Revisiting Medical Professionalism

Jen-Hung Yang1,2

The article will focus on discussing the dynamic nature of medical professionalism-
-moving from values to behaviors to identity formation in the changing world. It’s time
for medical educators and stakeholders of medical education and the healthcare system
to rethink and revisit medical professionalism in Taiwan’s context. We expect Taiwan’s
medical education will seamlessly connect with the international development of medical
professionalism and provide good physicians to offer high-quality patient care to our society.

Key words: medical professionalism, virtue, competency, identity formation,

Miller’s pyramid
( J Med Education 2023; 27: 20∼25 )

DOI: 10.6145/jme.202303_27(1).0010

“The most common criticism made at present
by older practitioners is that young graduates have
been taught a great deal about the mechanism
of disease, but very little about the practice of
medicine – or, to put it more bluntly, they are too
“scientific” and do not know how to take care of
patients” – (Francis W. Peabody, M.D., 1927)[1]
In the past 3 decades, we witness an explosion
of theory and research articles on how to define,
teach, and evaluate knowledge, attitudes that
constitute a physician’s professional role, and
addressing issues related to assessing and managing
unprofessional behavior by trainees. There are
503,085 articles (91.5% after 1990) with keyword
“professionalism”, and 10,718 articles (95% after
1990) with keyword “medical professionalism” in
the PubMed (Search on April 20, 2023). However,
when the topic of professionalism arises, the
clouds of confusion descend, making it difficult
to see the landscape. Cruess et al. argued the role
of the healer has remained fairly constant, but
the concept of professionalism has changed in
response to societal and professional needs. The
major areas of concern relate to professionalism
and its associated obligations are challenged, and
these challenges are not isolated events but are part
of a continuing process, altering and expanding

1
Chung Shan Medical University; 2 Taiwan Medical Accreditation Council (TMAC).
Received: 21 April 2023; Accepted: 28 April 2023
Correspondence to: Jen-Hung Yang, Chung Shan Medical University School of Medicine, No.110, Sec.1, Jianguo N. Rd., Taichung City
40201, Taiwan.
E-mail: jh1000521@gmail.com

