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1 - The Cognitive Base of Professionalism

Published online by Cambridge University Press:  01 September 2009

Richard L. Cruess
McGill University, Montréal
Sylvia R. Cruess
McGill University, Montréal
Yvonne Steinert
McGill University, Montréal
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As physicians, patients, and members of the general public have come to believe that medicine's professionalism is under threat, virtually all have concluded that any action to address the issue must include a major educational initiative aimed at ensuring that physicians both understand the nature of contemporary medical professionalism and live according to its precepts. As a result, there is now a substantial literature containing a variety of opinions as to how this can be best accomplished. One of the common themes that has emerged is that the approaches of the past are no longer sufficient.

For centuries, professionalism as a subject was not addressed directly. There were no courses on professionalism and it was not included in the standard medical curriculum. This is not because it was deemed unimportant. The Hippocratic Oath, subsequent codes of ethics, and a host of writers including Osler addressed the values and beliefs of the medical profession, often linking them to the word professionalism. However, it was assumed that these values and beliefs, which are the foundation of the profession, would be acquired during the process of socialization of students as they “acquire the complex ensemble of analytic thinking, skillful practice, and wise judgment.” The learning of professionalism depended heavily upon role models where students, residents, and indeed practicing physicians patterned their behavior on “individuals admired for their ways of being and acting as professionals.” While this method remains essential and powerful, by itself it is no longer felt to be adequate.

Publisher: Cambridge University Press
Print publication year: 2008

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Cruess, RL, Cruess, SR. Teaching medicine as a profession in the service of healing. Acad Med. 1997; 72: 941–952.CrossRefGoogle ScholarPubMed
Cruess, SR, Cruess, RL. Professionalism must be taught. BMJ. 1997; 315: 1674–1677.CrossRefGoogle ScholarPubMed
Freidson, E. Professionalism: The Third Logic. Chicago, IL: University of Chicago Press; 2001.Google Scholar
Inui, TS. A Flag in the Wind: Educating for Professionalism in Medicine. Association of American Medical Colleges. Washington, DC: Association of American Medical Colleges; 2003.Google Scholar
Sullivan, W. Work and Integrity: The Crisis and Promise of Professionalism in North America. 2nd ed. San Francisco, CA: Jossey-Bass; 2005.Google Scholar
Cohen, JJ. Professionalism in medical education, an American perspective: from evidence to accountability. Med Educ. 2006; 40: 607–617.CrossRefGoogle ScholarPubMed
Cote, L, Leclere, H. How clinical teachers perceive the doctor-patient relationship and themselves as role models. Acad Med. 2000; 75: 1117–1124.CrossRefGoogle ScholarPubMed
Hensel, WA, Dickey, NW. Teaching professionalism: passing the torch. Acad Med. 1998; 73: 865–870.CrossRefGoogle ScholarPubMed
Ludmerer, KM. Instilling professionalism in medical education. JAMA. 1999; 282: 881–882.CrossRefGoogle ScholarPubMed
Gordon, J. Fostering students' personal and professional development in medicine: a new framework for PPD. Med Educ. 2003; 37: 341–349.CrossRefGoogle ScholarPubMed
Bataldan, P, Leach, D, Swing, S, Dreyfus, H, Dreyfus, S. General competencies and accreditation in graduate medical education. Health Aff. 2002; 21: 103–110.CrossRefGoogle Scholar
,Royal College of Physicians and Surgeons of Canada. The CanMEDS Roles Framework. 2005. Accessed February 5, 2007.
,General Medical Council. Good Medical Practice. London; 2006.
,Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Washington, DC: Liaison Committee on Medical Education; 2007.
