COMMENTARY
MAYO CLINIC
Professionalism: Etiquette or Habitus? Ryan M. Antiel, MD, MA; Warren A. Kinghom, MD, ThD; Darcy A. Reed, MD, MPH; and Frederic W. Hafferty, PhD '
T
he past decade has witnessed an out- including (1) professionalism is not an innate trait, (2) more behavioral examples of profesburst of interest and scholarship about med'xal professionalism. The profes- sionalism are needed, and (3) professionalism sionalism movernent has a strong presence in is a lifelong pursuit influenced by environment and context. The professionalism milestones medical education, including efforts to define, for graduate medical education are another measure, and instill professionalism as a core example of the behavioral checklist framework competency of medical practice. As these efforts continue, there has been a shift toward empha- ' for professionalism.'' sizing measurable behaviors while downplaying We agree with both Kahn and Lesser et al the intemalization of values and virtues. As such, that medical professionalism is a competency we have concerns regarding the ability of medical that must be developed and formed in particstudents and physicians to display outward pro- ular social contexts and must display itself pubfessional behavior in a sustainable way without licly and behaviorally. Nonetheless, the call for actually internalizing the values of the medical specific examples of professional behaviors profession. should not be viewed as a mandate to create Kahn^ argues for an "etiquette-based medi- an exclusively behavior-oriented definition. Excine," which stresses behavior mastery over cTiar- amples and definitions are 2 different epistemoacter development. He proffers a list of behaviors logic creatures. Définirions tend not to reflect the complexities of a given issue, this being that include actions such as shaking hands with a patient, smiling at a patient, and explaining parricularly true for professionalism because one's role on the medical team. This emphasis it exists within occupational and public sectors, is both socially dynamic and relationally on deportment is attractive for those who wish to approach train.ee comportment as a checklist. grounded, and is widely acknowledged to be resistant to consensus.'*'^ Just as checklists are used in intensive care units to reduce central catheter infections, In addition, checklists of behaviors, however Kahn explicitly endorses etiquette checklists for exhaustive, are not sufficient to guide physicians physician trainees in an attempt to reduce nega- who seek virtue and excellence. Any checklist is tive patient encounters. This raises the question, both arbitrary (in what it includes vs leaves out) though, of how Kahn's account distinguishes the and by necessity incomplete (it must be strategiphysician-patient relationship from any other cally focused). Moreover, although behavioral customer service profession. Kahn acknowledges ideals and warning signs drawn from past cirthat "the goals of the doctor differ in obviously cumstances may inform future actions, they do important ways from those of a Nordstrom not necessarily provide physicians with a suffiemployee." However, we ask, "Does an approach cient foundation to approach the unanticipated to professionalism that focuses exclusively on be- challenges to professionalism that arise from haviors provide any meaningful distinction be- novel situations. tween the patient-physician • relationship and The frameworks described by Kahn and the relationship between a Nordstrom employee Lesser et al construct a divide between behavior and a customer?" The behavioral checklist Kahn on one hand and attitudes aind traits of chardescribes could apply to any customer service acter on the other. Eor example, Kahn states personnel. If the practice of medicine is about that etiquette-based medicine "would stress more than customer service, the prioritization practice and mastery over character developof behavior over character development fails to ment."^ Likewise, Lesser et al^ write that "just address this difference. as professionalism emanates from actions not virtues, the functionality of the health care sysLesser et al^ also adopt a behavioral view of tem also emanates from the myriad intersecting professionalism, advancing several conclusions. Mayo Clin Proc. • July 2013;88(7):651-652 •
http://dx.doi.Org/10.10U/j.mayocp.2013.05.008
