Abstract
Professionalism is an indispensable element in the compact between the medical profession and society that is based on trust and putting the needs of patients above all other considerations. The resurgence of interest in professionalism dates back to the 1980s when health maintenance organizations were formed and proprietary influences in health care increased. Since then, a rich and comprehensive literature has emerged in defining professionalism, including desirable individual attributes and behaviors and how they may be taught, promoted, and assessed. More recently, scholarship has shifted from individual to organizational professionalism. This literature addresses the role that health care organizations can play to establish environments that are conducive to the consistent expression of professionalism by individuals and health care teams. We reviewed interdisciplinary empirical studies from health care effectiveness and outcomes, organizational sciences, positive psychology, and social psychology, finding evidence that organizational and individual professionalism is associated with a wide range of benefits to patients and the organization. We identify actionable organizational strategies and approaches that, if adopted, can foster and promote combined organizational and individual professionalism. In doing so, trust in the medical profession and its institutions can be enhanced, which in turn will reconfirm a commitment to the social compact.
The medical profession enjoys certain rights and privileges that are granted by society and its representatives and agencies.
1
Included are a degree of self-regulation, oversight of medical education, the disciplining of errant physicians, and the attainment and maintenance of certification. In return, the profession is expected to respond by placing the needs of patients and society ahead of all other considerations. The compact thus formed is nurtured by the consistent expression of professionalism responsibilities by individuals, health care organizations, and learned societies. Threats to the compact resulted in alarm bells being sounded in the early 1980s, a time of rapid expansion of health maintenance organizations, other for-profit entities, and increasing proprietary influences in health care. The editorial pages of prestigious journals shone a light on the dangers associated with entrepreneurialism in medicine.2
, 3
A call to action around traditional professionalism values served to constrain the pure business model of medical care delivery and what Arnold Relman famously referred to as the “medical-industrial complex.”4
The movement was given further impetus by the identification of professionalism as a core competency and by the ground-breaking “physician charter.”6
The movement proceeded through discovery and definition of professionalism followed by assessment and institutionalization of standard requirements in measuring and teaching professionalism.7
, 8
, 9
, 10
, 11
These phases of the professionalism movement focused mostly on individual professionalism responsibilities rather than on the expectations for health care organizations. A broader role for professionalism was proposed that would serve to balance regulatory, oversight, and business influences in what was termed the “third logic.”12
More recently, greater attention has been paid to the roles and responsibilities of health care organizations in shaping practice, education, and research environments that promote professionalism. The importance of shaping organizational strategies around values and strong interpersonal relationships, reinforced by the alignment of systems and structures, has been emphasized.
13
Relevant competencies of organizational professionalism derived from ethical values that align corporate decisions and behaviors with their stated mission and vision have been outlined.14
Strategies to combine individual and organizational approaches through a dynamic and system approach have also been advocated.15
But it might be asked whether health care organizations can achieve such ideal environments at a time of spiraling costs and budgetary constraints. We have reviewed empirical evidence in support of the hypothesis that investment in organizational professionalism results in a number of benefits that include the following:
- 1.Increased patient and community trust in the organization;
- 2.Improved patient safety, satisfaction, and overall health outcomes;
- 3.Improved organizational performance and reputation;
- 4.Heightened sense of meaning and purpose that translates into greater staff morale, well-being, engagement, retention, and overall productivity; and
- 5.Formative learning environments conducive to continuous improvement.
Organizational Professionalism: Background and Outcomes
Professionalism and Trust
Trust is an essential social nutrient for optimal human flourishing within organizations and is the foundation for social harmony and commerce; it is included in many accepted definitions of professionalism.
