Chapter Outline
Understanding the Importance of Professionalism
Elements of the Physician Assistant Competency of Professionalism
Behavior Toward other Professionals
Responsiveness to Patient Needs and the Needs of Society
Accountability to Patients, Society, and the Profession
Commitment to Excellence and Professional Development
Demonstrate Self-Reflection, Critical Curiosity, and Initiative
Know Professional and Personal Limitations
Acknowledgment
The authors recognize the contributions of the late Paul Robinson to the initial version of this chapter.
Trust between the patient and clinician is central to the therapeutic relationship. Without this requisite level of trust, patients will not reveal information about themselves nor will they follow treatment recommendations. Trust builds from the belief that the clinician possesses expert knowledge (that will be applied to the benefit of individuals and society) and will avoid self-interest while acting on behalf of those served. Growing from that public trust, a level of autonomy to self-regulate is afforded to medicine. However, the autonomy extended to the profession must be in balance with medicine’s priority of advancing the public welfare. This combination of commitment to service, the possession of a specialized body of knowledge, and the ability to self-regulate are the key components of professionalism.
Some have questioned whether the shared body of medical knowledge and participation in a supervised practice qualifies physician assistants (PAs) for consideration as professionals. Others have clearly demonstrated that PAs should be considered as professionals. Soon after PAs began to practice, Tworek applied the standards of professionalism to PAs and concluded that those in the occupation had become professionalized. Picking up that distinction later, Gianola concluded that the evolution to the modern role of PAs has resulted in our becoming a full profession.
Thus, when the four leading PA organizations adopted the Competencies for the Physician Assistant Profession, they followed the lead of our physician colleagues and included professionalism as one of the six “general competencies.”
Recognition as a profession brings with it opportunities and responsibilities. In recent years, a variety of pressures resulting from changes in the health care delivery system have made it more difficult for medicine to live up to those responsibilities. As a result, the professional tenets of medicine have been called into question. A return to professionalism depends on clearly defining the term and identifying ways to foster and assess this competency. Lessons for PAs can be learned from the physician experience.
Understanding the Importance of Professionalism
Early in the history of medicine, the promises of the Hippocratic Oath grounded medicine and instilled in physicians a strong commitment to service. As attention later shifted to the science of medicine, the specialized knowledge associated with medicine became the central focus. Consequently, the understanding of and commitment to the service responsibilities diminished with significant consequences to the overall impression of physicians as professionals.
Compounding the consequences of that shift in focus, the business aspects of medicine also began to impact medicine’s image. Some have suggested that medicine used its significant knowledge base to find ways to manipulate the market to increase the demand for services, dramatically increasing costs for health care. In this scenario, physicians were thought to have put their own economic interests above the needs of patients and society—an action that goes against the precepts of professionalism.
As health care costs escalated, government and insurer involvement in health care increased with resulting tighter controls over medicine. Precertification and utilization review efforts by the government and insurers reduced the ability of health professionals to make autonomous medical decisions. Credentialing efforts by insurers that evaluated the performance of health professionals adversely impacted self-regulation efforts. As constraints over decision making and self-regulation have increased, the influence of medicine has decreased, and the image of physicians as professionals has been affected.
With changes in the health care system challenging the professionalism associated with medicine, today’s clinicians must understand what it means to be a professional and must be willing to abide by the expectations that result. However, questions have been raised concerning the uniform existence of that understanding of and commitment to professionalism. Despite a commitment to teaching clinicians in training about professionalism, these efforts have been hampered by a lack of universal agreement on the definition of professionalism.
The goal of teaching professionalism is to assist students with developing a professional identity. The process requires a dual focus on exploring through explicit curricula the definition of professionalism and the traits associated with professional behavior as well as teaching students to participate in experiential learning activities that include a component of reflection on professional behaviors.
After 2 years of observations during medical school interviews, as well as class discussions and exercises, Hafferty voiced concerns about the existence of the core values central to professionalism. He noted that medical students might feel less of an obligation to be bound by the expectations set forth in a code of ethics. He also suggested that they might not feel a need to ascribe to the values outlined in professional oaths that are generally part of most medical school graduations. He also observed that even White Coat Ceremonies, despite all their symbolism, seem to fail to remind medical students of the values and obligations of professionals.