www.mayoclinicproceedings.org • © 2013 Mayo Foundation for Medical Education and Research
From the Department of General Surgery (RMA.). Department of Medicine ( D A R ) , and Department of Medical Education (F,V\/,H,), Mayo Clinic College of Medicine, and Mayo Clinic Program in Professionalism and Ethics ( K M A , DAR.. F.W.H.). Rochester, MN; and Department of Psychiatry, Duke" University Medical Center, Durham, NC
651
MAYO CLINIC PROCEEDINGS
. and interacting behaviors of multiple agents." among trainees. Underlings, particularly in hierSuch a construction suggests the presence of archical and high-stakes environments, posture, an interrial-extemal, mind-body split in which slurp, or strive to look the part, regardless of what (external) professional behavior can be. mani- they actually believe or understand. Because fest apart from (internal) virtue and vice versa. checklists are prioritized over character, finesse We suggest that such a distinction is artificial rather than true professionalism becomes the and contrary to the ultimate purpose of medical rule of the day. The resulting milieu of socialiprofessionalism, which seeks to wed the interzation becomes essentially chameleon in nanalization of professional values with the out- ture. Being professional ceases to be part of ward display of behavior. , the equation. Although it is correct that we Instead, what is needed is a framing of pro- become virtuous by behaving well, Aristotle fessionalism in which virtuous behavior works was quite aware that one could behave well itself so deeply into the marrow of the physi- without being a good person and that such cian that it becomes "second nature," a teleo- behaving, well, underscored by intentional logic habitus, exhibiting itself freely and easily deception, would be neither pleasurable nor even in challenging clinical situations and in • sustainable in the long run.^ Action is the which no virtuous character is admitted to exist display of habit, neither internal nor external unless it so displays itself. Such, we believe, is but both at the same time. Trainees arid role the proper understanding of virtue as proposed models are authentic when they embody and .by Aristotle, particularly in his concept of phrodisplay virtue in this way. A truly professional nesis or practical wisdom.^ The virtuous physi- physician is one who can be trusted to do cian, for Aristotle, is the one who has been so what is right when stressed, burned out, and shaped and formed by teachers of excellence especially when no one else is watching. that excellent practice shows itself even in novel Correspondence: Address to Frederic W . Hafferty, PhD, or unpredictable situations; a student so habitMayo Clinic' Progranri in Professionalism and Ethics, Mayo uated would be disposed to navigate virtuously Clinic, 200 First St SW, Rochester, MN 55905 (hafferty. the complexities abundant in health care. A [email protected]). specific formula or behavioral repertoire, by REFERENCES contrast, may render professionalism piece1. Kahn MW. Etiquette-based medicine. N Eng/ J Med. 2008; meal and therefore incomplete. • 358(19); 1988-1989. . Our framework supports Kahn's acknowl- 2. Lesser CS. Lucey CR, Egener B, Braddock ÇH III, Unas SL edgment that character formation is most effecLevinson W . A behavioral and systems view of professionalism. JAMA. 20l0;3(M(24);2732-2737. tive when it resembles apprenticeship arid not 3. Nasca TJ, Philibert I, Brigham T, Flynn T C The next GME graduate school.'^ The apprenticeship model is accreditation system; rationale and benefits. N Engfj Med. 2012; necessary for trainees to develop not only the 366(II);IO51-1056. technical skills required by the specialty but 4. Ginsbur^ S. Regehr G, tingard L Basing the evaluation of professionalism on observable behaviors; a cautionary tale. Acod also the virtues necessary for that practice. Med. 2004;79( 10, suppl);S I -S4. Learning systems in which behavior de- 5. Kinghom W A . Medical education as moral formation; an Aristotelian account of medical professionalism. Perepect S/o/ Med. poses virtue as the pedagogic raison d'être may 2OIO;53(I);87-IO5. also spawn a sense of cynicism, resistance, and' 6. Aristotle 7?ie Nicomcchean Ethics. Ross D, tran. Bnown U ed. New the behaviors of "faking it" and gamesmanship York. NY; Oxford University Press; 2009. Oxford's World Classics.