17
Trust is also a collective social phenomenon reflected in the organization's culture; trust influences the extent to which individuals freely identify with the organization's values and commitments, a requisite of organizational professionalism18
and an indispensable feature of the doctor-patient relationship.19
The consistent expression of the attributes and behaviors of professionalism, including altruism, excellence, skillfulness, dutifulness, and accountability, generates and sustains patient trust.20
Patients with high trust in their physician are more likely to seek care, do so in a timely manner, are more willing to share highly personal and confidential information, adhere more to treatment recommendations, and return when needed for follow-up care21
; all these are important determinants of health care outcomes in which regulators and third-party purchasers of care increasingly grade both the individual physician and their organizations.22
, Quality check, online tool to compare hospital performance. The Joint Commission website. http://www.qualitycheck.org/consumer/searchQCR.aspx. Accessed February 13, 2014.
23
Patient loyalty is also enhanced and, with it, the reputation of the organization, driving ongoing support through word-of-mouth referrals.Medicare.gov Hospital Compare website. http://www.medicare.gov/hospitalcompare/. Accessed February 13, 2014.
20
Annual Gallup poll surveys confirm that trust in individual physicians by the public remains relatively high in contrast to the consistently low ratings of health maintenance organization managers.
24
But trust enjoyed by physicians can erode in conditions in which the physician's values, priorities, or norms conflict with those of the health care team or organization.Rating of honesty and ethics. GALLUP website. http://www.gallup.com/poll/159035/congress-retains-low-honesty-rating.aspx. Accessed February 13, 2014.
18
With an increasing percentage of physicians joining for-profit groups, this is of contemporary relevance.25
Concerns have been raised that profit incentives might be at odds with professionalism commitments, thus compromising the desire of individual physicians to serve as patient advocates. In the following sections, we discuss beneficial outcomes of high-trust cultures to the organization, individual physicians, and patients. We then discuss specific interventions proven effective in other industries, around the notion of shared values and norms based on trust. Our objective is to provide an evidence-based case for why developing a strong culture for organizational professionalism nurtured by trust promotes organizational and individual resilience.26
Patient Safety and Quality of Care
The aviation industry offers the most dramatic example of the benefits derived from cultures in which trust and organizational professionalism values thrive. As with health care, aviation is highly dependent on the coordination of specialists on a team. Investigation of the causes of airline accidents identified flawed communication resulting in poor coordination in decision making between crew members in the cockpit as a common denominator.
27
This denominator could frequently be traced to a lack of assertiveness in confronting members of a higher organizational rank or where lack of respect and mutual support dominated the work environment. After the introduction of mandatory team training programs that addressed these issues in the late 1980s, the risk of a passenger dying as the result of error in coordination among crew members was reduced by 60%.27
The relevance of this literature to medicine is illustrated by a much-cited study by the Institute of Medicine, in which medical errors were found to result in 98,000 deaths annually and that those errors could have been prevented through better coordination and communication.
28
The Joint Commission analysis of hospital sentinel events pointed to flawed communication as a frequent contributory factor and prompted an advisory about the importance of teamwork and communication.To err is human: building a safer health system. Institute of Medicine of the National Academies website. http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx. Accessed February 13, 2014.
29
Shifting the delivery of health care services from an individual to a team-based model has been found to increase efficiency and patient and staff satisfaction, improve internal communication, and improve quality of care, outcomes, and brand loyalty while reducing costs, medical errors, and malpractice claims.Sentinel event alert: behaviors that undermine a culture of safety. The Joint Commission website. http://www.jointcommission.org/assets/1/18/SEA_40.PDF. Accessed February 13, 2014.
30
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Recent studies examining factors associated with superior outcomes of acute myocardial infarction found that teamwork and communication are key characteristics of high-performing hospitals.
32
Such organizations were noted to have a strong sense of shared values, effective communication and coordination, an attitude of embracing ongoing learning and problem-solving (as opposed to blame or punishment), and adequate funding and support by senior managers.Litigation
Characteristics of communication between the patient and the physician in low-trust organizations include abrasive tone of voice or nonverbal cues that signal dominance and authority and are associated with an increased likelihood of malpractice claims and litigation.