Reinforcing the tenets of professionalism during medical education is critical because there is a strong link between what is learned about professionalism in medical school and what one exhibits later in practice. In a landmark study, Papadakis and colleagues at the University of California–San Francisco School of Medicine conducted a case-control study that compared medical school graduates who were disciplined by the Medical Board of California with control participants matched by medical school graduation year and specialty. Of the graduate physicians disciplined by the Medical Board, 95% experienced a violation associated with a professionalism lapse. When compared with control participants, the physicians who experienced professionalism lapses during medical school were twice as likely to later experience an adverse medical board action while in practice. Recognizing the importance of responding to those early lapses, many strategies for dealing with professionalism lapses have evolved, including remediation assignments, remediation contracts, professionalism mentoring, stress management or mental health intervention, and community service.
Elements of the Physician Assistant Competency of Professionalism
Recent efforts to define professionalism have shifted from the sociologic definition to a focus on values associated with professionals. The most commonly appearing elements identified in a recent literature search included a number of ill-defined concepts, such as “altruism, accountability, respect, integrity, ethic[ism], lifelong learn[ing], honesty, compassion, excellence, self-regulating, service,” that provide little guidance to clinicians who aspire to professionalism.
Van de Camp and colleagues provide an understandable overarching structure that brings together key values with service delivery concepts. The latest model includes four areas of professional behavior: toward the patient, toward other professionals, toward the public, and toward oneself. The authors note that their behavior-based focus intentionally avoided the use of vaguely understood elements that have been associated with professionalism. Another improvement in the recent model is that it included elements that grew from the models of competency developed by the Accreditation Council on Graduate Medical Education in conjunction with the American Board of Medical Specialties.
The Competencies for the PA Profession incorporate nearly all of the top 10 constituent elements of professionalism mentioned most frequently in the literature and fit well into the structure outlined by Van de Camp and colleagues ( Box 33-1 ). In addition, a number of other, less frequently mentioned elements are included.
Professional Behavior Toward the Patient
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PAs must prioritize the interests of those being served above their own.
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PAs must demonstrate a high level of ethical practice.
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PAs must demonstrate a high level of sensitivity and responsiveness to a diverse patient population, including culture, age, gender, and disabilities.
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PAs are expected to demonstrate respect, compassion, and integrity.
Professional Behavior Toward Other Professionals
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PAs are expected to demonstrate professional relationships with physician supervisors and other health care providers.
Professional Behavior Toward the Public
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PAs are expected to demonstrate responsiveness to the needs of patients and society.
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PAs are expected to demonstrate commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices.
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PAs are expected to demonstrate accountability to patients, society, and the profession.
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PAs must demonstrate adherence to legal and regulatory requirements, including the appropriate role of the PA.
Professional Behavior Toward Oneself
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PAs are expected to demonstrate commitment to excellence and ongoing professional development.
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PAs must know their professional and personal limitations.
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PAs must practice without impairment from substance abuse, cognitive deficiency, or mental illness.
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PAs are expected to demonstrate self-reflection, critical curiosity, and initiative.
Behavior Toward the Patient
Values: Respect, Compassion, and Integrity
Respect, compassion, and integrity are the hallmarks of being an admirable PA. Professionalism first and foremost involves respect for one’s patients, meeting them as equals no matter the situation. It requires a commitment to truly caring for and about another human being. Respect for others (e.g., the patient’s families, coworkers, physicians, nurses, residents), as stated in the American Board of Internal Medicine’s Medical Professionalism Project, is the essence of humanism, and humanism is central to professionalism and fundamental to the collegiality of medical providers. Compassion, similar to respect, embodies the ideals of a caring practitioner. Similar to the Norman Rockwell pictures of the kindly physician caring for the young child and demonstrating concern for the parents, we are charged with providing that same compassion in all of our interactions with our patients and others. We must treat each person as an individual, not allowing lifestyles, beliefs, idiosyncrasies, or family systems to influence or shape our respect or compassion. This unconditional compassion for patients serves as the foundation for another key element needed in patient care, empathy. Compassion and empathy are essential elements of a positive relationship with patients. Faced with a compassionate and empathetic clinician, patients are more likely to follow treatment plans and to be satisfied with the care received.
Integrity is the base from which respect and compassion grow. The definition of integrity is to be forthcoming with information and to not withhold or use that information for power. Integrity requires that we admit to our errors; use resources appropriately; and exercise discretion, especially in areas of confidentiality. In addition to these three, there are other humanistic values that foster positive relationships with patients. These include accountability, taking responsibility, punctuality, being organized, politeness, courtesy, patience, positive demeanor, and maintaining professional boundaries. These qualities demonstrate our respect and compassion for ourselves, our patients, their families, and our fellow health care providers.