Hamilton, JS. Scribonius Largus on the medical profession. Bull Hist Med. 1986; 60: 209–216.Google ScholarPubMed
DeRosa, P. Professionalism and virtues. Clin Orthop Relat Res. 2006; 44: 28–33.Google Scholar
Starr, P. The Social Transformation of American Medicine. New York: Basic Books; 1982.Google Scholar
Hafferty, FW, McKinley, JB. The Changing Medical Profession: An International Perspective. Oxford: Oxford University Press; 1993.Google Scholar
Krause, E. Death of the Guilds: Professions, States and the Advance of Capitalism, 1930 to the Present. New Haven, CT: Yale University Press; 1996.Google Scholar
Sox, HC. The ethical foundations of professionalism: a sociologic history. Chest. 2007; 131: 1532–1540.CrossRefGoogle ScholarPubMed
Cruess, RL, Cruess, SR, Johnston, SE. Professionalism and medicine's social contract. J Bone Joint Surg. 2000; 82A: 1189–1194.CrossRefGoogle Scholar
Cruess, SR. Professionalism and medicine's social contract with society. Clinical Orthop Relat Res. 2006; 449: 170–176.Google ScholarPubMed
Hafferty, FW. Definitions of professionalism: a search for meaning and identity. Clin Orthop Relat Res. 2006; 449: 193–2043.Google ScholarPubMed
Castellani, B, Hafferty, FW. The complexities of medical professionalism: a preliminary investigation. In Wear, D, Aultman, JM (eds.) Professionalism in Medicine: Critical Perspectives. New York: Springer; 2006, 3–25.CrossRefGoogle Scholar
Pellegrino, ED. Medical morality and medical economics. Hastings Cent Rep. 1978; 4: 8–11.CrossRefGoogle Scholar
Coulehan, J. Today's professionalism: engaging the mind but not the heart. Acad Med. 2005; 80: 892–898.CrossRefGoogle Scholar
Huddle, TS. Teaching professionalism: is medical morality a competency?Acad Med. 2005; 80: 885–891.CrossRefGoogle ScholarPubMed
Swick, HM. Towards a normative definition of professionalism. Acad Med. 2000; 75: 612–616.CrossRefGoogle Scholar
,ABIM (American Board of Internal Medicine) Foundation; ACP (American College of Physicians) Foundation; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002; 136: 243–246. Lancet. 359: 520–523.
Barondess, JA. Medicine and professionalism. Arch Int Med. 2003: 163; 145–149.CrossRefGoogle ScholarPubMed
Smith, R. All changed, changed utterly. British medicine will be transformed by the Bristol case. BMJ. 1998; 316: 1917–1918.CrossRefGoogle Scholar
Relman, AS. Medical professionalism in a commercialized health care market. JAMA. 2007; 298: 2668–2670.CrossRefGoogle Scholar
,American Board of Internal Medicine(ABIM). Project Professionalism (revised). Philadelphia, PA. 1999. Publisher ABIM Foundation. Accessed April 28, 2008.
Stern, DT. A framework for measuring professionalism. In Stern, DT (ed.) Measuring Medical Professionalism. New York: Oxford University Press; 2005, 3–15.Google Scholar
,Oxford English Dictionary, 2nd ed. Oxford, UK: Clarendon Press; 1989.
Cruess, SR, Johnston, S, Cruess, RL. Profession: a working definition for medical educators. Teach Learn Med. 2004; 16: 74–76.CrossRefGoogle ScholarPubMed
Cruess, R. Teaching professionalism. Clinical Orthop Relat Res. 2006; 449: 177–185.Google ScholarPubMed
Cruess, R, Cruess, S. Teaching professionalism: general principles. Med Teacher. 2006; 28: 205–208.CrossRefGoogle ScholarPubMed
Boudreau, JD, Cassell, EJ, Fuks, A. A healing curriculum. Med Educ. 2007; 41: 1193–1201.Google ScholarPubMed
Steinert, Y, Cruess, SR, Cruess, RL, Snell, L. Faculty development for teaching and evaluating professionalism: from programme design to curricular change. Med Educ. 2005; 39: 127–136.CrossRefGoogle Scholar
Steinert, Y, Cruess, RL, Cruess, SR, Boudreau, JD, Fuks, A. Faculty development as an instrument of change: a case study on teaching professionalism. Acad Med. 2007; 82: 1057–1064.CrossRefGoogle ScholarPubMed
Dixon, DM, Sweeney, KG, Pereira Gray, DJ. The physician healer: ancient magic or modern science?Brit J Gen Pract 1998; 49: 309–312.Google Scholar
Novak, DH, Epstein, RM, Paulsen, RH. Toward creating physician-healers: fostering medical students' self-awareness, personal growth, and well-being. Acad Med. 1999; 74: 516–520.CrossRefGoogle Scholar
Kearney, M. A Place of Healing: Working with Suffering in Living and Dying. Oxford: Oxford University Press; 2000.Google Scholar
Freidson, E. Professionalism Reborn: Theory, Prophecy, and Policy. Cambridge, UK: Polity Press; 1994.Google Scholar
,Royal College of Physicians of London. Doctors in Society: Medical Professionalism in a Changing World. London: Royal college of Physicians of London; 2005.