33
Higher social dominance hampers the patient-physician relationship around care decisions. There is a reduced risk of malpractice claims when physicians spent more time with each patient (an average of 3 minutes longer) orienting them to what would occur during the visit, used more active listening, and were more likely to use humor.34
These examples are characteristic of patient-centered communication, in which the power distance between the physician and the patient is reduced. The favorable effect of team-based care on malpractice claims has already been cited.30
Greater accountability and transparency in the disclosure of medical errors has occurred in recent years, which engenders trust and is interpreted as an expression of patient advocacy. Organizations that have adopted these approaches report a substantial reduction in the rates of new liability claims and costs.35
Physician Recruitment and Retention
The Association of American Medical Colleges predicts an overall shortage of 130,000 active care physicians by 2025.
36
With estimates that 1 in 3 medical school faculty is 55 years old and nearing retirement, the number of vacancies is predicted to increase over time and shortages are anticipated.Kirch DG. A future that inspires. President's address presented at the 2010 Annual Meeting; November 7, 2010; Washington, DC. https://www.aamc.org/download/169720/data/kirch-2010-future.pdf. Accessed February 13, 2014.
37
Many younger academic medical center faculty members have quite different career expectations related to work-life balance than do more senior colleagues.Alexander H, Liu CQ. The aging of full-time U.S. medical school faculty: 1967-2007. Anal Brief. 2009;9(4). https://www.aamc.org/download/102368/data/. Accessed February 13, 2014.
38
Physician shortages may be further exacerbated by budget constraints, early retirements, and the anticipated influx of newly insured patients as a result of the 2010 Affordable Care Act.Increased competition for talent requires health care organizations to have an integrated approach that focuses on employee engagement and well-being to improve retention. Research finds that the cost of replacing a physician ranges from $115,000 to $587,000,
39
and it is estimated that a minimum of 10 years is needed to recover the cost of recruiting a physician.40
A recent study shed light on cultural attributes that are predictive of faculty intentions to leave.41
Prominent among them is the sense that their personal values were at variance with those of the organization, which may lead to feelings of “isolation and invisibility.”41
Organizations that strategically cultivate an organizational culture based on respect, trust, inclusion, and mentoring in career and leadership development are more likely to retain talent. Because attrition rates are higher among early career women and minority academic physicians, a focus on strategic recruitment and retention can result in greater diversity within the organization.
37
This diversity can be highly beneficial to organizational performance, as companies with greater gender diversity in leadership have improved financial performance.Alexander H, Liu CQ. The aging of full-time U.S. medical school faculty: 1967-2007. Anal Brief. 2009;9(4). https://www.aamc.org/download/102368/data/. Accessed February 13, 2014.
42
Well-Being and Professionalism
Physician well-being is essential to their expression of their professionalism and capacity to provide compassionate and effective patient care.
43
Well-being is not simply contentedness, complacency, or passivity, but rather the emotions most prevalent in high-performing organizations are joy, interest, and caring.44
In positive psychology, well-being implies an individual's capacity to find meaning and purpose in work and life and achieving a sense of thriving; thus, well-being is more than the absence of discomfort or suffering.45
Well-being is shaped by both personal- and environment-level characteristics. Individual-level factors include personality traits or temperament, self-efficacy, ability to cope with stress, and general mental and physical health. Environment-level factors include organizational culture and societal systems of health care. Well-being can be enhanced through training in mindfulness, effective team skills, and fostering a culture of respect and caring.46
, 47
Burnout, the antithesis of individual well-being, involves a dampening of emotions such as empathy and compassion, also called compassion fatigue.
48
, 49
A recent large-scale study found that 1 in 2 physicians reported symptoms of burnout, which exceeds all other allied health professionals in the United States. In a large study that compared physicians with professionals from other fields, 38% of physicians reported symptoms of burnout compared with 28% of nonphysicians.50
The issue of physician burnout and its adverse effect on patient care prompted the Joint Commission to require health care organizations to address physician well-being in programs and policies.
