Neither economic incentives, nor technology, nor administrative control has proved an effective surrogate for the commitment to integrity evoked in the ideal of professionalism.
—William Sullivan (1995)
Although three IOM landmark reports—To Err Is Human (1999), Crossing the Quality Chasm (2001), and Health Professions Education: A Bridge to Quality (2003)—highlight the need for professionalism in health care, the word “professionalism” appears only once throughout all of these reports. In fact, the concept of professionalism, according to Frederic Hafferty, from the Program for Professionalism and Ethics at the Mayo Clinic, dates as far back as 400 BC, with Hippocrates’s oath of professional ethical standards, and has evolved over time in a series of waves of pulses.
One recent pulse came from Herbert Swick’s article identifying nine key behaviors of professionalism that focused on individuals (Swick, 2000). Although the article was very influential, Hafferty reminded the audience that there are other ways of thinking about professionalism. These “other ways” are less about the actions and acts of individuals and more about a profession as a whole that parallels notions of collective responsibilities. Such thinking developed when the American Board of Medical Specialties (ABMS) established a standing committee on professionalism and ethics and charged a subgroup of the committee to come up with some definitional framings that could be adopted by the ABMS. The subgroup consisted
of Frederic Hafferty, Maxine Papadakis, William Sullivan, and Matthew Wynia. Their definition states, “Medical professionalism is a belief system about how best to organize and deliver health care, which calls on group members to jointly declare what the public and individual patients can expect regarding shared competency standards and ethical values, and to implement trustworthy means to ensure that all medical professionals live up to these promises” (ABFM, 2012).
This is the short version of the professionalism definition that formed the basis for a longer, one-page definition used by the ABMS (ABMS, 2013). What Hafferty hoped was apparent in the subgroup’s version was the shift from the individual to the collective and from the framing of professionalism now as relational and a dynamic conversation between the professionals and the public. This underscores his belief (one not necessarily shared by the ABMS or the other Global Forum members and speakers) that professionalism is not so much a noun but a verb. It is a dynamic entity that changes over time. The professionalism of yesterday is not the professionalism of today, nor will it be the professionalism of tomorrow. Some core elements are the same, but the shadings change. And what issues get discussed as part of professionalism change as well.
Matthew Wynia, a co-chair of the workshop from the Institute for Ethics and Center for Patient Safety at the American Medical Association, picked up on the notion of trustworthiness that was cited in both Herbert Swick’s and his ABMS definition of professionalism. He commented that it is not merely trust between the clientele or the public and the profession, but that the profession in some way becomes worthy of that trust. Professionalism is the process through which a profession becomes worthy of the trust of patients and the public. This project is well represented in the American Board of Internal Medicine’s Medical Professionalism Project. Wynia thinks that in some ways, this concept exemplifies the thinking around how health professionals can ensure they are worthy of trust. They can do so by putting forward a set of practice standards, making the standards public, and listing the standards as specific behaviors to which the health professions will then hold themselves accountable.
Wynia sees these lists of desirable professional attributes as critical for behavioral assessments and for training, but they are not professionalism per se. In his view, professionalism is not the list of things health professionals say they are going to do; rather, it is the reason why the list was developed. Wynia explained his line of thinking about professionalism by looking at it etymologically as described in the following section.
Organizing Health Care
Professionalism starts with “profess,” which means to speak out or to declare publicly. According to Wynia, a profession is therefore a group of people coming together and speaking out by making a public declaration of the shared standards and values that govern their work. “Professional” as a noun is an individual member of the group or, as an adjective, an act or behavior that is in conformance with the articulated standards and values professed by the group.
Professionalism is an -ism, like communism, capitalism, socialism, cynicism, Protestantism, or Catholicism. It is a belief system about how the world works or how it ought to work. It is a belief system around the role of professions in delivering an important social good or service and protecting an important social value. In reference to health, professionalism is the belief that professions are the best way to organize and deliver health care, although it is not the only way to think about delivering such goods and services.
Consumerism is an alternative to professionalism. Consumerism has quality assurance through competition. For example, if two pizza parlors are in competition, a consumer can collect information and compare the two options. The bad pizza parlor will go out of business, and the good pizza parlor will stay open, and their business will spread. Consumerism emphasizes transparency in its ethics; it optimizes value with regard to resource allocation. Value is defined by the willingness to pay on the part of individual consumers. It treats health care as a normal good, just like toothbrushes and motorcycles.
Socialism is another way to think about organizing health care or any other social good. In socialism, a primary emphasis is on achieving equity for all, and this can be accomplished through regulatory mechanisms. The socialist agenda is to optimize the overall social benefit of any intervention or project, and it treats health care as a common good, like military protection of the community or environmental protections.
