Two new articles in Academic Psychiatry add to the existing literature related to professionalism. In the first, “Dismissed Residents Who Appeal: Exploring Unprofessional Behaviors” [1], the authors retrospectively examine publicly available data on Dutch psychiatry residents who had been dismissed by their program director and had appealed the decision to a national conciliation board. In the second, “How Therapists Experience and Manage Patients’ Romantic and Sexual Feelings for Them” [2], the authors use thematic data analysis based on focus group responses from 36 therapists-in-training and therapists-in-practice, 8 of whom were psychiatrists, to investigate how participants experience and manage situations in which a patient either displays or discloses attraction.

As professional behaviors need to be learned in the context of socialization into a profession (in this case, medicine), the teaching and assessment of professionalism is a vital part of medical education. The Liaison Committee on Medical Education (LCME), Accreditation Council for Graduate Medical Education (ACGME), and Association of American Medical Colleges (AAMC) all stress this importance of professionalism and set standards for professional development for medical students and resident physicians. Despite these recommendations, professional behaviors continue to be a complicated concern facing medical educators, as reflected in these two new articles [1, 2]. In order to put these articles into context, this editorial will briefly describe selected literature published on professionalism within this journal over the last two decades, with a focus on the definition of professionalism and on teaching and assessment methods.

Definitions of Professionalism

Educators need to have a clear and comprehensive understanding of the definition of professionalism, so that they may be effective role models for students, residents, fellows, and allied health care professionals and formulate appropriate curricular efforts and assessments. As Roberts et al. [3] wrote, “Definitions of professionalism are inconsistent and provide ambiguous guidance to educators.” The hidden curriculum in medical education that implicitly influences learners further complicates what is taught regarding professional behavior.

In a commentary on virtues-based advice for medical students, Coverdale [4] describes the earliest known definition of professionalism and professional virtues from the eighteenth century physician John Gregory. Due to concern over lack of standards for scientific competence and “rampant self-interest” among physicians, Gregory called for reliance on evidence in patient care and placing the patient’s interest before one’s own. There are four fundamental virtues developed from Gregory’s concept of professionalism, namely integrity (i.e., commitment to the lifelong pursuit of excellence in care); compassion for suffering; self-effacement (i.e., putting aside differences that should not count when caring for patients, such as social class, ethnicity, and religion); and self-sacrifice.

Although the LCME [5] considers professional development in its standards for accreditation, noting that medical schools must ensure an environment “conducive to the ongoing development of explicit and appropriate professional behaviors in its medical students, faculty, and staff at all locations,” the LCME does not provide a concrete definition. The AAMC [6], however, does, providing a list of professional and ethical attributes that medical students should develop by graduation. Per AAMC recommendations, medical school graduates should possess altruism; compassion and empathy; truthfulness and trustworthiness; knowledge of ethical decision-making; respect for patient privacy and dignity; an understanding of and respect for the roles of other health care professionals and the need to collaborate with others in caring for patients; a commitment to advocacy for the interests of patients; an understanding of the threats to medical professionalism; and the capacity to recognize limitations in one’s knowledge and clinical skills.

The ACGME [7] also provides a definition of professional behavior in the core competencies for all residents, many of which are similar to the AAMC definition. Per these competencies, residents are required to carry out professional responsibilities and adhere to ethical principles by demonstrating compassion, integrity, and respect for others; responsiveness to patient needs that supersede self-interest; respect for patient privacy and autonomy; accountability to patients, society, and the profession; and sensitivity and responsiveness to a diverse patient population.