43
Three psychological needs are necessary: (1) autonomy, or feeling that what one is doing is freely chosen and consistent with core values; (2) competence, or feeling that one is capable of the work one is performing and has adequate resources; and (3) relatedness, or feeling valued and appreciated.51
Three types of environmental factors can reduce physician well-being: (1) the nature of the physician's role, front and center in the human drama of patient illness or death, family distress, adverse outcomes, or medical errors that may or may not result in litigation; (2) policies that mandate increased workload to a degree that frustrates and compromises physician advocacy of patients; and (3) an organizational culture in which disrespect, intimidation, and incivility prevail.52
Research on group dynamics and teamwork establishes that high-performing teams generate the positive emotions associated with well-being.
53
This finding facilitates the development of strong social bonds that can buffer against stress, fatigue, or burnout.49
People who have their basic needs met will be more engaged, both cognitively and emotionally.54
A survey of managers found that 13% of their time is spent resolving conflicts arising from rude or uncivil behavior, the equivalent of more than 6 weeks per year.
55
In health care settings, a climate in which incivility, rudeness, and intimidation are permitted compromises patient safety.29
Professionalism and well-being are threatened by a pattern of insidious behaviors that signal a lack of respect for others and referred to as incivility in organizational psychology.Sentinel event alert: behaviors that undermine a culture of safety. The Joint Commission website. http://www.jointcommission.org/assets/1/18/SEA_40.PDF. Accessed February 13, 2014.
56
Incivility includes rudeness, overt intimidation, aggression, or humiliation; disruption; and uncooperative or passive-aggressive behavior.52
More subtle forms of incivility are less apparent to all except those immediately affected and are all too common.56
A survey by the Institute for Safe Medical Practices (2004) found that 40% of pharmacists had experienced intimidation by prescribers, which kept them from contacting the prescribers to clarify medication orders. Intimidation is conveyed both verbally with condescending language and nonverbally by showing impatience through tone of voice or body language.55
In a study of a state licensing and supervision board, roughly one-half of the patient complaints stemmed from rude behavior by the physician or employees. The cost of settling these disputes can exceed those from malpractice lawsuits.56
In contrast, a culture of respect increases patient safety, reduces medical errors, and reduces the incidence of sentinel events in hospital care. The necessity of modeling respect and holding all members of the health care team accountable is clear.
52
Staff Engagement and Productivity
Recent studies find a strong causal link between levels of employee engagement, business outcomes, and profitability; the cost of lost productivity in the United States stemming from a lack of employee engagement has been estimated at $350 billion annually.
57
Engaged employees are less likely to use sick time, have a stronger commitment to their employers, are less likely to leave the organization, and are more willing to expend discretionary effort. Organizations with high levels of employee engagement have reduced error rate, better quality, higher sales and profits, greater levels of customer satisfaction, and greater rates of business growth.58
Organizations with highly engaged employees boast 4 times the earnings per share than those of companies with less engaged workers.31
, 59
An organizational culture that is thriving is a valuable intangible asset that represents 65% to 85% of the company's stock price.Harter J, Agrawal S, Plowman S, Asplund J. Employee engagement and earnings per share: a longitudinal study of organizational performance during the recession. GALLUP website. http://www.gallup.com/strategicconsulting/157199/employee-engagement-earnings-per-share.aspx. Accessed February 13, 2014.
26
Organizational environments that promote professionalism can enhance employee engagement
60
and are characterized by (1) job role clarity, (2) feeling appreciated and valued, (3) having positive relationships with coworkers or colleagues, and (4) opportunities for learning and skill development.44
Disengaged employees, however, are at significant risk for illness and chronic health problems, which represent increased cost to employers. They are more likely to receive a diagnosis of depression and have increased stress levels and greater risk of heart disease, which results in company health care costs being twice as much as those for engaged employees.
61
Healthy Learning Environments
Professional attitudes and behaviors are shaped during the period of student residency and fellowship training.
8
Academic medical centers and other teaching facilities, therefore, have a great responsibility to adequately prepare medical students and residents through well-structured formative educational programs that emphasize frequent and constructive feedback within an environment of challenge and support. Professionalism lapses in medical students have been found to be a predictor of subsequent action by state boards of medical examiners.62
It is therefore an important responsibility of medical schools to continually assess professionalism behavior and act when lapses are documented.Society and its governing agencies place great importance on high-quality training to which the Medicare program commits more than $3 billion annually in direct support for residency training. The pursuit of mastery in the art and science of medicine is facilitated through formative educational programs complemented by on-the-job clinical experience in an environment conducive to learning. Faculty must provide oversight, support, and encouragement.
