The University of Kansas School of Medicine, under the guidance of former Executive Dean Barbara Atkinson, MD, Robert Klein, PhD, and Mark Meyer, MD, has undertaken a "Professionalism Initiative," conceived to raise awareness of professionalism within the KU medical community as a whole, from the first day of medical school, throughout one's career in the health sciences. As part of the KU - SOM initiative, this document is intended to establish guidelines for professional attitudes and behaviors for all medical professionals, regardless of position or seniority in the medical community. Thus students, residents, fellows and faculty, both in the basic and clinical sciences, are all invested in the goals set forth in this document. Although many issues of professionalism are directly patient-related, the tenets of professionalism hold true for all. We thank the American Board of Internal Medicine for their permission to use portions of their "Project Professionalism" in these writings. As stated in their document, "The ABIM presents guidelines for ideal behavior while recognizing that the ideal is something we endeavor to achieve but do not always reach."
The medical profession has traditionally enjoyed a highly respected position in society. This position is threatened not only by the overt unprofessional behavior and attitudes of some individuals, but also by ongoing changes in the health care system. Rapid advances in medical knowledge and technology are putting increased pressure on medical professionals to process huge quantities of information, with requirements for continuous learning and updating knowledge and skills which are time consuming but essential. Changes in the health care system and reimbursement have created a competitive environment with new associated stress factors. All these changes to the venerated status quo of the medical profession have created an environment that may have a negative impact on professional behavior. These new demands and the expectations of the public and the medical community have altered the image of the medical professional: Professionalism, once so ingrained in that image, must be preserved and enhanced.
While knowledge and technical skills are crucial in medicine and science, the manner in which they are used is equally important. In addition to competence in their field, all medical professionals must strive to retain those humanistic qualities - integrity, respect, and compassion - that constitute the essence of professionalism. The core of professionalism thus includes altruism, accountability, excellence, duty, service, honor, integrity, and respect for others. These qualities apply to all aspects of the professional's life, including the relationships between medical professionals, between specialties, and between professional organizations.
Medical professionals should always strive to reach the highest standards of excellence in their clinical practice and in the generation and dissemination of knowledge. With the external pressures imposed on it, the medical profession is facing a critical moment in time: its ability to retain its leadership role in society depends largely on its willingness to abide by a standard of excellence and behavior that requires a commitment by each individual to professional ethics and high standards of moral and ethical behavior. As members of the academic medical community, we are obligated to set an example for both our students and community peers.
Altruism is the essence of professionalism. The best interest of others including patients, colleagues, mentors and trainees, rather than self-interest, is the rule.
Accountability. Medical professionals are accountable to their patients, colleagues and society as a whole for the health needs of the public and the advancement of science. They are accountable to their profession for adhering to medicine's time-honored ethical principles.
Excellence is a conscientious effort to exceed expectations and to make a commitment to life-long learning. Commitment to excellence is an acknowledged goal for all medical professionals and should begin on the first day of Medical School.
Duty is the free acceptance of a commitment to service. This commitment entails being available and responsive when needed, accepting inconvenience to meet the needs of patients, advocating the best possible care regardless of ability to pay, seeking active roles in teaching and professional organizations, and volunteering skills and expertise for the welfare of the community. Medical professionals, therefore, should be encouraged to participate in professional organizations, community programs and institutional committees.
Honor and integrity are the consistent regard for the highest standards of behavior and the refusal to violate personal and professional codes. They imply being fair and truthful, keeping one's word and meeting commitments. They also require recognition of possible conflicts of interest and avoidance of relationships that allow personal gain to supersede the best interest of the profession.
Respect for others, including patients and their families and other professional colleagues is the essence of humanism, which is both central to professionalism, and fundamental to enhancing collegiality among medical professionals.
A personal commitment to life-long learning is essential to assure the highest quality of medical care and scientific progress and stay abreast with the constant changes in scientific information, technology and tools. This commitment must be accepted from the very beginning, and must be honored throughout one's life as a physician and scientist.
Challenges to professionalism - Issues that challenge the previously identified elements of professionalism include:
Abuse of Power - The respect enjoyed by scientists and physicians results in significant influence to medical professionals. When used appropriately, this authority can accomplish enormous good and can set the standard for behavior that is in society's best interest. When abused, this power can establish a norm for deviant behavior in many settings, including the interactions with patients, colleagues and trainees. The respect and trust of patients and professional colleagues are to be cherished, not abused. Abuse of power can take many forms: not allowing patients to contribute to decision-making in their own care; allowing financial and academic competitiveness to affect judgment, including the honest evaluation of peers and trainees; using the work of junior colleagues to enhance one's academic career; deliberately retarding the academic development of junior colleagues; the unwarranted undermining of junior colleagues; medical student abuse and abusive behavior toward colleagues.