Primacy of Patient Welfare
Altruism is central to professionalism, but the concept is both controversial and difficult to understand. Definitions of altruism include a focus on actions that benefit others and are voluntary without promise of external rewards.
Arguing that the actions of health professionals are not altruistic, critics note that health professionals experience both external and internal rewards from their efforts. They note that the knowledge and skill applied by health professionals often bring wealth, status, and power to those individuals. The critics also point to the internal rewards gained (the gratitude from patients served, satisfaction from being involved in the lives of those patients, feeling good about growing knowledge and skills, and the satisfaction of curiosity, the acquisition of wisdom, and attainment of the respect of colleagues for those achievements). Those who believe the actions of health professionals are indeed altruistic counter that although those rewards do accrue, they follow the service, are secondary to them, and are not conditions that are set before services are delivered. Those proponents also remind us that health professionals attempt to deliver the highest quality service even when no reward is anticipated.
It seems logical then that gaining rewards through service does not invalidate altruism for health professionals. However, what is equally clear is that clinicians must avoid conflicts of interest that result from financial or organizational arrangements. For example, referral decisions cannot be influenced by managed care agreements that return bonuses when visits to specialists fall below projections.
In addition to meeting the needs of patients, altruism means advocating for patients. Some have even suggested that the PA acronym should stand for “patient advocate.” In this environment of preauthorization before the use of diagnostic studies or treatment modalities, it often takes a lot of effort to assist patients in understanding the system and overcoming the obstacles it presents. Another dimension of altruism relates to making yourself available to patients even if it means your personal plans might be affected. Wilkinson believed that the responsibilities of meeting such an expectation were lost in the broader term of altruism, which led this dimension to be characterized as “balance availability to others with care for oneself.”
Ethical Principles and Practice
Ethical components are evident in approximately 25% of all clinical decisions that occur in the inpatient setting. In outpatient settings, estimates of the involvement of ethical components have ranged from 5% to 30%. The ethical components result from value judgments regarding the consequences of decisions made by the decision maker and fulfillment of the rights of others. Usually, the ethical aspect is not explicitly considered because it is a garden-variety ethical conflict for which universal agreement on the resolution exists. To develop skills in applying ethical principles, PAs should make a habit of recognizing the presence of ethical dilemmas that surface even when they are a minor component of the decision making (see Chapter 34 for further exploration of ethics).
Sensitivity and Responsiveness to a Diverse Population
The U.S. Census Bureau highlights dramatic changes in our country’s ethnic makeup over the next 45 years. For example, the portion of the population identified on the census as “White alone, not Hispanic” is expected to drop from the current level of 63% to 44% by 2060. As a result of these changes, health care professionals will be practicing in an increasingly diverse cultural environment and will be called on to provide services to individuals from cultures other than their own. In addition, increasing attention is focused on existing racial/ethnic disparities in health care delivery that are affecting outcomes.
The success of the health care encounter depends primarily on accurate and effective communication between patient and clinician. Failures of communication can result from differences in language, culture, and perspectives regarding health. Communication between patient and clinician affects “patient satisfaction, adherence to medical instructions, and health outcomes.” It is clear that the education of health professionals must address cultural competence (see Chapter 38 for further exploration of health disparities).
Behavior Toward other Professionals
Professional Relationships With Physicians and Other Health Care Providers
The physician–PA team relationship is fundamental to the PA profession and enhances the delivery of high-quality health care. In its 1998 report, the Pew Health Professions Commission highlighted the relationship between PAs and physicians, noting, “The frequent consultation, referral, and review of PA practice by the supervising physician is one of the strengths of the PA profession. The characteristics of this relationship are also considered to be the elements of professional relationships in any well-designed health system.”
Team practice is an essential component of the effort to improve the quality of health care. The Institute of Medicine (IOM) has called for a campaign of “Cooperation among Clinicians.” Effective teams require that team members work together with clear goals and expectations. Leadership, communication, and conflict management are key to that clarity. Matching the roles and training of team members to the tasks at hand will promote cohesiveness in interdependent teams. (See Chapter 7 for further exploration of the physician–PA relationship.) Mounting consensus exists that a failure of teams to establish a culture of professionalism can lead to disruptive behaviors that can result in medical errors adversely impacting patient safety.
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