Behind book on professionalism: ‘we can do better’

It is unlikely that most hospital or medical administrators would devise this scene with individuals draped in saris or dashikis—regardless of how formal this attire is considered in its home culture—or of an individual visibly adorned in ink. Hair is likely short and well kept for men. No bright colors, no braids or afros. Men wear masculine clothing, women aren’t showing too much skin. Everyone dresses and behaves as expected of their sex at birth.

This picture is the ideal that defines the norm. The picture we conjure becomes the appropriate model of conduct. What is apparent in this scene? What is missing? The issue inherent within the conversation about diversity and professionalism is that the demand to conform to this picture identifies a corollary threat: Deviance from this norm—and from what is perceived as professionalism—has its consequences.

Consider: A black female resident received a negative evaluation that critiqued her for standing while engaging with a patient. It was noted she was “too tall,” which was “intimidating for the patient.” Of note, an equally tall white male medical student in her cohort was also standing in this encounter. Why is the same characteristic commented upon for being intimidating and unprofessional for a black woman but ignored in a white man? What identities are unfairly scrutinized and surveilled, and then rationalized as important to address in order to embody professionalism?

Consider: A male resident was advised to remove his earrings due to considerations of professionalism. The individual in question felt it was an important expression of his gender but submitted to the demand because he felt it would negatively impact his future career trajectory. Why does the type of jewelry signal a physician’s capacity to perform as an employee? How do other adornments—tattoos, piercings, a hijab, hair color—undermine perceived authority or competence, and what is the relationship of these stereotypes with status, race, faith, gender, and class?

Consider: In preparation for residency interviews, a black female classmate was told she would need to change her natural hairstyle to something more “professional,” such as straightened hair, in order to present her “best self” to potential residencies. This was a particular point of difficulty for this classmate, who had only recently made a shift to natural hair. Altering its appearance in this way would require significant time, effort, and financial resources. In addition, the decision felt personal, expressive, and political. In a nation where beauty standards were outfitted upon people who did not look like her, whose hair followed the rules, accepting herself and her features for what they were was an act of self-acceptance and love. It was an arena of self-care, a move towards embracing better mental health. This classmate struggled with the decision—should she surrender herself to demands, and tame her hair into something different and notably not herself? Should she surrender her future to herself as a fair price for any indictments of professionalism that might be flung her way? Consider the energy spent on making and following through with this decision, which could have been better spent preparing for interviews. What kind of emotional taxes are placed upon people who look different; what taxes are placed on them in efforts to look less like themselves? How might this scenario look for individuals with disabilities, with traditional clothing, with body art or jewelry? Indeed, how is professionalism defined in this context?

Professional Behavior
Our room of professionals also includes imagined behaviors. What unspoken norms do they follow? How do they react during disagreement? In medical settings, how do they speak about and refer to patients?

Consider: One intern with a physical disability requiring a wheelchair was reprimanded for being absent from Grand Rounds. But the issue was not his dedication, preparedness, or attention. The issue was a consequence of his environment. This student was given limited time to travel from the hospital floors on which he worked to the auditorium where Grand Rounds was held. This time was deemed adequate by others who could walk comfortably through the hospital. He, on the other hand, would arrive late, only to encounter further difficulty maneuvering into a small and already crowded space, impeding his movement and drawing unwanted attention to his chair. Eventually, the physical and emotional labor of negotiating this journey impacted his ability to attend. How does a culture of professionalism inhibit one from asking to have one’s need met? How does an unscrutinized demand for punctuality have more deleterious consequences for some people than others, particularly when some disabilities are more or less visible? Though others perceived the problem to be within the control of this individual, the problem could also have been avoided if the institution itself was more dedicated, prepared, or attentive to creating a more conducive environment where professionalism could have been facilitated by easier access. This student could have presented his cases earlier to allow for extra travel time, and the route to the auditorium could have been examined for accessibility.

Consider: A resident was joking with a bilingual patient in Arabic during rounds. The attending asked that they speak in English in order to ensure other patients feel comfortable, especially since the patient is able to. On another floor, a resident is complimented by a nurse and his attending for sharing stories in French with a patient who had just returned from Paris. What languages are associated more regularly with professionalism, class, and comfort? Whose comfort—patient and provider—takes precedence over others? And what is the source of discomfort or glee when we hear the tones of different languages?

Consider: A male patient made several remarks about a Latina senior resident’s “sexy” figure. She felt uncomfortable and diminished, and clearly stated his comments were inappropriate and would not be tolerated again. He responded with a racialized comment about her “spicy attitude.” She chose to disengage by leaving the room immediately and was later reprimanded for “unprofessional behavior.” How are the “professional” demands to remain pleasant under personal attack much more costly for some individuals? What does it mean to ask someone to calmly and kindly work when their personhood is insulted? In this scenario, the patient inflicted unprofessional behavior upon a provider, and yet the student provider was punished. This scenario can and has been repeated in other iterations. Residents who disagree vocally about the use of derogatory remarks and names when speaking about patients are labeled as oversensitive or angry, and are commanded to meet with leadership about their defensiveness. Women who alert others about instances of sexual harassment often face punitive professional consequences for the disruption, though the violation of professionalism came from another party. What is the emotional burden of working with people who do not respect or defend your personhood, and how does the cumulative impact take a toll?

