"Professionalism can be defined as any behaviors that support trustworthy relationships."
Respectful, professional behavior fosters trust and is positively correlated with team and workplace satisfaction. Being treated with respect is correlated with increased job satisfaction and decreased burnout.8 Conversely, a toxic work environment has a negative effect on clinician wellness. Professionalism also influences morale, productivity, recruitment, and retention. An organizational approach to professionalism needs to be comprehensive, including developing a code of conduct to set institutional expectations for everyone.
In a wider sense, the problem can be framed as one of professionalism in the workplace. Professionalism is an umbrella term to define behaviors that support trustworthy relationships. Unprofessional behaviors range from criminal, such as sexual assault; non-criminal but illegal, such as sexual harassment; and disruptive, such as bullying, which is not illegal but harmful and unacceptable. I will focus here on non-criminal behaviors. Many people have examined the definition of medical professionalism as well as the sociological contexts and prevalence of unprofessional behaviour.1-3 But we face great challenges in preventing recurrent unprofessional behavior. We urgently need to meet these challenges more effectively.4
CALL TO ACTION?
Understanding the effects In handling reported concerns of unprofessional behavior involving over 400 health professionals, I have rarely met anyone who intended to demoralize or intimidate. Yet that is precisely the effect their behaviors have had on others. What matters is the effect, not the intent. Unprofessional behavior can be devastating and can affect patient safety and quality,5-7 the clinical learning environment,8 and the wellbeing of the healthcare team.9 Over time, this may contribute to clinician burnout10 and even suicide, as well as to poor workplace morale and reduced productivity, retention, recruitment, and institutional reputation. This harm is often hidden but truly costly.
In the past, we may have been unaware of how destructive and dangerous such behaviors were, both to patients and to the healthcare team, including vulnerable learners. But given the unassailable data on the damage of such behaviors,2 5-9 we can no longer turn away. Cognitive and technical competence is not sufficient and can never outweigh the responsibility we each shoulder to behave professionally and to hold ourselves and our colleagues accountable.
Meeting these challenges requires institutional will and collective responsibility. For prevention, we must set clear expectations for behaviors, including the responsibility to confront or report colleagues’ lapses of professionalism. It is especially important to determine whether there is a pattern of unprofessional behavior and if the behavior is illegal, egregious, or both.
We should train healthcare providers in skills such as giving difficult feedback, conflict management, and combating unconscious bias.
We need to create safe, accessible processes at the local level for reporting concerns and have a process for assessing the validity of the concerns; the process needs to be fair to both the reporters and those accused.11
We should give feedback so that the individual has an opportunity to improve, focusing on behaviors, not on character or diagnoses.
We should listen with compassion to the response to feedback, including what the triggers and contributing systems issues are.
Although we must work to improve systems, we must simultaneously be clear that the behaviors are harmful and must stop. It is crucial to state explicitly our zero tolerance for retaliation, as well as the process for monitoring the behavior.
Finally, we need to impose escalating consequences for those who continue to behave unprofessionally.
It is our collective responsibility to support a culture of trust in medicine.12 Just as we hope to be treated with trust and respect by our patients and society we need to uphold that trust as individuals and as a profession. The stakes are high, but the rewards are even higher.
PUBLICATIONS & RESEARCH
Professionalism in Surgery. Shapiro J, Steinberg S, Souba W. In: Ashley S et al, Eds. ACS Surgery, Principles and Practice. Ontario: Decker Intellectual Properties, 2011.
Professionalism for clinicians and scientists. Shapiro J and Employment Learning Innovations. Facilitators guide, Participants Manual, and DVD (simulation scenarios). Employment Learning Innovations, Inc. 2011 Atlanta, GA.
Perspective: The educational community must develop best practices informed by evidence-based research for remediation of lapses of professionalism. Papadakis M, Paauw D, Hafferty F, Shapiro J, Byyny R, For the Alpha Omega Alpha (AΩA)Honor Medical Society Think Tank. Acad Med 2012 Dec;87(12):1694-8
Interns & experiences of disruptive behavior in an academic medical center. Mullan C, Shapiro, J, (Co-corresponding author) McMahon G. JGME 2013; 5(1):25-30.
Supporting Professionalism and Trust. Shapiro J, Nadelman S. In: Plews-Ogan M, Beyt G, Eds. Wisdom Leadership in Academic Health Science Centers: Leading Positive Change. London: Radcliffe Publishing, 2014:74-88.
Instituting a culture of professionalism: the establishment of a center for professionalism and peer support. Shapiro J, Whittemore AW, Tsen LC. Jt Comm J Qual Patient Saf 2014; 40(4):168-177.
Cultural Transformation in Professionalism. In: Medical Professionalism: Best Practices, eds. Shapiro J. Byyny RL, Papadakis MA, Paauw DS. Menlo Park, CA: Alpha Omega Alpha Honor Medical Society, 2015.
Professionalism in Surgery. McMains KC, Shapiro J. In: Ashley S et al, Eds. Scientific American Surgery. Hamilton: Decker; March 2016.
Instituting a culture of professionalism: the establishment of a center for professionalism and peer support. In: Strategies for Creating, Sustaining, and Improving a Culture of Safety in Health Care, 2nd Edition. Shapiro J, Whittemore AW, Tsen LC. Oak Brook, IL: Joint Commission Resources, 2017.
We Have Enough Information to Act. Shapiro J. Otolaryngol Head Neck Surg. 2018;158(6):985-986.
Confronting unprofessional behavior in medicine. Shapiro J. BMJ. 2018 Mar 7;360:k1025.
IN THE MEDIA
RTE Radio 1 Drivetime Interview with Jo Shapiro – July 2019. Professionalism.