652
Mayo Clin Proc. • July 2013i88(7):651-652
http://dx.doi.org/10.1016/j.mayocp.2013.05.008 www.mayoclinicproceedings.org
Copyright of Mayo Clinic Proceedings is the property of Quadrant HealthCom Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
MAYO CLINIC
Professionalism: Etiquette or Habitus? Ryan M. Antiel, MD, MA; Warren A. Kinghom, MD, ThD; Darcy A. Reed, MD, MPH; and Frederic W. Hafferty, PhD '
T
he past decade has witnessed an out- including (1) professionalism is not an innate trait, (2) more behavioral examples of profesburst of interest and scholarship about med'xal professionalism. The profes- sionalism are needed, and (3) professionalism sionalism movernent has a strong presence in is a lifelong pursuit influenced by environment and context. The professionalism milestones medical education, including efforts to define, for graduate medical education are another measure, and instill professionalism as a core example of the behavioral checklist framework competency of medical practice. As these efforts continue, there has been a shift toward empha- ' for professionalism.'' sizing measurable behaviors while downplaying We agree with both Kahn and Lesser et al the intemalization of values and virtues. As such, that medical professionalism is a competency we have concerns regarding the ability of medical that must be developed and formed in particstudents and physicians to display outward pro- ular social contexts and must display itself pubfessional behavior in a sustainable way without licly and behaviorally. Nonetheless, the call for actually internalizing the values of the medical specific examples of professional behaviors profession. should not be viewed as a mandate to create Kahn^ argues for an "etiquette-based medi- an exclusively behavior-oriented definition. Excine," which stresses behavior mastery over cTiar- amples and definitions are 2 different epistemoacter development. He proffers a list of behaviors logic creatures. Définirions tend not to reflect the complexities of a given issue, this being that include actions such as shaking hands with a patient, smiling at a patient, and explaining parricularly true for professionalism because one's role on the medical team. This emphasis it exists within occupational and public sectors, is both socially dynamic and relationally on deportment is attractive for those who wish to approach train.ee comportment as a checklist. grounded, and is widely acknowledged to be resistant to consensus.'*'^ Just as checklists are used in intensive care units to reduce central catheter infections, In addition, checklists of behaviors, however Kahn explicitly endorses etiquette checklists for exhaustive, are not sufficient to guide physicians physician trainees in an attempt to reduce nega- who seek virtue and excellence. Any checklist is tive patient encounters. This raises the question, both arbitrary (in what it includes vs leaves out) though, of how Kahn's account distinguishes the and by necessity incomplete (it must be strategiphysician-patient relationship from any other cally focused). Moreover, although behavioral customer service profession. Kahn acknowledges ideals and warning signs drawn from past cirthat "the goals of the doctor differ in obviously cumstances may inform future actions, they do important ways from those of a Nordstrom not necessarily provide physicians with a suffiemployee." However, we ask, "Does an approach cient foundation to approach the unanticipated to professionalism that focuses exclusively on be- challenges to professionalism that arise from haviors provide any meaningful distinction be- novel situations. tween the patient-physician • relationship and The frameworks described by Kahn and the relationship between a Nordstrom employee Lesser et al construct a divide between behavior and a customer?" The behavioral checklist Kahn on one hand and attitudes aind traits of chardescribes could apply to any customer service acter on the other. Eor example, Kahn states personnel. If the practice of medicine is about that etiquette-based medicine "would stress more than customer service, the prioritization practice and mastery over character developof behavior over character development fails to ment."^ Likewise, Lesser et al^ write that "just address this difference. as professionalism emanates from actions not virtues, the functionality of the health care sysLesser et al^ also adopt a behavioral view of tem also emanates from the myriad intersecting professionalism, advancing several conclusions. Mayo Clin Proc. • July 2013;88(7):651-652 •
http://dx.doi.Org/10.10U/j.mayocp.2013.05.008