Several authors within this journal have also discussed and studied the definition of professionalism within medical education. Lapid et al. [8] include “boundaries and appropriate relationships” as a key domain for both ethics and professionalism education, a concept that is especially pertinent in psychiatry, given the amount of personal information patients share with psychiatrists and the potential for transference and countertransference. Marerro et al. [9] utilized the definition provided by the Charter on Medical Professionalism, which includes social justice; the primacy of patient welfare and autonomy; and commitment to professional competence, honesty with all patients, patient confidentiality, appropriate relations with patients, improvements in quality of care and access to care, a just distribution of resources, scientific knowledge, and maintaining trust by managing conflict of interest. In a survey of medical students, psychiatry residents, and faculty from one institution, Morreale et al. [10] asked participants to rate items that were important to their individual definition of professionalism. All of those surveyed rated items associated to personal characteristics (e.g., punctuality, honesty, adherence to ethics), interactions with patients (e.g., respect, confidentiality), social responsibility (e.g., treating underprivileged patients, advocating for patients, managing conflict of interest), and interactions with team members (e.g., respect, reporting dishonesty) as important. Finally, in an article on family-work balance, Louie et al. [11] challenge the ACGME definition of professionalism, specifically the statement that the needs of patients and society should supersede self-interest. They note that doing so creates a “double-bind,” in which physicians are unable to role model appropriate self-care and well-being for their patients. In sum, medical students, residents, and faculty may perceive appropriate professional behavior as vague and confusing due to the continued lack of one, unifying definition of professionalism in medical education.

Teaching Professionalism

A survey of psychiatric residents from seven US institutions indicates that residents desire more education on multiple topics related to professionalism [12]. In addition, psychiatry residents expressed the need for additional education on issues specifically related to relationships and boundaries, such as personal relationships with patients, giving medical advice and writing prescriptions for family and friends, and accepting gifts from patients [8].

For professionalism to be comprehensively taught, there needs to be both a culture of professional behavior within the clinical settings where learners rotate and effective curricula. Schwartz et al. [13] make multiple suggestions for establishing a robust culture of professionalism, including the sharing of patient feedback surveys on faculty physicians with those responsible for medical education, staff inclusion in the evaluation of attending physicians’ professional behaviors, and open discussion of deficits in professionalism. In addition, several authors stress the importance of establishing concrete mentorship in this area, such as pairing students/residents with faculty members who have established themselves as models of professionalism at the beginning of their education to allow discussion and supervision of professionalism in an environment where the learner is not formally graded or judged [12, 13].

The residents who were surveyed from the seven US institutions [12] rated role modeling, discussion groups led by a knowledgeable clinician, incorporation into lectures and clinical rounds, case conferences, and routine interactions with patients as the most effective methods for teaching about professionalism and ethics. Educators from the University of Washington created a curriculum on professionalism in medicine that is available through the American Association of Directors of Psychiatric Residency Training [14] and incorporates one method listed above, case-based discussion. This curriculum covers many of the areas suggested by the ACGME and AAMC, includes ethical concepts and an examination of boundaries in psychiatric practice, and has adaptations for use with medical students and psychology trainees. In addition, a self-study professionalism and ethics guide by Roberts and Termuehlen [15] provides multiple case-oriented questions with answers that can be used in small group discussions.

Assessing Professionalism

Given ACGME core competencies, all medical residents are evaluated on their professionalism. In addition, the AAMC requires that all medical students’ professional behaviors be evaluated and that professionalism is discussed in the medical school performance evaluation included in the Electronic Residency Application Service [16].

There are challenges to consistent, reliable assessment of professionalism in medical education. As noted above, the definition of professionalism is not concrete, and thus, faculty who evaluate learners may have different perceptions of professional behavior, which can be confusing to learners. Schwartz et al. [13] give an excellent example of this situation, where one attending might advise a learner to hold a patient’s hand if the patient is distressed and another might believe this act is unprofessional. In addition, medical students and residents regularly rotate through different clinical services and come in contact with multiple members of the treatment team, and problematic behaviors could depend on both the setting and nature of the relationship. For example, as Schwartz et al. [13] describe, a student or resident might interact differently in front of nursing staff on an inpatient unit, who have no opportunity for contributing to the formal evaluation process, compared to a senior faculty member directly supervising and evaluating in an outpatient clinic. Interestingly, at least for medical students, serious deficiencies in professionalism are more apt to be noticed in the inpatient versus outpatient setting [17]. Furthermore, many students and residents often do not disclose episodes of unprofessional behavior, as they feel that it would be used against them for future job positions or promotion. In short, saying nothing seems safer than full disclosure, even if confidentiality and anonymity are ensured.

