The University of Kansas School of Medicine, under the guidance of Executive Dean Barbara Atkinson, MD, and Robert Klein, PhD, Associate Dean for Professional Development and Faculty Affairs, have 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.
The environment in which the training and education of medical professionals takes place serves in many ways as the incubator of professionalism. Standards for professional and ethical conduct are beginning to be addressed within the formal curriculum of medical schools but must be re-enforced by example of the faculty and staff. Factors which aid and obstruct professionalism coexist to a greater degree in this environment.
Positive factors - The profession of medicine, and academic medicine in particular, is recognized by society for its service to societal goals, its commitment to healing the sick and the advancement of knowledge. Professionalism is enhanced by the high standards of the educational environment and its dedication to collegiality, support of formal mentoring programs, and formal recognition of faculty, housestaff and student role models.
Negative factors - The increasing expectations in the face of decreasing resources confronting medical professionals, particularly in the academic environment, can threaten professionalism. The list of challenges to professionalism is extensive, but most prominent are stress and overwork; chronic fatigue and sleep deprivation; lack of confidence, self-esteem and experience due to inadequate supervision; tension with other professionals; arrogant and demeaning behavior; exposure to health risks; decreasing revenues despite increasing workloads and not least family obligations. The academic environment may never be able to eliminate all of these barriers, but by their recognition, efforts may be successful in circumventing them and their potential damage.
Medical professionals, by definition, are expected to demonstrate professionalism. Recognizing that the focus of the Professionalism Initiative document is to define professionalism, the following descriptors serve only as a baseline to identify behavior which is unacceptable for meeting the standards of professionalism inherent in being a medical professional.
Unmet professional responsibility - This includes requiring continual reminders about responsibilities to patients, to the institution and to other health care professionals; unreliability in completing tasks, misrepresenting or falsifying actions and/or information. Accepting but not fulfilling responsibilities on committees, teaching, and mentoring are unfortunately common examples.
Lack of effort toward self-improvement and adaptability - Medicine and academic science demand continuous personal growth and improvement. Resistance or defensiveness in accepting criticism, remaining unaware of one's own inadequacies, resisting changes, not accepting responsibility for errors or failure, being overly critical, being verbally abusive during times of stress and displaying arrogance are reflections of a poor professional attitude.
Poor interactions with patients and families - A lack of empathy, insensitivity to patients' needs, feelings and wishes or to those of the family, lacking rapport with patients and families, inadequate commitment to honoring the wishes of the patient are symptoms of poor professionalism, not mitigated by skills and good outcomes.
Inappropriate relationships with health care professionals - The inability to function within a team, lacking sensitivity to the needs, feelings and wishes of colleagues, harassment and discrimination are major hindrances to creating a healthy and satisfying professional environment.
The values of professionalism as described above combine to create a milieu which enhances patient care, a continued commitment to scholarship and high standards of research, the health care needs of society, and the ability of all colleagues in the health professions to interact and carry out their responsibilities optimally. Medical knowledge is simply not enough. Optimal medical and scientific practice also require good judgment, respect for the art of medicine and the values learned from mentors and role models and respect toward patients and families. For the medical profession to retain its hard-earned prestige well into the 21st century, a renewed effort toward the revitalization of professionalism is essential.
All entering Medical Students at the University of Kansas School of Medicine take an oath of commitment during the "White Coat Ceremony", at the onset of Medical School, the very beginning of their medical careers. This oath summarizes the essence of professionalism: we encourage all medical professionals to honor the guidelines set forth in this document.
View the 2007 White Coat Ceremony video clip.
View the 2006 White Coat Ceremony video clip.
White-Coat Ceremony
The University of Kansas School of Medicine
As I begin my training as a physician at the University of Kansas School of Medicine I pledge the following:
I promise to earn the trust and respect of my teachers and to return them in kind,
for only through mutual trust and respect can we learn the skills required of a physician.
I will accept responsibility for those medical duties that I feel prepared for;
I will hold back when I am not prepared;
and I will seek the experience that I need to prepare myself.
I will strive to preserve the dignity, the humanity and the privacy of all my patients,
and through my openness and kindness I will seek to earn their trust in turn.
I will treat my patients and my colleagues as my fellow beings and never discriminate against them for their differences;
and I will ask that they do the same for me.
I will value the knowledge, and the wisdom of the physicians who have preceded me;
I will add to this legacy what I am able, and I will pass it on to those who come after me.
As my skills and my knowledge grow so too will my awareness of my limitations and my errors;
I will strive to recognize and understand my weaknesses;
And I promise never to put an end to my studying and learning that I might improve myself every day of my practice, in all the years to come.
In 2004, on the occasion of the admission of the 100th class to the School of Medicine, the Honor Council introduced the Book of Honor. Each first year student signed the book as a celebration of the school's trusting community and its foundation in the Honor Code. The book stands as a testament to the special environment we take part in, an environment of integrity and character grounded in the Honor Code. The signing of the Honor Book serves as a symbol and a celebration of the Honor Code, and as affirmation of one's belief in a community guided by the principles of professionalism.
The Knowledge is Healing Program honors donors to the KUMC Willed Body Program. Each fall students and School of Medicine faculty participate and express their appreciation and gratitude to the donor families.
The Transition Ceremony at the University of Kansas, School of Medicine is a rite of passage which signifies that students have attained the knowledge, skills, attitudes, and behaviors required to begin to care for patients. The Transition Ceremony is held as Medical Students complete their second year of studies and prepares them to begin their role as student clinicians. Making the transition from the first two pre-clinical years of medical school to the clinical rotations is a critical transition in a medical student’s life. It is a landmark in the educational career of each student and celebrates the students' readiness to use their basic science and clinical science skills in the care of patients on their clerkships.
The event celebrates the success of our students, alleviates some of the anxiety associated with the transition from an emphasis on classroom learning to the clinical rotations, and reviews the critical issues of professionalism, HIPAA, confidentiality, and the importance of humanism and compassion in patient care. An important part of the event is discussions with fourth year students in which senior students mentor entering third year students and provide practical information on how to survive on patient care units and how to provide optimal care to patients.
Project Professionalism - ABIM Committee on Evaluation of Clinical Competence and Clinical Competence and Communications Programs. Fifth printing 1999. ©American Board of Internal Medicine, 510 Walnut Street, Suite 170, Philadelphia, Pennsylvania, 19106-3699
Silver HK: Medical Students and Medical School: JAMA, 247(3): 309-310, 1982
Rosenberg DA, Silver HK: Medical Student Abuse, JAMA, 251(6):739-742, 1984
The Advisory Group on Professionalism at The University of Kansas School of Medicine, (August 2001) is composed of:
©
The University of Kansas Medical Center