www.mayoclinicproceedings.org • © 2013 Mayo Foundation for Medical Education and Research
From the Department of General Surgery (RMA.). Department of Medicine ( D A R ) , and Department of Medical Education (F,V\/,H,), Mayo Clinic College of Medicine, and Mayo Clinic Program in Professionalism and Ethics ( K M A , DAR.. F.W.H.). Rochester, MN; and Department of Psychiatry, Duke" University Medical Center, Durham, NC
651
MAYO CLINIC PROCEEDINGS
. and interacting behaviors of multiple agents." among trainees. Underlings, particularly in hierSuch a construction suggests the presence of archical and high-stakes environments, posture, an interrial-extemal, mind-body split in which slurp, or strive to look the part, regardless of what (external) professional behavior can be. mani- they actually believe or understand. Because fest apart from (internal) virtue and vice versa. checklists are prioritized over character, finesse We suggest that such a distinction is artificial rather than true professionalism becomes the and contrary to the ultimate purpose of medical rule of the day. The resulting milieu of socialiprofessionalism, which seeks to wed the interzation becomes essentially chameleon in nanalization of professional values with the out- ture. Being professional ceases to be part of ward display of behavior. , the equation. Although it is correct that we Instead, what is needed is a framing of pro- become virtuous by behaving well, Aristotle fessionalism in which virtuous behavior works was quite aware that one could behave well itself so deeply into the marrow of the physi- without being a good person and that such cian that it becomes "second nature," a teleo- behaving, well, underscored by intentional logic habitus, exhibiting itself freely and easily deception, would be neither pleasurable nor even in challenging clinical situations and in • sustainable in the long run.^ Action is the which no virtuous character is admitted to exist display of habit, neither internal nor external unless it so displays itself. Such, we believe, is but both at the same time. Trainees arid role the proper understanding of virtue as proposed models are authentic when they embody and .by Aristotle, particularly in his concept of phrodisplay virtue in this way. A truly professional nesis or practical wisdom.^ The virtuous physi- physician is one who can be trusted to do cian, for Aristotle, is the one who has been so what is right when stressed, burned out, and shaped and formed by teachers of excellence especially when no one else is watching. that excellent practice shows itself even in novel Correspondence: Address to Frederic W . Hafferty, PhD, or unpredictable situations; a student so habitMayo Clinic' Progranri in Professionalism and Ethics, Mayo uated would be disposed to navigate virtuously Clinic, 200 First St SW, Rochester, MN 55905 (hafferty. the complexities abundant in health care. A [email protected]). specific formula or behavioral repertoire, by REFERENCES contrast, may render professionalism piece1. Kahn MW. Etiquette-based medicine. N Eng/ J Med. 2008; meal and therefore incomplete. • 358(19); 1988-1989. . Our framework supports Kahn's acknowl- 2. Lesser CS. Lucey CR, Egener B, Braddock ÇH III, Unas SL edgment that character formation is most effecLevinson W . A behavioral and systems view of professionalism. JAMA. 20l0;3(M(24);2732-2737. tive when it resembles apprenticeship arid not 3. Nasca TJ, Philibert I, Brigham T, Flynn T C The next GME graduate school.'^ The apprenticeship model is accreditation system; rationale and benefits. N Engfj Med. 2012; necessary for trainees to develop not only the 366(II);IO51-1056. technical skills required by the specialty but 4. Ginsbur^ S. Regehr G, tingard L Basing the evaluation of professionalism on observable behaviors; a cautionary tale. Acod also the virtues necessary for that practice. Med. 2004;79( 10, suppl);S I -S4. Learning systems in which behavior de- 5. Kinghom W A . Medical education as moral formation; an Aristotelian account of medical professionalism. Perepect S/o/ Med. poses virtue as the pedagogic raison d'être may 2OIO;53(I);87-IO5. also spawn a sense of cynicism, resistance, and' 6. Aristotle 7?ie Nicomcchean Ethics. Ross D, tran. Bnown U ed. New the behaviors of "faking it" and gamesmanship York. NY; Oxford University Press; 2009. Oxford's World Classics.
652
Mayo Clin Proc. • July 2013i88(7):651-652
http://dx.doi.org/10.1016/j.mayocp.2013.05.008 www.mayoclinicproceedings.org
Copyright of Mayo Clinic Proceedings is the property of Quadrant HealthCom Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
