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Introduction

Dr. X is a 53-year-old surgeon who is nationally recognized for his surgical skills and innovative surgical techniques. He is a top revenue producer in his department. Recently, reports have surfaced that he often fails to show up for mandatory huddles in the operating room and often curses at nurses for being incompetent. His patient communication scores are low. Patients comment that his listening skills are poor, and time spent with patients is short with no opportunity for them to ask questions.

Professionalism as an Emerging Concept

In light of this scenario, it isn't surprising that there is a renewed emphasis on professionalism in American medicine. In 2002, a Physician Charter on Medical Professionalism was published with wide endorsement from multiple medical organizations in the United States and Western Europe.1 This document aimed to update the concept of professionalism and bring it in line with values of late twentieth-century medicine. The charter is based on three principles (social justice, patient welfare, and autonomy) and nine commitments, including honesty with patients, patient confidentiality, maintaining trust, and professional competence. Most medical schools now have an explicit emphasis on professionalism as a core competency that students must demonstrate prior to graduation. Similarly, in 2003, the Accreditation Council for Graduate Medical Education (ACGME) established professionalism as one of six required core competencies that every graduate medical education program is required to incorporate into training.2 The other five are patient care, medical knowledge, practice-based learning and improvement, systems-based practice, and interpersonal skills and communication.

Dr. X's behavior demonstrates a lapse in professionalism, is disruptive, and threatens the quality and safety of patient care. Poor communication skills are clearly part of his problem; however, a formal curriculum and training in communication skills was not included in his surgical residency. When medical students or residents exhibit poor communication skills that lead to lapses in professionalism, there are clear mechanisms for identification and remediation. For attending physicians, such as Dr. X, the path to reporting and remediation of professionalism lapses is often unclear.

The focus in the physician charter, and the ACGME competencies for medical schools and residency programs, is on the responsibilities of individual physicians to fulfill the obligations of a medical professional. Recently, the question of "organizational professionalism" has been raised.3 Organizational professionalism recognizes the fact that there are important and systematic ways that organizations behave that are out of an individual's control but that nonetheless impact professional behavior.4 Conceptually, there is increasing recognition that professionalism is more than a simple set of rules that medical professionals follow blindly, but is, rather, a complex interplay between individuals and the environments in which they work, or what has been termed a complex adaptive system.5 Along with recognizing the importance of context and complexity, scholarship is emerging around the theme of relationship-centered care, the idea that the smallest unit of measure in understanding communication ...

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