20 J Med Education Vol. 27 No. 1 2023


what is expected of the professional and the role of
medicine in society.[2]
DYNAMIC NATURE OF
MEDICAL PROFESSIONALISM:
THREE FRAMEWORKS
L i v i n g u p t o p r o f e s s i o n a l i s m ’s c o r e
expectation to subordinate self-interest in deference
to the interest of others has always required the
surmounting of formidable challenges, not the
least of which is overcoming human nature itself.
[3]
Therefore, knowing the virtue, value or principle
of good medical practice is not enough, we must
do in medical practice. Irby and Hamstra (2016)
proposed an evolution perspective of medical
professionalism in three frameworks: virtue-based,
competency-based, and identity formation. The
oldest framework is virtue based and focuses on
the inner habits of the heart, the development of
moral character and reasoning, plus humanistic
qualities of caring and compassion. The second
framework is behavior-based, which emphasizes
milestones, competencies, and measurement
of observable behaviors. The third framework
is identity formation, with a focus on identity
development and socialization into a community
of practice.[4] The frameworks provide a useful
and understandable approach to learn, to teach, to
assess, and to evaluate teaching and learning of
medical professionalism in an institution.
Each framework has strengths and limitations
and contributes to the larger whole. For example,
the strength of the virtue-based framework is
its emphasis on character–the inner life of the
physician, aspirations, moral reasoning, and
habits of the heart; the strength of the virtue-
based framework is its clarity of expectations and
connection to assessment; however, the framework
of identity formation is more difficult to describe,
Revisiting Medical Professionalism 21
interpret, and assess.
FROM VIRTUE TO
PROFESSIONALISM
The morality of medicine is not new and can
be traced back to Hippocratic oath “physicians
espoused ethical practice – primum non nocere
-and altruism”. [5] Virtues has been recognized
as the underpinning of professionalism and the
interplay between virtue and behavior has ancient
roots.[6] The word “professionalism” is frequently
and widely used and is a recent phenomenon
in medicine since 1990s. The American Board
of Internal Medicine (ABIM) turned to using
“professionalism” and delineated its elements
including humanism, altruism, duty, service,
accountability, and excellence (ABIM 1994). The
Physician Charter, endorsed by ABIM, ACP-ASIM
Foundation, and European Federation of Internal
Medicine, defined three fundamental principles
(primacy of patient welfare, patient autonomy,
and social justice) and 10 commitments in the
Charter.[7] Stern (2006) discoursed “professionalism
demonstrated through a foundation of clinical
competence, communication skills, and ethical
and legal understanding, upon which is built the
aspiration to and wise application of the principles
of professionalism: excellence, humanism,
accountability, and altruism.” delineates that
professionalism as virtue toward which physicians
continually strive and thereby offers a bridge
to medical ethics. [8] Furthermore, medical
professionalism has been an important element
in accreditation standard of the international and
national accreditation agencies, such as the World
Federation for Medical Education (WFME),
Liaison Committee on Medical Education (LCME),
UK General Medical Council (GMC of UK), and
Taiwan Medical Accreditation Council (TMAC).
J Med Education Vol. 27 No. 1 2023 21
22 Jen-Hung Yang
Inui highlights the essential attributes of the
trustworthy physician at an AAMC article “A flag
in the wind”, he wrote “In the end, it is not because
we have special knowledge and technology
that we can be trusted – instead, we are trusted
only if this knowledge and technology is firmly
attached to values that are explicit, understood,
and altruistic.” [9]. The trust-worthy physician
internalizes and constructs a personal value system
of values to evaluate external messages about their
role and competence within a society.[10] However,
when the topic of professionalism arises, the
clouds of confusion descend, making it difficult
to see the landscape. Wynia argued that medical
professionalism is more than a list of attributes,
values, and desired behaviors, it needs foundational
understanding. The “list-based” definitions of
professionalism are quite feasible for teaching,
measurement, and certification, but they also risk
obscuring the foundational meaning, purpose,
functions and demands of professionalism.[11]
PROFESSIONALISM AS
COMPETENCY
For two decades, the Accreditation Council
for Graduate Medical Education (ACGME), the
American Board of Internal Medicine, the Royal
College of Physicians and Surgeons of Canada,
and the General Medical Council in the United
Kingdom have all subscribed to an outcomes-based
education model that is anchored in competencies.
ACGME introduced the six general competencies
to the medical profession in 1999, and medical
professionalism is one of the 6 competencies.
In addition, the Carnegie Foundation for the
Advancement of Teaching endorsed this framework
by calling for standardization of learning outcomes
and individualization of the learning process.[12]
ACGME states that residents must demonstrate
22 J Med Education Vol. 27 No. 1 2023
a commitment to carrying out professional
responsibilities, adherence to ethical principles,
and sensitivity to a diverse patient population,
and residents are expected to demonstrate respect,
compassion, and integrity; a responsiveness to the
needs of patients and society that supersedes self-
interest; accountability to patients, society, and the
profession; and a commitment to excellence and
on-going professional development; to demonstrate
a commitment to ethical principles pertaining
to provision or withholding of clinical care,
confidentiality of patient information, informed
consent, and business practices; and to demonstrate
sensitivity and responsiveness to patients’ culture,
age, gender, and disabilities.[13]
The behavior-based competency framework
emphasizes the importance of clarifying
outcomes and of teaching to and assessing
observable behaviors. The challenge that medical
education face in evaluating professionalism can
be summarized 2 aphorisms: (1) if it can’t be
measured, it can’t be improved, and (2) they don’t
respect what you expect; they respect what you
inspect. Unfortunately, professionalism remains
among the most difficult domains of medical
students’ and residents’ competence to assess.[3]
Taiwan Medical Accreditation Council
(TMAC) serves public trust by setting
accreditation standards that govern and provide
quality education of the next generation of
physicians. TMAC attaches great importance to
medical professionalism in its standards based
on competency-based education model, [14] and
there are as many as 52 occasions mentioning
medical professionalisms in the standards to
evaluate how a medical school’s outcome to
demonstrate the operation definition, teaching and
learning, and assessing the knowledge, skills, and
behaviors/attitudes of professionalism, and how
a medical school to enrich hidden curriculum and