Emanuel, EJ, Emanuel, LL. Four models of the patient-physician relationship. JAMA. 1992; 267: 1221–1226.CrossRefGoogle Scholar
Chisholm, A, Cairncross, L, Askham, J. Setting Standards: The Views of Members of the Public and Doctors on the Standards of Care and Practice that They Expect of Doctors. Oxford, UK:Picker Institute Europe; 2006.
Coulter, A. Patient's views of the good doctor. BMJ. 2002; 325: 668–669.CrossRefGoogle Scholar
Emanuel, EJ, Emanuel, LL. What is accountability in health care?Ann Intern Med. 1996; 124: 229–239.CrossRefGoogle ScholarPubMed
Moran, M, Wood, B. States, Regulation and the Medical Profession. Buckingham, UK: Open University Press; 1993.Google Scholar
Broadbent, J, Laughlin, R. “Accounting logic” and controlling professionals. In Broadbent, J, Dietrich, M, Roberts, J (eds.) The End of Professions? The Restructuring of Professional Work. London: Routlegde; 1997, 34–49.Google Scholar
Bloche, MG. Clinical loyalties and the social purposes of medicine. JAMA. 1999; 268: 274–281.Google Scholar
Gruen, RL, Campbell, EG, Blumenthal, D. Public roles of US physicians: community participation, political involvement, and collective advocacy. JAMA. 2006; 296: 2467–2475.CrossRefGoogle ScholarPubMed
,Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
Irvine, D. The Doctor's Tale: Professionalism and Public Trust. Abington, UK.Radcliffe Medical Press; 2003.Google Scholar
Vogel, D. National Styles of Self-regulation. Ithaca, NY: Cornell University Press; 1986.Google Scholar
Rosenbaum, S. The impact of United States law on medicine as a profession. JAMA. 2003; 289: 1546–1566.CrossRefGoogle ScholarPubMed
,Secretary of State for Health. Trust, Assurance, and Safety—The Regulation of Health Professionals in the 21st Century. London: Stationary Office; 2007.
Neufeld, VR, Maudsley, RF, Pickering RJ Turnbull, JM, Weston, WW, Brown, MG, Simpson, JC. Educating future physicians for Ontario. Acad Med. 1998; 73: 1133–1148.CrossRefGoogle ScholarPubMed
Coulter, A. What do patients and the public want from primary care?BMJ. 2005; 331: 1199–1201.CrossRefGoogle ScholarPubMed
Irvine, D. Patients, professionalism, and revalidation. BMJ. 2005; 330: 1265–1268.CrossRefGoogle ScholarPubMed
Dauphinee, WD. Revalidation of doctors in Canada. BMJ. 1999; 319: 1188–1190.CrossRefGoogle Scholar
Norcini, JJ. Recertification in the United States. BMJ. 1999; 319: 1183–1185.CrossRefGoogle ScholarPubMed
Pellegrino, ED. The medical profession as a moral community. Bulletin N.Y. Acad Med. 1990; 66: 221–232.Google ScholarPubMed
Mechanic, D, Schlesinger, M. The impact of managed care on patient's trust in medical care and their physicians. JAMA. 1996; 275: 1693–1697.CrossRefGoogle Scholar
May, WF. Money and the medical profession. Kennedy Inst Ethics J. 1997; 7: 1–13.CrossRefGoogle ScholarPubMed
Wynia, MK, Latham, SR, Kao, AC, Berg, JW, Emanuel, LL. Medical professionalism in society. NEJM. 1999; 341: 1612–1616.CrossRefGoogle Scholar
McGaghie, WM, Mytco, JJ, Brown, N, Cameron, JR. Altruism and compassion in the health professions: a search for clarity and precision. Med Teacher. 2002; 24: 374–378.CrossRefGoogle ScholarPubMed
