Defining Professionalism in Residency
Professionalism in residency is defined by the ACGME as the ability to carry out professional activities and adhere to ethical principles, with foundational attributes including honesty, integrity, compassion, respect for others, and accountability—demonstrated through specific observable behaviors in patient care, team interactions, and professional development. 1, 2
Core Foundational Attributes
The framework established by the American Board of Pediatrics applies across all medical specialties and defines professionalism through specific behavioral standards: 2
Honesty and integrity embody fairness, the ability to meet commitments and keep one's word, and the duty to be intellectually honest and straightforward in all interactions with patients, peers, and professional communication 2
Reliability and responsibility represent accountability to patients, families, other physicians, medical staff, community, and society, requiring acceptance of responsibility for errors made, including willingness to acknowledge and discuss errors, consequences, and alternatives with families and peers 2
Respect for others involves treating all persons with respect and regard for individual worth and dignity, including sensitivity to gender, race, and cultural differences, as well as maintenance of patient confidentiality 2
Compassion and empathy require the ability to understand patients' and family members' reactions to pain, discomfort, and anxiety from their point of view, not that of the physician 2
How Professionalism Is Demonstrated in Daily Practice
Patient Care Behaviors
Communication excellence involves effective, respectful, and compassionate two-way communication with patients, parents, and other members of the health care team 1
Documentation proficiency using the OLFACTORY principles: Original, Legible, Factual, Accurate, Consistent, Timely, Objective, Rational, and Yours—an area medical liability risk managers identify as needing improvement 1, 2
Altruism and advocacy refer to unselfish regard for the welfare of others, with patient well-being as the primary motivating factor in patient care, ahead of physicians' own interests and needs 2
Team and Colleague Interactions
Collaboration and communication involve recognition that patients' families and the health care team must work cooperatively with each other and communicate effectively to provide the best patient care 2
Accountability behaviors include being present when expected, completing tasks on time, and demonstrating reliability in team settings—research shows accountability in the learning environment is negatively associated with residents' perceived competence when lacking 3
Respectful conduct with all healthcare team members, avoiding verbal or physical abuse and sexual harassment in the workplace 4
Professional Development Behaviors
Self-improvement involves a commitment to lifelong learning and education to maintain and enhance clinical knowledge and skills 2
Self-awareness and knowledge of limits represent the maturity to recognize when a problem involves knowledge or technical skills beyond the experience of the provider and to ask for consultation or assistance 2
Error acknowledgment requires gracefully and honestly acknowledging errors and explaining to children and parents when things have "gone wrong" 1
The Critical Role of the Learning Environment
Faculty Modeling and the Hidden Curriculum
Faculty must model the professional behavior they seek to instill in trainees, as the "hidden curriculum" (what is taught by observing daily behavior of healthcare professionals) may influence trainees more than formal ethics training 1, 2
Opportunities to model behavior occur in the clinic, at the bedside, on the telephone, and in the patient's chart 1, 2
Clinical teachers must demonstrate how to manage difficulties in relationships with patients or colleagues, effectively communicate with interdisciplinary teams, gracefully acknowledge errors, and confront poor practice in colleagues or trainees 2
Common Observed Lapses
Research reveals important gaps between professionalism expectations and reality:
Disrespectful behaviors are the most frequently witnessed professionalism lapse in the learning environment, with residents reporting this as occurring 41.1% of the time 3
Only 25% of faculty model professionalism behaviors all the time, and more than half of residents state that poor role modeling impacts their attitudes about the importance of professionalism 5
Residents rate their personal commitment to professionalism significantly greater than the institution's commitment, suggesting an institutional culture gap 5
Critical Pitfalls and How to Avoid Them
When physicians keep silent in the face of inappropriate behavior, the implication is that the status quo is acceptable, and the opportunity to discuss professional behavior in the clinical context is lost 1, 2
Poor documentation skills represent an area of professionalism needing improvement, with medical liability risk managers emphasizing the importance of clear, concise, and correct medical record documentation 1, 2
Physicians who attend to their own needs are better able to show compassion and empathy to patients, making self-care a professional responsibility rather than a luxury 2
Stress management and coping strategies should be taught from the outset of training, as improved orientation regarding residency demands benefits resident well-being and professional development 2
Assessment and Evaluation Framework
Professionalism should be viewed as a developmental process across all stages of a medical career, requiring longitudinal assessment throughout residency training 2
Multiple assessment methods should be used including patient/nurse surveys, faculty observation, objective structured clinical exams (OSCE), ethical reasoning tests, and completion of administrative tasks 6
Behavioral benchmarks must be developed and utilized rather than relying solely on abstract definitions of attitudes and traits 6