The preponderance of these stories makes it clear that these are not isolated incidents. Professionalism implies a particular normativity that applies to both appearance and behavior, and these examples illustrate how deviation from this norm results in consequences—especially for individuals who hold identities that sit outside of the “norm” for whom these standards were created. The policing of such standards thus not only defines an “in group,” but also consequently excludes and marginalizes others. While the cases above suggest that this is explicit, we invite the reader to consider the importance of how these issues more often play out implicitly.

Consequences of Implicit Application of a Normative “Professional”
In the fall of 2017, the administration for Yale School of Medicine proposed changes to the evaluation of medical student clerkship performance. One key proposed change was the requirement of a perfect score on the “Professionalism” rubric in order to receive a final evaluation of “Honors.” This was followed by a swift response from students, particularly those holding marginalized identities, arguing that this would have inequitable, harmful consequences, however unintended. The argument hinged on more than such stories as those above that indicated explicit reprimands when conformity to professionalism was not met. In fact, this issue fell conveniently on the tail of the release of a study at Yale that highlighted potential consequences outside formal reprimand.

This study, published in August 2017, examined the performance evaluations (aka the “Dean’s Letters”) of 6000 medical students from 134 schools applying to 16 different residency programs at Yale to investigate the possibility of gendered or racialized differences in how students were subjectively described. They found that white applicants were more likely to be described using “standout” or “ability” keywords (“best,” “exceptional”), while black applicants were more likely to be described as “competent”—and this result remained significant after controlling for board scores. Along lines of gender, they also found that women were more likely to be described in language such as “caring,” “compassionate,” and “empathetic.”¹

Few would argue that these differences were intentional on the part of the evaluators. However, these data support the assertion that implicit (unconscious) biases will inadvertently play a role in trainee evaluation. Thus, when we consider how professionalism is evaluated—a subjective evaluation based in part on particular behaviors and interactions with patients—this study allows us to identify tangible effects of the blanket, uncritical application of a normative “professionalism.”

What Is the Purpose of Professionalism?
So far, we have introduced a variety of ways in which the enforcement of professionalism causes harm to individuals, with some affected more than others. This begs the question: What is the purpose of professionalism to begin with?

The notion of professionalism stems from the verb, “to profess,” a public declaration of knowledge and skill. What skill is declared, and how, in particular, can we implement this skill? What corpus of knowledge encircles what our profession professes? What is appropriate to profess? What is barred, mirrored, fed, and threatened?

A nod to the Hippocratic Oath is important, because it elicits a historical grounding to the concept of professionalism. The Oath is not a demand for pupils to be guided by mastery of a particular set of knowledge and skills but rather is a vow to dedicate using one’s knowledge and skills in ethical ways: to do no harm.

The relationship between professionalism and ethics has become so inextricable that they were practically synonymous through much of the historical discussions on this topic. In fact, the critique thrown to medicine has often centered on the fear of losing “professionalism” to the onslaught of corporate and commercial interest (ranging from pharmaceutical influence to for-profit hospitals), and how this would result in the erosion of medical ethics like compassion and altruism.²

With this historical understanding, few would argue that the concept of professionalism itself—as defined by a relationship of occupation with ethics—is inherently problematic. Few would argue with the inherent value of virtues such as compassion and altruism.

However, professions—and therefore any ideology of “professionalism”—are not stagnant Platonian ideals. They are embodied in the real world and therefore will always be reflections of the sociocultural environment in which they operate.

In medicine, we “profess” ourselves throughout our careers. We fix our lips into the phrasing of the Hippocratic Oath, we declare the values of the physician-patient interaction in our embodiment of the clinical encounter. But the authorities that reside in medicine—the bodies that construct, reify, produce, and define physician professionalism—are vulnerable to the same powers that muscle inequality and marginalization in the world. It is important to recognize how principles of professionalism can be endlessly hostile to individuals that the hospital did not consider when the culture of medicine was being built.

Conclusion: Where Do We Go Next?
What would professionalism look like if it were designed by people who were differently abled, of color, parents, poor? How might it avoid the use of societal standards of professional appearance and behavior (defined by those who do not look or experience the world like them) as a proxy for competence and ethical conduct when caring for patients, which is in fact the historical intent of professionalism?

There is no simple solution to this critique, and we avoid the trap of proposing one. Having expressed the ways in which professionalism is tied to hierarchy and power by nature of being defined by particular individuals at the table, we invite a reimagining of professionalism that genuinely centers on the ethics of the profession: nonmaleficence, beneficence, autonomy, and justice. This requires the very individuals who have been marginalized to take their place at the table in redefining what professionalism is: What it looks like, ways it can be embodied, how it is taught rather than enforced, how it is evaluated rather than policed, and how it can best benefit the entire community, including both patient and provider.

References

1. Ross DA, Boatright D, Nunez-Smith M, Jordan A, Chekroud A, Moore EZ. Differences in words used to describe racial and gender groups in medical student performance evaluations. PLOS One. 2017;12(8):e0181659.
2. A brief history of medicine’s modern-day professionalism movement. In: Levinson W, Ginsburg S, Hafferty FW, Lucey CR. Understanding Medical Professionalism. New York, NY: McGraw-Hill Education; 2014:37–51.