63
The learner's development of professionalism values and behaviors is profoundly influenced by good faculty role models.64
The attitudes and behaviors of learners can be reinforced or undermined by what is observed as well as by what is interpreted from the hidden curriculum or the implicit norms and values of the organization.10
The faculty must in turn be appropriately supported and resourced by the organization; that is, clinical productivity expectations should not overburden faculty, taking them away from their teaching responsibilities.65
Medical training is not alone in this, as innovative and curricular changes are proving to be effective in the formative education of law and business school graduate students.66
, 67
Johnson DW, Johnson RT, Monson V. Cooperation-competition and constructive controversy in developing professional ethics in law school classes. University of St. Thomas Legal Studies Research Paper No. 12-43. http://ssrn.com/abstract=2169496. Published Sept 22, 2012. Accessed February 13, 2014.
Implications for Health Care Leaders: Engineering a Professionalism Compact
Social capital business strategies characterized by informal, supportive, and trusting networks have been found to enhance teamwork and mutual understanding among employees of highly successful multinational corporations. The term cultural capital describes the intangible asset of a thriving, resilient organizational culture.
26
What can leaders do to engage in lasting culture change? In the following section, we review key elements that together promote organizational professionalism and sustainable results that benefit the patient and the organization. They include (1) leadership development, (2) fostering an organizational professional identity among personnel, (3) cultivating the core values of teamwork, (4) support for autonomy, and (5) fostering employee well-being and engagement as a core strategy.Leadership Development
The Healthcare Leadership Alliance posits professionalism as 1 of the 5 competency domains for all practicing health care managers that, when combined, form a “Competency Directory” that may be used in both individual and organizational assessment.
69
Physicians must exhibit both professionalism and leadership skills to function effectively in environments that are team based, recognition of which has prompted new curricular approaches.70
The attainment and maintenance of environments conducive to professionalism is heavily dependent on the active support of institutional leaders who, through their words and deeds, exhibit high standards of professionalism. The favorable effect of professionalism on the conduct of clinical trials, industry relations, and the clinical and educational environment of academic medical centers has been confirmed.71
When policy decisions are at variance with stated values, trust erodes. What follows is dysfunction and cynicism, which ultimately results in substandard care and compromised patient safety.52
It is incumbent on organizations to implement best practices in evidence-based leadership development.72
National Healthcare Leadership Survey: implementation of best practices. National Center for Healthcare Leadership website. http://www.nchl.org/Documents/Ctrl_Hyperlink/doccopy4080_uid872013448472.pdf. Accessed February 13, 2014.
Organizational Professional Identity
A method called recategorization of social identity
73
from an individual to an organizational level makes salient the importance of the organization's broader purpose and values, providing the basis for a diverse team of professionals to work cooperatively and efficiently in placing the needs of the patients and society above self-interest.74
When individuals can cognitively shift from a singular identity as a surgeon, oncologist, nurse, or administrator to a more complex and overarching identity on the basis of the organization's values and purpose, greater alignment between espoused values and those in practice occurs.46
Organizational identity does not compete with individual professional role identity or imply reduced individual accountability. The mechanism by which this works stems from the human tendency to categorize self and others as either an in-group or an out-group member.75
When team members shift self-categorization to the organizational level, a new and overarching in-group is then created that is interdependent with individual role identity and trust among group members is enhanced.62
The ideas of organizational professional identity76
and organizational trust46
extend scholarship on organizational professionalism in health care.14
Organizational professionalism is reflected in cultures in which individual values and sense of purpose align with the organization's values and mission.26
Fostering a collective organizational professional identity typically involves education and training in teamwork, human relations, and group dynamics.27
Core Values of Teamwork
For health care teams to function well, members need to identify with a common set of norms and values that are central to organizational professionalism.