Professionalism is an alternative to both consumerism and socialism. It assures quality primarily through collegial review, not through state regulatory or market competitive mechanisms. There are fiduciary obligations that are the core of health professional ethics, putting the patient’s interests first. There is also the balance between individual and social needs and how to garner the trust of both individual patients and the community as a whole.
The reality, according to Wynia, is that most health care systems employ all three of these mechanisms—consumerism, socialism, and professionalism—and, in fact, they blend together. A highly successful profession is one where professional standards are built into the state
regulatory mechanisms, blending and making it difficult sometimes to distinguish the two. In Wynia’s opinion, that is the hallmark of a successful profession. In the end, accountability in health care is a balancing act among the three ways to organize and deliver health and health care goods and services.
Health Care Structure
John Weeks from the Academic Consortium for Complementary and Alternative Health Care, pointed out that the role of markets in health care caused a shift in how the U.S. health and educational systems view integrative medicine. When researchers discovered in the 1990s that consumers spent an estimated $21 to $27 billion yearly on complementary and alternative medicines and services, hospitals began offering these as options, medical schools began teaching them, insurers began to reimburse for them, and employers began to add them to their benefits packages (Eisenberg et al., 1998). The evidence had not changed; it was simply that the market became a factor. Once there was an awareness that consumers were willing to pay for these services, it provided professions more flexibility to practice outside of traditional Western medicine.
Payment also came up within the context of state regulation. Wynia talked about the set of rules regarding who gets to do what, and what will be reimbursed and for whom. And broadly speaking, these are issues in which the professions have a tremendous stake but do not make the final decisions; in fact, society decides. Although society encompasses a wide array of actors, the social norms that dictate regulatory and legal mechanisms are how society decides who gets to do what. Issues around scope of practice and other manifestations of professional closure are social conversations as well, not just professional conversations. This observation triggered a comment from Forum member George Thibault from the Josiah Macy Jr. Foundation. He brought up the impingement of the political process on health care, and the real-life example today of Medicaid expansion, where the profession does not get to decide whether low-income people in one state will receive health care coverage—the political process decides. The reality is that the professional desire to serve is limited by the political process.
Workshop planning committee member Nancy Hanrahan from the University of Pennsylvania School of Nursing noted that state regulation and market competition are being represented as the public word. What is missing, in her view, is the patient’s voice. Such input from patients would serve as a constant reminder of the financial constraints and social circumstances within which many patients live. Another point Hanrahan raised was the variability in state regulations. Each state can regulate nursing
practice differently and with significant variability, creating a great deal of confusion for consumers and other disciplines.
Workshop planning committee member Sally Okun with PatientsLikeMe reinforced Hanrahan’s comments. In her opinion, equating state regulation and market competition as representing societal or patient views seemed a little disingenuous—that possibly some of the state regulatory issues related more to organizational influence, the professional organizations themselves, and their ability to lobby for what they want versus what the public might even understand, and that the market competition is not necessarily fair in health care.
Patients often do not have a sense of the actual cost of health care goods and services and what would be a fair price. Okun believed that this might create an opportunity for a new voice, and that voice could be collective and include consumers who are typically underrepresented in conversations about the structuring of health care services.
Following Okun’s comment, Wynia observed that the U.S. health care system does not appear to be functioning well; however, it is difficult to imagine a structure that does not involve a mix of market, state, and professional forces. He then asked the participants, What is a legitimate way to establish professional standards for practice and shared values that incorporate the voice of the public and individual patients? Forum member Malcolm Cox of the Department of Veterans Affairs, who co-chaired the Josiah Macy Jr. Foundation conference titled “Transforming Patient Care: Aligning Interprofessional Education with Clinical Practice Redesign,” responded that the first recommendation from their conference was to form a new partnership between patients and professionals or between communities and professionals. The recommendation reads: “We envision a healthcare system in which learners and practitioners across the professions are working collaboratively with patients, families, and communities and with each other to accomplish the Triple Aim” (Josiah Macy Jr. Foundation, 2013). It was prioritized as the first recommendation because it was by far the most important one. It involves creating a new, unique voice that would be different from those that make up the present system of unstructured input into state decision making that is often driven largely by lobbyists.
Wynia then asked, How does one create such a thing, and how does one prevent it from becoming what we have right now? “After all,” he added, “this is in some ways what representative democracy looks like: it’s special interest groups, it’s loud people, it’s vested interests.” Workshop speaker Richard Cruess from McGill University in Canada responded to the question by saying that the discourse would need to change. More specifi-
cally, the conditions under which a social contact—that supports the ideal of professionalism—is negotiated would need to change. This change is fraught with challenges because it is currently the health professionals who speak for what the public wants, rather than having patients and society driving the discussion.
