The Professionalism Movement: Behaviors Are the Key to Progress

We applaud Delese Wear and Mark G. Kuczewski's efforts (2004) to improve the discourse of professional development. We particularly applaud their belief that too much of the discourse on professionalism is at the level of values and attitudes and too little at the level of behaviors of teachers, learners, and practitioners. From the ground level these abstract, principle-based arguments look optimistic at best and at worst appear to represent wishful thinking on the part of leaders who might have little or no connection to the realities of medical education and practice. Tyack and Cuban (1995) have suggested that in times when rhetoric seems futile and irrational but continues in spite of this perception, the rhetoric might well be reflecting what they call "policy talk." Policy talk is "an inevitable result of conflicts of values and interests ... reflecting changing climates of public opinion.... In such periods, policy elites often take the lead in diagnosing problems and proposing educational solutions."

This describes well the situation in which we exist today. Policy elites propose optimistic value-laden principles, while students and teachers struggle to make sense of the conflicting values abstracted from their daily lives. The empirical research in professionalism over the past decade has indeed focused on the lives of student and resident learners, documenting this discordance (Feudtner, Christakis, and Christakis 1994; Stern 1996; 1998). Much of the current focus on professionalism benefits from these studies—including the ideas that teaching and learning should be behavior-based, that professional-values conflicts are important learning opportunities, and that changing the formal curriculum might not ultimately change the hidden curriculum. Only recently are efforts underway to understand how institutions can alter a course that is predominantly taught in the hidden curriculum (Liaison Committee on Medical Education Colloquium 2003; Ginsburg, Regehr, and Lingard 2003).

Wear and Kuczewski further suggest that "the theory of professionalism should be constructed from a dialogue with those we are educating." In fact, several recent papers have done just that, adding to the discourse by seeking to understand students' own perceptions of professionalism and lapses in professionalism. For example, we found that a behavior-based framework, grounded in the students' own language and perceptions of lapses in professionalism, was perhaps more reflective of their reality than the abstract definitions often promoted (Ginsburg et al. 2002). By framing professionalism in terms of behaviors rather than abstractions, we come much closer to a context-bound, realistic framework for understanding professional behavior.

Other studies have explored the reasoning strategies that students engage in when dealing with challenging professional situations, to better understand how students make decisions and justify their actions. In two studies that analyzed written essays, it was found that when students report these experiences they invoke reasoning strategies that enable them to "re-story" the lapses in professionalism that they have encountered (Lingard et al. 2001; Ginsburg, Regehr, and Lingard 2003). This re-storying provides insight into the "double-binds" that students experience and into their efforts to transcend these binds and develop their own professional identities. Further work has examined students' reasoning strategies in response to videotapes of five standardized professional dilemmas. In one study students were motivated to consider actions by referencing a principle (an abstract or idealized concept), an affect (a feeling or emotion), or a potential implication of a proposed action (Ginsburg, Reger, and Lingard 2003). Some of these principles and implications are avowed as ideals of our profession, while others are unavowed or even actively disavowed (e.g., considering implications for the student himself or herself). Understanding what motivates students to act is an important step in developing appropriate educational interventions.

Apart from the need to ground our theory in the language of our learners, we also must look at the discourse on professionalism assessment. The language often used to define professionalism, such as altruism, honor, and integrity...