Hall, MA. The importance of trust for ethics, law, and public policy. Camb Q Healthc Ethics. 2005; 14: 156–167.CrossRefGoogle Scholar
Levinson, W, Lurie, N. When most doctors are women: what lies ahead?Ann Int Med. 2004; 141: 471–479.CrossRefGoogle ScholarPubMed
Borges, NJ, Stephen, MR, Elam, C, Jones, BJ. Comparing millennial and generation X medical students at one medical school. Acad Med. 2006; 81: 571–576.CrossRefGoogle ScholarPubMed
Watson, , Slade, S, Buske, L, Tepper, J. Intergenerational differences in workloads: a ten year population-based study. Health Aff. 2006; 25: 1620–1628.CrossRefGoogle Scholar
Johnston, S. See one, do one, teach one: developing professionalism across the generations. Clin Orthop Relat Res. 2006; 449: 186–192.Google ScholarPubMed
Sullivan, W. What is left of professionalism after managed care. Hastings Cent Rep. 1999; 29: 7–13.CrossRefGoogle ScholarPubMed
Brennan, TA, Rothman, DJ, Blank, L, Blumenthal, D, Chimonas, SC, Cohen, J, Goldman, J, Kassirer, JP, Kimball, H, Naughton, J, Smelser, N. Health industry practices that create conflicts of interest. JAMA. 2006; 295: 429–433.CrossRefGoogle ScholarPubMed
Cohen, JJ, Cruess, SR, Davidson, C. Alliance between society and medicine: the public's stake in medical professionalism. JAMA. 2007; 298: 670–673.CrossRefGoogle ScholarPubMed
Dunning, AJ. Status of the doctor—present and future. Lancet. 1999; 354(suppl.): SIV 18.CrossRefGoogle Scholar
Rosenblatt, RE, Shaw, S, Rosenbaum, S. Law and the American Health Care System. New York: Foundation Press; 1997.Google Scholar
Ludmerer, KM. Time to Heal. Oxford: Oxford University Press; 1999.Google Scholar
Stevens, R. Public roles for the medical profession in the United States: beyond theories of decline and fall. Milbank Q. 2001; 79: 327–353.CrossRefGoogle Scholar
Kurlander, JK, Morin, K, Wynia, MK. The social-contract model of professionalism: baby or bathwater?Am J Bioethics. 2004; 4: 33–36.CrossRefGoogle ScholarPubMed
Iglehart, JK. The emergence of physician-owned specialty hospitals. NEJM. 2005; 352: 78–84.CrossRefGoogle ScholarPubMed
Gough, JW. The Social Contract: A Critical Study of Its Development. Oxford: The Clarendon Press; 1957.Google Scholar
Ham, C, Alberti, KJ. The medical profession, the public, and the government. BMJ. 2002; 324: 838–842.CrossRefGoogle ScholarPubMed
Rosen, R, Dewar, S. On Being a Good Doctor: Redefining Medical Professionalism for Better Patient Care. London, UK: King's Fund; 2004.Google Scholar
Salter, B. Patients and doctors: reformulating the UK health policy community?Soc Sci Med. 2003; 57: 927–936.CrossRefGoogle ScholarPubMed
Tuohy, C. Agency, contract, and governance: shifting shapes of accountability in the health care arena. J Health Pol Policy Law. 2003; 29: 195–215.CrossRefGoogle Scholar
Kultgen, JH. Ethics and Professionalism. Philadelphia, PA: University of Pennsylvania Press; 1998.Google Scholar

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