As a cancer survivor and law professor at the University of Wisconsin Law School, workshop speaker Meg Gaines stated that among the three choices, consumerism, socialism, and professionalism, she places no hope in the market. Because the market is heavily controlled, she said, consumers are not truly influential in the decisions being made. Also, health is a market in which consumers are not skilled purchasers.
Gaines would place greater value in professionalism, although she thinks the best way to structure health care is through socialism as it was previously described at this workshop. Providing the greatest good for society and balancing the needs of society with individuals seem like valuable goals for health care as opposed to generating health care at a profit, she said. But in response to Wynia’s question about how to get the new discourse, she responded that patients should be asked their opinion rather than relying solely on professionals to speak for patients’ wants and needs.
In acknowledging the importance in bringing patients and the community into the conversation about professionalism, Hafferty admitted to having difficulty in conceptualizing how this would be operationalized in a pluralistic society like the United States. What are patients? What is the public? There are all kinds of publics, interest groups, and other organizations. This is not necessarily how things are in other countries. Hafferty hoped that individuals from other countries could help the United States begin to think about how to accomplish a collective conversation. Hafferty noted the ease with which colleagues from the United Kingdom describe public engagement. But he then qualified the thought by saying that the United Kingdom has a national health care system and that they are a much smaller country, which are significant differentiating factors when compared to the United States.
The United States could also learn from Canada. In Canada, public forums take place around issues of professions and professionalism and issues of practice and quality. Hafferty suggested that the United States could create a series of town hall meetings to engage the public on matters of professionalism. But, he asked, who would represent health and health care at these meetings?
The question raised by Hafferty regarding who should represent health and health care in conversations with the public was partially addressed by workshop planning committee co-chair Cynthia Belar from the American Psychological Association. In her opening remarks, Belar described the different ways in which disciplines can work together to address problems. Some of these approaches are better than others in capturing the more unified voice that would be needed for a single representation of health and health care at a town hall meeting. Described more fully in Part II of this report, these approaches go from one professional working alone (unidisciplinary), to multiple professions working individually on an issue or with a patient (multidisciplinary), to multiple professions working together toward a common goal (interdisciplinary or interprofessional), to multiple professions working together under a shared model with a common language (transdisciplinary).
The increased focus on collaborative care in health to reduce errors and improve quality has been accompanied by an increased need to build linkages across the health professions. According to Belar, some warn that with the increased complexity of care, siloed approaches to professionalism may actually undermine safety and quality as well as patient-, family-, and community-centeredness. With this understanding, efforts have been made to conceptualize professionalism not within the silos of an individual profession, but in terms of a set of behaviors and attributes that are uniquely relevant to collaborations across professions. This is known as “interprofessional professionalism” (see Chapter 4 for Jody Frost’s description and definition of interprofessional professionalism). The cooperation and communication inherent in interprofessional professionalism cut across the professional boundaries to link common behaviors and attributes but does not jointly link the social contracts. With interprofessional professionalism, each profession has a separate contract with society.
In contrast, transdisciplinary professionalism leads to a social contract that is shared by all the professions through a unifying set of beliefs and behaviors that are professed to the public. This is not the same as transdisciplinary practice, which would indicate a blurring of boundaries with respect to skills, competencies, and practice. As workshop speaker Sylvia Cruess explained in her presentation on the social contract, there are similarities and differences among the health professions’ social contracts, but the underlying principles of all health care social contracts are the same. According to Belar, these shared principles would be the foundation on which to build the shared contract with society.
In their paper (found in Part II of this report), Richard Cruess and Sylvia Cruess, who are physicians from the Centre for Medical Education at McGill University in Canada, explain their perspective on the social contract. They say that within health care, the social contract lays out expectations between society and the health professions—expectations that are constantly evolving as societies and cultures change. The assumption is that each side will live up to the terms of the contract as they are redefined. When one party fails to meet their expectations, there is a loss of trust. For health professionals, this loss of public trust results in decreased autonomy for the profession, as was exemplified in the United Kingdom’s Bristol case. In this case, public trust of pediatric cardiac surgeons collapsed following the exposure of exceptionally high child mortality rates at the Bristol Royal Infirmary—about two times the national average in 5 out of 7 years between 1988 and 1994 (Kennedy, 2001). This revelation led to government reforms that stripped the medical profession of its privilege to self-regulate. It occurred, said Richard Cruess, because the medical profession failed to meet the legitimate public expectations in a domain which was under its jurisdiction.