14
, 76
Effective health care teams identify with an overarching goal of helping patients.62
Teamwork is described both as a value and as a group characteristic that promotes a subset of shared values that are intrinsic to professionalism. The Agency for Healthcare Research and Quality has identified that organizational climates in which teamwork is a core value are positively related to improved patient safety and quality outcomes.77
Group cohesion is reflected in teams in which members signal mutual respect and trust.TeamSTEPPS: National implementation. Agency for Healthcare Research and Quality website. http://teamstepps.ahrq.gov/about-2cl_3.htm. Accessed February 13, 2014.
47
A recent working group of the Institute of Medicine defined the values associated with teamwork as honesty, discipline, creativity, humility, and curiosity.
53
The values of cooperative teams are defined as self-respect, mutual respect, and equality.78
Organizational theorists describe team building as integral to developing organizational resilience.79
Teams operating with a collective organizational professional identity can more fully focus on helping the patient and delivering quality care—beyond the sum of abilities of individual team members.80
The capacity for individuals to work effectively within a team and across role boundaries can be fostered through education, training, and modeling27
and is critical to addressing issues of cost, quality, and safety.53
, 81
Coburn, AF, Gage-Croll Z. Improving hospital patient safety through teamwork: the use of TeamSTEPPS in critical access hospitals. Policy Brief #21. www.flexmonitoring.org. Accessed February 13, 2014.
In high-functioning health care teams, all members are empowered to ask for clarification should concerns arise, which helps to create a learning culture that is critical to reducing medical errors. Extending trust fosters a sense of competence and autonomy, which is essential to human motivation that promotes discretionary effort.
82
The opposite paradigm relies more heavily on monitoring, assessment, and measurement, which may be instructive but can sow distrust.Autonomy and Trustworthiness
Organizations that operate on a foundation of trust provide members of the health care team with a degree of autonomy and flexibility that takes into account individual patient needs and preferences while adhering to validated practice guidelines. Patient-physician relationships in which patient needs and preferences are understood and supported translate into improved outcomes of care. Patients with diabetes mellitus who rated their physicians' support for their autonomy as high had statistically significantly improved levels of hemoglobin A1c (P<.01).
83
A meta-analysis of studies involving the use of patient autonomy support reported a consistent positive relationship with physical and mental health outcomes84
while increased levels of employee autonomy consistently enjoy higher levels of motivation.85
Fostering Employee Well-Being and Engagement as a Core Strategy
The final element that leaders should pay attention to is the development of organizational strategies that promote and sustain employee well-being and engagement. Most of the elements that Gallup has identified as predictive of improved financial performance of the organization occur through a strong emphasis on organizational professional identity and teamwork, but others are more directly shaped by the hidden curriculum of compensation policies and target goals for productivity or performance. Several prominent and highly successful health care organizations have structured their compensation program in a manner that serves to reinforce professional identity and foster teamwork through the use of salaried models of compensation. These organizations, notable for high levels of discretionary effort and low turnover rates, support practice efficiencies, work-life balance, scholarship, and advancement rather than productivity bonuses. Such outcomes are consistent with research findings that rewarding work motivates and is sustained by constructive individual feedback and authority. Further work is needed to identify strategies to mitigate physician burnout, but some recently reported approaches show promise.
86
Conclusion
Health care delivery in the United States is undergoing rapid and systemic change, which is accompanied by rising concerns among patients and physicians as to what it may mean for them. It is against this background that health care organization leaders are attempting to understand and successfully navigate the increasingly complex regulatory and payment system environments, which together have the potential to relegate medical care to the status of a mere commodity. Such an outcome will not serve patients' needs but rather will have the effect of undermining trust, which is an essential component in the compact between the medical profession and society. To avoid such a bleak outcome, a determined recommitment to professionalism by physicians and health care organizations is required. The approaches outlined in this review carry a realistic promise of improved patient safety and outcomes, rewarding and meaningful careers, healthy formative educational environments, and resilient health care organizations combined with renewed trust and respect for the medical profession, which will serve to sustain the social compact.
Supplemental Online Material
References
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