Professionalism : the indicator of a civilised and exemplary medical profession

Vasanthy Arasaratnam MSc, PhDD N Atukorala MD, FRCPVaruni De Silva MBBS, MDS A S Goonewardena MS, FRCSMalik Goonewardene MS, FRCOGRenuka Jayatissa MD, MScNeelika Malavige MRCP, DPhilA Pathmeswaran MBBS, MDB J C Perera MD, FRCPCHChanna D Ranasinha DTM&H, FRCPUdaya K Ranawaka MD, FRCPShalini Sri Ranganathan MD, PhDD N Samarasekera MS, MD, FRCSManouri Senanayake MD, FRCPKamani H Tennekoon MBBS, PhD


Professionalism: the indicator of a civilised and exemplary medical profession
Medicine is more than a vocation, i.e. an occupation for which a person is specifically trained and qualified.It is meant to be a profession that practices and displays high standards of self-regulation [1].However, the overemphasis of the vocational element of medicine but sub-optimal expression of selfregulation, both in practice and in education, has been recognised as an almost global phenomenon in the recent past [2].As a result, medical professionals have faced uncomfortable but unavoidable questions about 'professionalism'.Therefore, the traditional definition of fitness to practice medicine, as the presence of necessary skills and the absence of physical or psychological impairments (i.e. the doctor as a competent person), has been transformed to encompass professionalism (i.e. the doctor as a professional person) [2].Many regulatory and professional bodies [3][4][5] not only in the western but also in the eastern parts of the world [6] have adopted and embraced this significant and important change in order to prepare the medical profession for the demands of the new millennium.
Historically, professionalism characterised medicine as a profession [7].For example, when allopathic medicine was in its infancy and when 'doctors' were no different to soothsayers due to lack of knowledge underpinning their clinical decisions and practices, the Hippocratic Oath defined medicine as a profession by advising practitioners a) to 'do no harm' clients, b) to work for the betterment of the profession, and c) to introduce some elements of 'evidence-based practice' [7].The surge of technology and knowledge in the 18th and 19th centuries created by the industrial revolution led to considerable advances in medicine.Codes of conduct for doctors emerged in this period, especially in the western world, and helped protect medicine as a profession against the threat of it becoming an industry [7].Professional codes emerging in many countries during the last three decades suggest that the main focus of medical professionalism is on protecting patients from the conflicts of autonomist, commercialist and consumerist interests within the profession [4,8].Hence, throughout the history of medicine, professionalism has acted as a social contract between doctors and society to maintain public trust in the profession [9].Professionalism, however, is a moveable feast as it responds to social and societal dynamics; it is context and culture specific [10,11].Therefore, it has no concrete and universal definition.It is generally agreed that professionalism encompasses a set of attitudes, values and behaviours which are associated with the practice of medicine [12].Professionalism can be understood broadly as the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice in a given context for the benefit of the individual and

