When Joel Bervell thought of professionalism as an undergraduate, he thought of “Grey’s Anatomy.” Specifically, he thought about how the show’s residents were expected to be, though they often weren’t: on time, prepared for their situations, and respectful of everyone around them.
“That was the only role model I had for what it means to be a doctor — especially someone like me, who doesn’t come from a family of doctors,” Mr. Bervell said. 28, fourth year medical student at Washington State University. Mr Bervell, who is Ghanaian-American, is one of the first black medical students at the medical college, which opened in 2017.
From the moment students set foot in medical school, they are instilled with the concept of medical professionalism: their sacred responsibility to conduct themselves with the values of a profession that is automatically trusted by society. “It’s the first thing they tell you: You are now literally a medical professional,” Mr. Bervell said.
The same metric can be used to determine whether a medical student will become a doctor or not.
Beginning in their third year, Mr. Bervell learned, he and his classmates would be regularly evaluated on their professional behavior, along with other attributes such as communication skills. Faculty, staff and other students could also report specific concerns about an individual’s professionalism, resulting in records, the contents of which could be attached to their permanent records, following them like scarlet letters.
The problem, as many medical students have learned, is that where “professional” is vague, “nonprofessional” is even more so. Depending on who’s making the call, unprofessional behavior can mean hugging your program director, letting a bra show, wearing braids, wearing a swimsuit on the weekend, or wearing a “Black Lives Matter” sweatshirt to the ER
As a result, professionalism exists on two levels, both as a high standard of behavior and as a (sometimes literal) list of dos and don’ts that cloud ethics and appearance. That second meaning can prove particularly damaging to residents of color, said Dr. Adaira Landry, a consultant at Harvard Medical School and co-author of a recent journal article on the “over-policing” of Black residents.
The article was published in The New England Journal of Medicine, adds to the growing literature documenting the ways in which residents of color are disciplined or removed from medicine. In 2015-16, 20 percent of interns dismissed from residency were black, although black students make up only 5 percent of residents, according to unpublished data from the Accreditation Council for Graduate Medical Education, or ACGME
For students who did not grow up in the culture of medicine or who do not resemble an outdated notion of what a doctor should look like (white, male, elite), these opaque rules can be a minefield. “The environment is so restrictive in terms of what’s allowed that when you act or look or speak differently, it feels unprofessional,” Dr. Landry said.
Among the minority students with whom Dr. Landry and those facing probation or dismissal, has seen a common thread. “I’ve never had a student tell me they’re being kicked out because of a grade,” he said. “The overwhelming theme is that these are interpersonal conflicts, characterized as challenges to professionalism.”
From the code of ethics to the dress code
The high ideals that Mr. Bervell met on his first day are more in line with the original conception of professionalism, said Dr. David C. Leach, who served as the ACGME’s executive director from 1997 to 2007.
At the time, medicine was at a crossroads. Giant corporations were grabbing individual practices and turning them into for-profit businesses. Doctors saw their time with patients decrease and patients saw their quality of care decrease.
“There was a growing public perception that doctors were just like everyone else: They just want to make money,” said Dr. Matthew Winia, a medical ethicist who studies managed care ethics during this period. “The fear was that our sense of professionalism had been lost.”
In response, the board began defining a set of general competencies: measurable outcomes that a resident had to demonstrate before proceeding on the journey to becoming a physician.
Of the six competencies the board eventually established, professionalism came closest to the heart of what it meant to be a physician. “It is a set of promises for the credibility of both the profession as a whole and the individuals who practice it,” wrote Dr. Leach in 2014. Many believed that professionalism was the key to helping medicine restore its values as an ethical-based altruistic profession — one devoted to patients, not substance.
Professionalism was also the most vague skill on the list. The 1999 definition characterized professionalism as “a commitment to the performance of professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.” Doctors were also expected to display a number of characteristics in every interaction, including compassion, respect, humility, integrity, accountability.
Institutional managers complained that, compared to things like patient care and medical knowledge, professionalism was hard and hard to measure. The concerns boiled down to, “I’m a very busy program manager, so what the hell am I supposed to do?” Dr. Leach recalled.
The problem of ambiguity never went away, said Dr. Deborah Powell, a former executive dean at the University of Kansas School of Medicine who was on the ACGME board at the time. In the 2000s, debates about what constituted professionalism often focused on how doctors should dress. “You shouldn’t have beards, you shouldn’t have long hair, women should wear skirts,” Dr Powell said. “It was crazy. We crossed the sea.”
These discussions are still happening today. Dr. Londyn Robinson, now a resident at Duke University, learned the second definition of professionalism in 2020. While looking for advice on applying to residencies, she came across an article in the journal Vascular Surgery titled “Prevalence of Unprofessional Media Content social networking among young Vascular Surgeons”.
The authors had read the social media accounts of 500 surgical interns and rated them for professionalism without knowing it. By the authors’ definition, potentially unprofessional content included photos of residents holding alcoholic beverages, wearing carnival costumes, or “provocatively posing in bikinis/swimsuits.”
To Dr Robinson, who is the first in her family to earn an MD, the paper revealed that, for some, professionalism had been reduced to superficial attributes rather than ethical behavior with patients. “Basically, they said the quiet part out loud,” he said.
A new ideal
As Dr. Robinson learned, professionalism now radiates beyond the clinic or classroom. Mr. Bervell’s instructors had warned him about the consequences of social media: Because medical students represented the profession at all times, they said, being professional meant thinking twice before speaking online about politics or issues. such as abortion.
Mr. Bervell did not heed precisely this warning. During the Covid-19 pandemic, he started making TikTok videos highlighting racial bias in medical tools like pulse oximeters and lung function tests. (Both are less accurate for nonwhite patients, according to studies), giving it the moniker of “medical myth.” His videos have been added to medical school syllabi, garnered accolades from the American Medical Association, and earned him a spot on the White House Health Leaders in Social Media Roundtable.
By his school’s standards, Mr. Bervell said, his social media activism could be considered unprofessional. But, he added, he saw challenging health care’s gaping racial disparities as part of his role in changing medicine — and, perhaps, giving doctors something better than “Grey’s Anatomy” as a model for how to be a professional.
The ambiguity of professionalism can be a challenge not only for students of color but also for anyone who escapes the historical stereotype of the physician. Dr Robinson noted that people judged on their swimwear in the journal Vascular Surgery were more often women than men.
In 2020, exasperated by the paper, posted a photo of herself in a bikini and shorts on X, formerly known as Twitter, with the hashtag #MedBikini. “I’ll say it: I wear a bikini. I’m going to be a doctor,” Dr. Robinson wrote. By the next day, her post had gone viral and the paper was officially retracted.
In an apology, the journal’s editors acknowledged that “professionalism has historically been defined by and for white, heterosexual men and does not always speak to the diversity of our workforce or our patients.”
As the face of medicine changes and platforms like TikTok and Twitter transform the way medical knowledge is shared, the original architects of professionalism still believe that the basic tenets of the term will remain central to medicine.
For Dr. Leach, the definition is simple. “Do you discern and tell the truth? Do you put the patient’s interests before your own? And do you develop practical wisdom that can integrate the best science with that particular patient’s evidence to arrive at a creative clinical decision?” he said. “If you do these three things, then you are a professional.”
He added: “And the dress code is so far and away from those three things.”
