Professionalism – Do you know it when you see it?



Our most important role as medical educators is to develop students and residents into expert physicians. Another role, which is particularly important this time of year, is to try to predict which students and residents possess the qualities to become expert physicians. The ability to accurately predict who will and will not become an expert is not only sought by us, but by all parties involved in the medical system, perhaps, most so by patients.

It takes a lot to be an expert physician, but the one attribute that is likely the most important is also the hardest to define, measure, and predict. That one attribute, which more than any other, differentiates the truly excellent from the adequate is professionalism. But how do we measure it? Or more importantly, for many of us in the education community, how do we predict it?

What is professionalism?

There are many definitions, but one which has been quite useful in the medical context, is by Epstein and Hundert:

Professional competence is the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served.1

So often, professionalism is separated from the somewhat more easily defined competencies such as medical knowledge and patient care. However, the above definition rightly includes those competencies in the description of professionalism. It forces us to ask the question, “Can someone be professional without possessing a standard level of knowledge and technical competence?” Or to ask it another way, “Is professionalism actually a global assessment of the physician rather than one aspect of that physician’s performance?”

How is professionalism measured?

A multitude of professionalism measures have been developed and tested and while many are useful, there does not appear to be one single best measure of professionalism.2,3 Perhaps the difficulty in finding one single best measure of professionalism lies in the question from the above section. If professionalism truly is a global assessment of the physician, then the best measurement of professionalism would likewise be a global assessment.

Such a simple conclusion is at the same time both logical yet somewhat unsatisfying. So what makes the best global assessment?

How to predict professionalism?
If professionalism really does encompass all of the qualities listed in the definition above, then the best assessment, and therefore likely best predictor of future professionalism, would have to be all encompassing as well. The obvious best fit for this is the letter of recommendation, or more specifically, a letter of recommendation, which includes a comparative statement.

Cullen et al. demonstrated this concept and explored it further in a paper published in the Mayo Clinic Proceedings in March 2011.4 In the study, the authors used a multisource professionalism score based on observational assessment to grade the professionalism of interns in an Internal Medicine residency program. They then examined 10 independent variables contained in the intern’s applications to the residency program to determine which were most closely associated with high mean professionalism scores as an intern. The only association, which remained significant throughout their analysis was the comparative statement in letters of recommendation.

First, to clarify, a comparative statement in a letter of recommendation is simply a statement comparing the subject of the letter to other students with whom the letter writer has worked. The paper classified statements into three categories based on the level of enthusiasm of the comparative statement:

Neutral: “at the level of their peers”, “as expected for training level”, etc. Moderate: “above level of peers”, “top group of medical students”, etc. Most: “best medical student”, “top 10%”, etc.

They examined 725 distinct letters of recommendation, but unfortunately 503 (69.4%) did not contain a comparative statement, so were excluded. The letters were assigned a point value of 1, 2, or 3, corresponding to neutral, moderate, and most enthusiasm respectively. These comparative statement scores were then compared to the professionalism scores that each intern received.

They found a direct association between the strength of the comparative statement in the letter of recommendation and the professionalism score earned by each intern. And despite the small sample size, the findings were significant (p=.002).

Take home message

I think two related conclusions can and should be drawn from the above findings, both of which are of tremendous importance to all medical educators. First, while new and more accurate measures of professionalism will continue to be investigated, at this time, the best measure seems to be a simple, global evaluation based on direct observation of the student or resident. Instead of actually measuring professionalism with a test or mock encounter, perhaps the best evaluation is gained simply by gestalt while observing the student.

Second, as medical educators who routinely both read and write letters of recommendation, we must be cognizant of the importance of these letters. As writers, we should understand the value of adding a comparative statement to the letter instead of writing a more generic or descriptive letter. As readers, we must be alert to finding these comparative statements and considering them with the appropriate magnitude.

Perhaps the best way to measure professionalism is simply to use US Supreme Court Justice Potter Stewart’s quote, “I know it when I see it.”5

For further reading on this topic, consider:

  1. Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287(2):226–235.
  2. Stern DT, Frohna AZ, Gruppen LD. The prediction of professional behaviour. Med Educ. 2005;39(1):75-82.
  3. Stern DT. Measuring Medical Professionalism. New York, NY: Oxford University Press Inc; 2006.
  4. Cullen MW, et al. Selection criteria for internal medicine residency applicants and professionalism ratings during internship. Mayo Clin Proc. 2011;86(3):197-202.
  5. Stewart Potter. Concurring opinion in Jacobellis v Ohio 378 U.S. 184 (1964).

Reviewed in October 2013 by
Jonathan S. Jones, MD FAAEM FACEP
Program Director
Associate Professor
Department of Emergency Medicine
University of Mississippi Medical Center