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community being served as normatively defined by all stakeholders [2].The attributes of professionalism identified from the literature range from interpersonal and personal skills (e.g.teamwork, communication, reflective practice) to values (e.g.honesty, integrity, accountability), and attitudes (e.g.collegiality, respecting patients' autonomy).Complying with the current conceptualisation of professionalism, in our own research, we explored the importance of these attributes from the perspectives of the public and also of medical professionals.
In our first study [13], we conducted a survey among a nationally representative sample of 958 members of the UK general public to explore their understanding of medical professionalism and identify its essential attributes.It showed that the public identify three facets to professionalism.Certain essential attributes were related to the doctor-patient relationship (clinicianship), e.g.respecting a patient's autonomy, being empathetic when caring for patients, communicating in a clear and effective manner, treating patients fairly and without prejudice.Another group of essential attributes reflected the relationship between doctors and their co-workers (workmanship), e.g.working well as a member of a team, treating other healthcare professionals fairly and without prejudice, reflecting on one's actions with a view to improvement, being able to manage situations where there is a conflict of interest.Finally, there were those attributes relating to doctors in society (citizenship), e.g.functioning according to the law, behaving honestly and with integrity, avoiding substance or alcohol misuse, being accountable for one's actions.Interestingly, the findings challenged the common belief that personal appearance, including dress code, and conforming to social norms are important to be a 'doctor' [13].
In the second study [14], we surveyed a group of 584 clinicians and medical educators from different parts of the world, e.g.UK, Europe, North America and Asia.The majority of the respondents were from the UK and several Asian participants were from Sri Lanka.In general, their overall conceptualisation of medical professionalism overlapped largely with the public model of professionalism.The responses of the medical practitioners from different geographical regions on the essentialness of individual attributes reflected important similarities and differences.The similarities depicted the core values of practicing allopathic medicine wherever in the world, e.g.moral behaviour, reflective practice, lifelong learning, empathic and caring attitude.These similarities may be simply due to a western influence on an eastern 'definition' of professionalism or vice versa.Whatever the reason, it was encouraging to observe that these universal attributes of professionalism were largely in concordance with the expectations of regulatory and professional bodies worldwide.The differences may be explainable by socioeconomic and cultural variations between the geographical regions they represented.For example, to North American medical professionals, being altruistic was more essential than looking after their own health and wellbeing; to UK medical professionals, their own health and well-being was more essential than altruistic attitudes.This may well be attributable to the fee structure of the two healthcare systems.In North America, patients personally pay for their healthcare, but in the UK patient care is funded by the state.It may be that the North American doctors feel they should at least demonstrate that they are altruistic.The essentialness of 'acting with confidence in one's duties' to Asian medical professionals, but not to others, may reflect socio-cultural differences [14].The notion that 'doctor knows what is best' is still deeply rooted in Asian societies and demonstrating confidence may be a determinant of a 'good' doctor-patient relationship [15].However, in an environment where patient safety is at the heart of regulatory and legal frameworks [8], doctors in western countries may need to portray themselves as safe rather than confident practitioners.Regardless, certain responses were counter-cultural; medical practitioners attempted to break the cultural barriers to provide better healthcare.For example, Asians, who are considered culturally to have less flexible attitudes [16] indicated that the adaptability to workplace changes should be an essential attribute of professionalism.
There are several implications of understanding professionalism to clinical practice and medical education.The insight gained from similar studies to those described above has been translated into practice in many countries.As a result, self-regulation of the medical profession has been exposed to regular public scrutiny to ensure public trust in the profession [17].This insight should also be transferred to all levels of medical education (undergraduate, postgraduate and continuing medical education).A lecture delivered in a classroom setting may be useful to introduce the expectations of professionalism to undergraduates [18], but they will not be fully grasped by students until they experience these attributes being practiced, encouraged and rewarded in the clinical environment [18].Therefore, every clinician who shares the working environment, with or without a specific educational role, knowingly or unknowingly contributes to fostering professionalism among their colleagues, trainees and students [18].It is also important to assess professionalism explicitly based on the understanding gained, because it has been demonstrated that professional lapses during the undergraduate stage predict doctors who end up before fitness-to-practice committees later in their careers [19].Professionalism can be assessed, for example, in OSCEs, but also needs to be observed or collated from multiple sources in the working environment to ensure its persistence [20].Given the nature of the concept and the sensitivity of its consequences, it is more effective to adopt an inclusive, supportive and constructive approach to assessment for professionalism (i.e.assessment for learning) than an exclusive and punitive approach (i.e.assessment of learning) [21].
The emphasis on professionalism is still a growing trend, not only in Sri Lanka but also in the eastern parts of the world in general.But with the rapid expansion of an empowered and knowledgeable society and the globalisation of healthcare, the day that Sri Lankans embrace this trend completely cannot be too far away.It is important to adapt the concept of professionalism to suit the social, cultural and economic realities of the Sri Lankan context whilst upholding its guiding principles, rather than adopting the western concept simply because it is western [22].This needs willingness and openness to selfreflection, creating dialogue and researching the area.As for every country that has made this transition, what the future holds for Sri Lankan doctors in terms of public expectations of professionalism will be a challenge rather than a threat.It will strengthen the profession if these expectations are grasped willingly.Amidst the technological and scientific revolutions currently taking place in the field of medicine, professionalism, the social contract between doctors and society, has been and will be the indicator of a civilised and exemplary medical profession.The responsibility of this contract lies with each and every member of this profession, to be handed over further enhanced to the next generation.