special relevance when it comes to establishing the criteria for its assessment. Given that learning involves incorporating certain types of knowledge and that acquired knowledge can be measured, it must be possible to assess professionalism as the type of knowledge to be acquired by all professionals with the purpose of determining the extent to which it has been made a part of professional practice. In this context, a deﬁnition from the ﬁeld of medical research, with assessment purposes, mainly suggests that professionalism is a type of knowledge reached from a starting point of three essential bases: (i) clinical skills, (ii) communicative skills, and (iii) an appropriate understanding of ethical and legal framework of the professional behavior. These three elements are the grounds upon which the founding characteristics and core values of medical professionalism are built: excellence, humanism, accountability, and altruism (Stern 2006). This deﬁnition introduces the idea of professionalism as a virtue to which physicians continue to aspire and, therefore, provides a bridge to medical ethics. In this deﬁnition, excellence, humanism, accountability, and altruism act as aspirational principles more than a normative framework that provide an assessment tool of observable professional behaviors. Meanwhile, communication skills, which are also included in the deﬁnition of professionalism, not only involve the ability to communicate with patients and their families but also with the rest of professionals that are members of professional and interprofessional teamworks. Now, more than ever, there is a need for these skills at the global and intercultural level. Their development also facilitates the opening of new paths of knowledge born from positive cooperation between patients and their environment, as well as from the contribution made by interprofessional and multidisciplinary collaboration toward the improvement of professional care within a framework of ethical practice.

Ethical Dimension

Technical expertise, skills, ethics, and communications are all essential components of professionalism. However, ethically speaking, professionalism can be described as a status that is reached, maintained, and improved through the continuous effort and perseverance of those who practice the human principles and values that make it up. In fact, according to the ABIM’s Medical Professionalism Project, professionalism is directly associated with the following concepts: excellence, accountability, duty, altruism, respect, compassion and empathy, honor, and integrity (ABIM 1994). Underlying all these elements is a strong ethical dimension that acts as the backbone of professionalism. In spite of the numerous differences that naturally emerge from interprofessional and intercultural dialogue, there is a degree of consensus as to acknowledge the preponderant role of all these elements and to group them, for practical purposes, into four main dimensions: excellence, accountability, altruism, and humanism.

Excellence

Within the broad framework of professionalism, excellence begins with a commitment to competence, the understanding of ethical principles and values, awareness of legal boundaries, and communication skills. However, excellence cannot be understood without a personal commitment to exceed ordinary standards, which is a speciﬁc characteristic of this principle that sets it apart from the rest. In terms of excellence, a commitment to acquire minimum standards is not enough, since its essence lies in exercising a continued and conscious effort to go beyond ordinary expectations.

Excellence is closely linked to a permanent readiness to engage in lifelong learning, which implies more than a set of self-programmed activities. According to several authors (Hojat et al. 2003), this quality is deﬁned as the set of skills developed by individuals to gather knowledge from different sources, catalyze it, and include it in their professional practice. It requires sustained motivation, humility in the acceptance of one’s own limitations, and an attitude of wonder and openness to new forms of knowledge. Another expression of excellence is dedication to the continuous improvement of quality through reducing medical errors, working toward patients’ protection and well-being, concern with the misuse of healthcare resources, and the search for efﬁciency.

Excellence is also closely related to interprofessional collaboration, which is a strength that every professional should cultivate, especially in multidisciplinary environments such as the healthcare area. It is not enough for professionals to be skilled at their jobs; they must also be able to create, sustain, and maintain mechanisms to encourage improvements in their team’s performance. At this level, collaboration takes on a preponderant role that has been explicitly acknowledged by the World Health Organization (2010). Excellence should be an aim in healthcare, although difﬁcult to achieve in most cases.

Finally, an essential aspect of excellence is the promotion and innovation of knowledge based on scientiﬁc evidence and medical expertise. Professionals, in this case physicians, therefore, have a duty to protect and preserve the integrity of their medical expertise and technological resources while at the same time ensuring integrity as regards their proper use. Nevertheless, this must not lead to confusing excellence with technical improvements. In the case of professionals with scarce material resources, excellence allows for the development of creative skills and innovative capacities to better cope with the limitations that may arise. For example, the skills developed by physicians in resource-constrained countries to meet the health needs of their communities are bold and impressive. Apart from being a clear example of excellence, in certain cases the development of these skills has led to signiﬁcant contributions to medicine and global health (Dandonoli 2013).

Accountability

Accountability includes self-regulation, the setting of standards, the management of conﬂicts of interest, duty, and responsibility. All these characteristics, through accountability, closely associate professionalism with the ideal physician-patient and physician-society relationships. Certain authors deﬁne accountability as the set of procedures and processes by which individuals justify and take responsibility for their actions (Emmanuel and Emmanuel 1996). Accountability implies not only professional responsibility in patient care but also the responsibility – in the case of physicians – of ensuring that the actions undertaken at all times are consistent with the standards of the profession and with society’s responsibility to safeguard the health needs of its members.

In a broader sense, responsibility is an action derived from freedom and always attached to commitment, a personal commitment to take charge of patients’ health despite the hardships that might be involved in such a task and the personal risk it may involve. Commitment born from responsibility also translates into a duty to cooperate with other health professionals, taking on leadership tasks and submitting to the leadership of others when required (Stern 2006).