positive role models, and to address and manage
unprofessional behaviors of a student. However,
as a senile assessor of TMAC, my personal
perspective is that we have to seamlessly connect
with the international development on pedagogy,
teaching, learning, and assessment of medical
professionalism in most medical schools in Taiwan.
FROM PROFESSIONALISM TO
IDENTITY FORMATION
Professional identity as a concept has also
had a long existence in medicine, for example, an
Aristotelian term “phronesis” is largely descriptive
of a professional identity.[15] Becoming a physician
is considered a “journey beyond competence”
and involves a “shift in medical education toward
emphasis on the “being” as well as “doing the
work” of a physician”, which “involves the
development of professional values, actions and
aspirations and is central to medical education.[16]
The 2010 Carnegie Foundation report on the future
of medical education stated that “professional
identity formation–the development of professional
values, actions, and aspirations–should be the
backbone of medical education.”.[12] Cruess defined
PIF as “A representation of self, achieved in
stages over time during which the characteristics,
values, and norms of the medical profession are
internalized, resulting in an individual thinking,
acting and feeling like a physician”, and they stress
that each individual’s journey from layperson to
skilled professional is unique and is affected by
“who they are” at the beginning and “who they
wish to become.”.
Identity formation is a dynamic process
achieved through socialization; it results in
individuals joining the medical community of
practice. Multiple factors within and outside of
the educational system affect the formation of
Revisiting Medical Professionalism 23
an individual’s professional identity. [17] Jarvis-
Selinger et al. emphasize competency is not
enough, we have to integrate identity formation
into the medical education course, which allows
a reframing of approaches to medical education
away from an exclusive focus on “doing the work
of a physician” toward a broader focus that also
includes “being a physician”.[18] “Before become a
doctor, become a man.” is a quote from Dr. Kun-
Yen Huang (the Founding Chairman of TMAC),
which encourages medical student through the
processes of identity formation and will be a
Tomorrow’s good doctor.
Ve e n a n d C r o i x i d e n t i f y t h r e e m a i n
approaches medial education has taken to identity:
as an individual trait, as a set of behaviors, and
a socialization process. [16] Socialization-with
its complex networks of social interaction, role
models and mentors, experiential learning, and
explicit and tacit knowledge acquisition-influences
each learner, causing them to gradually "think, act,
and feel like a physician”.[18] However, the process
of identity formation is qualitatively distinct, and
the transition from stage to stage is not a process
of gradual change but, rather, is marked by abrupt
discontinuities precipitated by emerging “crises.”.
For example, a medical student may define a
physician identity in terms of a metaphor such
as “physician as healer,” but when faced with
the death of a patient, it may challenge his or her
notions of physician.[19]
Cruess et al. advocate to amend Millers’
Pyramid from 4 levels (knows/knows how/shows/
does) to 5 levels to include professional identity
formation (PIF) as the fifth level “Is”. Miller’s
pyramid has been frequently used as an analytic
tool to guide the assessment of professionalism at
the “Does” level, and the assessment of “Is” will
undoubtedly prove to be more difficult than the
assessment of “Does”.[15]
J Med Education Vol. 27 No. 1 2023 23
24 Jen-Hung Yang
SUMMARY
Professionalism is an important component of
medicine’s contract with society. Each framework
has strengths and limitations and contributes to
the larger whole. Remember the proverb “The
whole is more than the sum of its parts.” when
you will apply the professionalism frameworks.
Being a good doctor is supreme goal of medical
education. We expect Taiwan’s medical education
will seamlessly connect with the international
development of medical professionalism and
provide good physicians to offer high-quality
patient care to our society.
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