Discrimination, bias and harassment - While these concepts are not unique to medicine and have been formally regulated by state and federal government agencies, the profession has a particular responsibility to ensure an environment in which all colleagues enjoy equal respect and where they can advance to their full potential, irrespective of disability, ethnicity, gender, race, or religion. Inequities that impair the professional and personal development of any individual cannot be allowed. Attitudes that may have been tolerated in the past are no longer acceptable. Even seemingly minor events, such as ethnic or gender-related jokes, may create a hostile environment which negates the basic principles of humanism in the medical profession. Medical student abuse is a problem formally recognized only in the early 1980's. It has been well described in the medical literature. Such behavior, whether directed toward medical students or professional colleagues, is unacceptable at the University of Kansas School of Medicine.
Breach of confidentiality - This can affect both physicians and basic scientists, in different but equally important ways. Patients trust that conversations and information obtained as part of the patient/physician relationship will be held in strictest confidence. This trust is not to be violated. Casual comments or discussion of patients in public (e.g. a crowded elevator) are breaches of confidentiality and are unacceptable. Disclosures are allowed only in the course of patient care, in the patient's best interest or when disclosure is a legal requirement. Likewise, confidential communications of scientific data, manuscripts and intellectual property should not be used for personal gain or divulged publicly.
Arrogance - Arrogance is an offensive display of superiority and self-importance. Unfortunately, by their nature, medicine and science can foster arrogance in the medical professional. The training is long and arduous with a seemingly endless mass of knowledge, which at times feels impossible to master. Students of science are thus prone to assume an air of self-importance, having survived such an initiation. Arrogance destroys professionalism by reducing the individual's ability to think for himself or herself, making empathy for others difficult and removing the checks and balances of self-doubt.
Greed - Greed can be defined as the inappropriate aspiration of fame, power or money. Greed impairs altruism, caring, generosity and integrity and therefore negates professionalism. In order to avoid greed, it must be recognized as a potential component of our professional lives, and the medical professional must constantly re-evaluate his/her motives to ensure that no actions are dictated solely by personal gain.
Misrepresentation - In the context of unprofessional behavior, misrepresentation consists of lying and fraud. Lying requires a conscious effort to not tell the truth. It is not simply relating an untruth, or any erroneous statement could be construed as lying. Lying about class assignments or experiments, or misrepresenting patient related data because of failure to complete an assignment or find the correct information, are serious breaches in professionalism, which raise the specter of overall dishonesty in the individual responsible. Fraud is a conscious misrepresentation of information with the intent to mislead. It can occur in both medical practice and research. Lying about the services performed in order to obtain reimbursement and misrepresentation of experimental data are examples of fraud.
Impairment - Medical professionals who are impaired in their ability to carry out their professional obligations must relinquish their responsibilities, particularly when caring for patients. Professional colleagues, likewise, have a duty to assure that this standard is maintained. Impaired cognitive abilities and judgement due to illness are no less common among medical professionals than among the public at large. Substance abuse may be more prevalent among physicians because of the physician's relatively easy access to controlled substances and because of high levels of occupation-related stress. While severe impairment may be easy to recognize, marginal impairment may not be readily detectable and doubt may exist about whether it is even present.
Reluctance to draw attention to an impaired or potentially impaired colleague is a significant problem associated with this aspect of medical professionalism. Rationalizations that inhibit prompt and appropriate action are common, but such inaction in dealing with an impaired colleague is a failure of professional obligation.
Lack of Conscientiousness - Lack of conscientiousness is a failure to fulfill responsibilities, and is incompatible with the essence of professionalism. Doing only the minimum, being "too busy" to commit the time and effort required for teaching or service commitments, delegating the care of patients to unsupervised trainees, not participating or contributing to committee meetings exemplify a lack of conscientiousness and a deviation from expected standards of professionalism.
Conflicts of Interest - Recognition and avoidance of conflicts of interest represent a core issue of professionalism. The medical professional must avoid situations in which the interest of the physician is placed above that of the patient, or where the scientific process is affected by other interests. Medical professionals must be trained to recognize, understand and avoid potential conflicts of interest in medicine and science. Conflicts of interest include self-referral, interpretation of data based on influence from pharmaceutical companies and the acceptance of gifts. In this regard, organizations such as the American Medical Association have indicated in their policy statements that personal acceptance of substantial gifts or subsidies from manufacturers of drugs and devices that are being prescribed or used by the medical professional is considered inappropriate professional behavior and is strongly discouraged.