In an attempt to address some of the challenges to assessing professionalism, as mentioned above, Schwartz et al. [13] make multiple concrete recommendations for assessing professional behaviors, as follows: professionalism should be included as an objective and evaluated in every educational activity; professionalism should be clearly defined using objective criteria and measured by different evaluators across sites; the evaluation of professionalism should begin in the first year of medical school, allowing learners the opportunity to grow; assessment should be completed by multiple evaluators including patients, attendings, staff, and colleagues; and longitudinal assessment should occur.

Psychiatry residents have voiced preferences for how the assessment of knowledge and skills related to professional attitudes, values, and ethics should occur. In the same cohort of residents studied by Lapid et al. [8] and Jain et al. [12], residents strongly agreed that clinical supervision was an appropriate method for assessing knowledge and somewhat agreed that oral examinations were appropriate [9]. Regarding the assessment of skills in these areas, residents strongly agreed that direct faculty observation of interactions with patients and the clinical team and somewhat agreed that faculty observation of videotaped resident-patient encounters and evaluations by patients and staff would be effective. While these efforts are admirable and a sound first step, we have yet to see how these measures would not be subject to the Hawthorne effect—the modification of behavior under the situation of being observed [18].

Future Directions

One area related to professionalism that has not been discussed within this journal is appropriate and effective remediation strategies. Given that problematic behavior during medical school is associated with later disciplinary action by state medical boards, it is vital to identify and remediate unprofessional behaviors at an early stage of professional development [19]. Although Schwartz et al. [13] mention the use of a progress and promotions committee, which would provide support to those medical students and residents who have been identified as having unprofessional behaviors, and recommend that a psychiatrist be included on this committee to assess potential mental health concerns, they do not discuss specific remediation methods other than increasing insight. Data on current remediation practices that are not specific to psychiatric education have been published elsewhere [20] and indicate the importance of academic psychiatrists’ involvement, as, interestingly, approximately 80% of medical schools surveyed recommended mandated mental health evaluation as a response to professionalism lapses in medical students. Additional common strategies utilized by participant medical schools in this study include a remediation assignment (directed readings and writing), mandated mentoring, stress management counseling, and community service [20]. For residents, the ACGME [21] suggests individual learning plans as faculty-guided but self-directed learning process for residents to “identify and/or acknowledge learning needs, find resources to meet those needs, and subsequently evaluate their own achievement.” Per the ACGME, this process is an integral part of maintaining professional competence and should be utilized not only for those residents who have been identified as problematic by clinical competency committees but for all trainees.

While academic psychiatrists might be sought after for their ability to provide information on mental health conditions that may impact professionalism or arise from the stress of the evaluation and remediation process or to provide referrals for mental health treatment and assessments of ability to return to work, they must be clear on their roles and boundaries. Academic psychiatrists have the unique perspective of being both educators and clinicians specialized in understanding and addressing conditions that may affect professionalism and other competencies, but when functioning as medical educators, they need to apply standards that are consistent with training requirements across all medical specialties and with general laws of employment. We hope that future work could elaborate on this distinct challenge in psychiatric education.

Despite the clear importance of professionalism in medical school and residency training, the articles published within this issue highlight continued difficulties with remediation and education on this topic. Godschalx and van Mook [1] point to the need for evidenced-based strategies to rectify professionalism, as residents in their study who were dismissed for unprofessional behaviors had failed multiple methods of remediation. Vesentini et al. [2] discuss the need for more practical and solutions-oriented education related to romantic and sexual feelings in psychotherapy training. Academic psychiatrists and educators should be aware of the needs of students as they progress through medical school and residency training and create, study, and disseminate curricula, assessment methods, and remediation strategies that help to develop professional and ethical physicians.