In the reverse situation—when society fails to meet expectations of the health professionals—there is a similar loss of trust, although the outcome is less clear. Oftentimes health professionals experience diminished job satisfaction when they feel overburdened by paperwork, excessive regulation, and decreased reimbursement. In these instances, health professions can begin to view their work as a job rather than a “calling.”
Elements of social contracts in the United States and Canada have evolved over the last 50 years in parallel with changing societal norms and values. These changes include greater patient autonomy, calls for more transparency in the work of health professionals, and an emphasis on collaborative care. In addition, the financial rewards, particularly in medicine, have increased, leading to more conflicts of interest as providers of care balance patients’ needs with potential financial gains. These changes have altered expectations of both society and the professions. Still, the United States would negotiate a very different contract than Canada because of the fundamental differences in the way these societies are oriented. The United States emphasizes individualism and individual performance, whereas Canadians stress collective responsibility. Thus, in Canada, the social contract is dominated by the state, whereas in the United States the corporate sector strongly influences elements of health and health care with additional input from the health professional associations’ lobbyists. According to Forum co-chair Jordan Cohen of George Washington University, until American culture recognizes the limitations of individualism, the current heterogeneous chaotic
system is probably going to remain. He later commented, however, that one way to try to develop a coherent dialogue with “society” could be to engage social media. It would be an interesting experiment to try, he added.
Greater patient engagement in the U.S. health care system is being called for by society and, according to Forum member Liana Orsolini, is being required by law through the new Patient Protection and Affordable Care Act. In addition, Barbara Kornblau remarked that federally qualified health centers must have at least 51 percent of their board members come from the community they serve and that board members must include patients. Moreover, not-for-profit hospitals are required to conduct a community health needs assessment to maintain their tax-exempt status under the IRS. Patients are not an afterthought, she said—they they are part of everything health professionals do. Educating the next generation of health professionals with this patient-centered focus would better prepare them for work in clinical and community health settings.
Okun also weighed in from a patient perspective on the notion of greater engagement of community members and users of the health system. She said that a shared social contract would not be embraced by the general public unless the message was easily understood and could be conveyed through, for example, a public service announcement. Workshop speaker Jody Frost, who leads the Interprofessional Professionalism Collaborative (IPC), agreed with Okun that interprofessional or transdisciplinary professionalism is a complicated topic that would need to be explained in a language that makes sense to the public. This may be a challenge, however, given that it took more than 2 years for their IPC health professionals representing 14 different professions to agree upon a definition of interprofessional professionalism. Much of the time was spent trying to understand other professions’ terms and uses of the language to describe a situation. Although the process was arduous, the exercise of finding a common language provided a unique opportunity that underscored the importance of communication, collaboration, and negotiation across professional boundaries. The work of the IPC focused on professionalism as a resource for promoting skills, values, and organizational structures that facilitate interprofessional care. Likewise, the professionals’ joint efforts on addressing competencies that cut across multiple professions promote effective interactions and collaborations that could bridge academic and practice settings and could be modeled and promoted in both environments.
Questions raised by speaker Patricia Werhane (described more fully in Chapter 3 of this report) ask how different health and health care “tribes” might come together to talk and to build a transdisciplinary professional-
ism. In her view, there would have to be a central base that enables effective communication across communities and organizations. Without a common language, she said, silos will persist where instead of talking to each other, various stakeholders are talking at each other. Werhane emphasized listening as the most important component of communication that could be improved among all parties involved. Listen to the narratives of different people, she said. Translate what everyone says and come to consensus over the basic values. No doubt there will be different viewpoints on how the values are prioritized, which is alright, she said, as long as everyone involved respects this difference of prioritization.
In summary, the individual speakers’ reasons to focus on a shared social contract are
- to improve communication and collaboration among health professionals (described by Frost and Werhane) that improve safety and quality of care (pointed out by Belar);
- to respond to the desires of the public to participate actively in deciding the future of their personal health and to influence how health care could be structured (mentioned by Kornblau, Okun, Orsolini, and Weeks);
- to avoid the impingement of the political process on health care (noted by Thibault); and
- to create a health care system in which learners and practitioners across the professions work collaboratively with patients, families, and communities and with each other to accomplish the Triple Aim (described by Cox).
And the reasons professionalism should be the tie that binds health professions to each other and to the public are
- to strengthen the trust among the health professionals and between the health professionals and the public (emphasized by the Cruesses, Hafferty, and Wynia); and
- to hold health professionals accountable to professional standards (stated by Hafferty and Wynia).
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