Self-regulation is a core element of accountability through which physicians take on their role of main primary responsibility for exercising a legal and ethical behavior in their professional practice (Emmanuel and Emmanuel 1996). In terms of education, accountability provides an adequate framework of action for designing professional training schemes through which, in addition to developing clinical skills and building sufﬁcient medical knowledge, physicians acquire the commitment to ensure that their professional performance is responsible toward patients and society (Gonnella and Hojat 2012).

In countries with a free market economy, the danger of erosion of physicians’ ethics as a result of the ﬁnancial interests of third parties is not very different to the situation of vulnerability faced by physicians in countries with scarce resources, where bribery and the unlawful use of inﬂuence are well-known problems that corrupt the very essence of the profession, including physicians, patients, and society. To address these issues, accountability provides a tool that works “from within” in protecting professionals and maintaining a healthy relationship between them and society. This dimension of accountability establishes a bridge between professionalism and social justice in the search for an equitable distribution of resources, access to healthcare, and the cultivation of an increasingly caring society.

Altruism

The third ethical dimension of professionalism is altruism, which requires physicians to give priority in the performance of their profession to the best interest of patients above their own (ABIM 1994). However, these “best interests” are not to be interpreted as uncritical subordination to patients’ autonomy. Several authors agree upon the need for awareness of the potential risks involved in a misunderstanding of medical altruism. The literature states that altruism is expressed in speciﬁc situations as concern for the welfare of others. Nevertheless, whether or not this behavior is to pose a risk for the well-being of the benefactor, a certain degree of sacriﬁce, or renunciation to self-interest to be considered altruism strictly speaking, is an issue that remains unclear (Stern 2006). There is no question as to the strong bond between altruism and compassion. In this sense, both the operational principles of bioethics and the natural link between life, health, and disease provide an illuminating framework for action. There is no health without life, and behind the loss of health is disease. This fact tacitly provides an order of values that deﬁnes the scope of action of altruism through the regulation of physicians’ professional work. As regards sick patients, physicians perceive the responsibility to take action for the beneﬁt of an asset that is in danger. However, this performance cannot involve a higher risk than there already is, neither for the patient nor for the physician. From there on, all action taken in the direction of the “best interest” or patients’ welfare is not only welcome but also necessary. This is a task where responsibility is shared among physicians, patients, and society itself.

Humanism

As already mentioned, humanism is made up of a set of elements that, throughout history, have been part of the very essence of professional medical performance. These are respect, compassion, empathy, honor, and integrity.

Humanism involves a sincere concern for the interest of humanity embodied, in the case of medicine, in the ﬁgure of the patient. It is a crucial principle in a profession that is born from the interaction between people in need of care and those who provide it.

Respect means treating others with regard, deference, and dignity. It involves sensitivity and receptivity to the characteristics and peculiarities of the personal and cultural history that is a part of the individuality of others. Furthermore, it is a basic attitude that is often termed as the essence of humanism, since it awards recognition both to the worth of human beings as individuals and to their system of beliefs and values (Abbot 1983). Therefore, both patients and other professionals are entitled to respect.

Compassion and empathy are closely complementary concepts. Empathy is the ability to understand the views of others, together with their inner experiences and feelings, without getting intensely emotionally involved (Hojat 2007). Thus, empathy is the result of the human need for understanding and is the backbone of physician-patient professional relationships. However, empathy goes beyond understanding and communication. Its more human dimension is given by compassion, which allows physicians to perceive a patient’s emotional disposition toward a disease or ailment and motivates them to ﬁnd the causes that might explain such condition. Compassion binds physicians and patients, while empathy transforms this bond into an instrument for caring and healing, in the case of patients, and into an element for the protection of health and welfare, in the case of physicians. Medical literature extensively discusses both the dangers to physicians of a loss of compassion and those that might arise from excessive emotional involvement with patients. However, as with empathy, compassion is not exclusive to the physician-patient relationship, but it is also extensive to the ﬁeld of interprofessional collaboration (Hojat et al. 2014).

Finally, honor and integrity refer to “being fair and truthful, keeping one’s word, meeting commitments and being straightforward” (ABIM 1994). Both qualities, as is the case of the previously mentioned, apply to all human actions, including those carried out within private contexts where the only witness is one’s own conscience. Professionals that assume these qualities as a general standard in their professional work acquire in practice the habit of adapting to the situation at hand or “living in the truth.” Living the truth is a way of deﬁning humility. This is recognizing their own limitations and having an objective vision of the situation without generating false expectations or being seized by self-deception. Living in the truth also means being able to acknowledge one’s own mistakes, dealing with the mistakes of others, and giving due recognition to the work of others. This is conceptually opposed to plagiarism, fraud, and deception.

Conclusion

Professionalism introduces a new paradigm for professional performance consisting of a body of values and professional skills and includes, in addition to the components derived from medical humanism, others that are common to professional practice in general.

Given its common and universal nature, professionalism is not only global in its reach, covering the different geographical and cultural realities where the medical profession is practiced, but its timeless dimension makes it present at all stages of professional life. Namely, its scope of inﬂuence covers students, professionals in training, and professional physicians.

In terms of knowledge, professionalism poses the challenges of teaching, learning, and assessment, areas that are of particular interest to medical education.

The ﬁrst recipients of the beneﬁts of professional care are professionals themselves, followed by the recipients of professional service who, in the case of medicine, are patients and ultimately by the professional environment where it takes place, represented by both other professionals and society as a whole.

Within the context of an increasingly globalized society, professionalism provides a series of tools that play an extremely useful role for bioethics to meet the major challenges that concern it in terms of health and education at the global level.

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