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Chapter 10: Identity Formation and Trustworthiness: Foundations of Professionalism

Chapter Authors: Nicole R. Washington, MD, Carol L. Carraccio, MD, Jessica Fowler, MD, and Beth Rezet, MD

Trust is a foundational component of the doctor–patient relationship and physicians’ professional contract with society. Kennedy et al define trustworthiness as a multidimensional construct that includes the following: clinical knowledge and skills, recognition of one’s own limitations, conscientiousness, and honesty.1 As medical educators, one of our major goals is to develop trainees into independently practicing physicians who embody the attributes listed above and can establish effective, healing relationships with their patients and families.1 Patients and families must be able to not only trust individual clinicians’ competence, but also their moral character, in addition to the profession as a whole.2 In our complex medical environment, in which technological, political, legal, and changing market forces can all influence the practice of medicine, optimal patient care cannot be provided unless our patients and families trust us to do what is right.2,3 The American Board of Internal Medicine (ABIM) Foundation’s Physician Charter3 makes explicit the profession’s commitment to serving the best interests of the patient regardless of external forces, respecting patient autonomy, and promoting social justice within health care as fundamental, guiding principles for the practice of medicine. These principles are grounded in the concept of trustworthiness, making this virtue the foundation of medical professionalism.

While The Physician Charter3 provides a comprehensive list of professional responsibilities, the few listed below are key to physicians’ establishing and maintaining a trusting relationship with patients and society.

  • Commitment to honesty with patients — Honesty with patients encompasses informed consent for treatment, procedures, and/or clinical research that is complete and truthful regarding the benefits, as well as the potential adverse consequences; and our responsibility to fully disclose medical errors. Honesty is an important and necessary attribute in establishing and maintaining trust. Therefore, lapses in this principle can undeniably compromise trust between physicians and their patients.
  • Commitment to patient confidentiality — Patients’ sharing of personal information with their physician is essential to the practice of medicine. In order for patients to comfortably disclose the details of their life and illness to physicians, they must have full confidence in their ability to keep this information confidential and protected against inappropriate disclosure.
  • Commitment to maintain appropriate relations with patients — Physicians have a professional responsibility to maintain appropriate boundaries in their relationships with patients. They should never exploit their relationships with patients for personal gain (e.g., sexual, financial) and recognize that patients often experience a state of dependency which enhances their vulnerability when ill.
  • Commitment to managing conflicts of interest — Conflicts of interest are a reality in medicine. Physicians have a duty to appropriately manage these conflicts of interest, which includes disclosing them to the general public. Transparency in disclosing conflicts of interest aids in maintaining physicians’ trust with society.
  • Commitment to professional competence — Our patients and families trust us to provide high quality care. To do so, physicians must have a commitment to lifelong learning to maintain their medical knowledge and clinical skills. A patient’s trust is linked to our competence and abilities as a professional.
  • Commitment to improving quality of care — Human error and less-than-optimal systems exist in medicine, and our patients and families experience the effect on a day-to-day basis. Earning and maintaining trust in this environment requires physicians to demonstrate their commitment to the continuous quality improvement of health care (e.g., consistently working to reduce medical errors, eliminating inefficiency and waste, and rebuilding unsafe systems. The need for the development of better quality measures and their subsequent application to care delivery must also be addressed.

Recognizing trust as the core of medical professionalism provides us with a foundation upon which we can begin to teach the essential knowledge, skills, and attitudes of medical professionals. Our trainees’ learning is dependent upon their participation in patient care activities that allow them to make critical decisions with increasing levels of autonomy.4 In order for this process to occur successfully, supervising physicians must be able to trust their trainees. Specifically, supervising physicians have to decide when to trust a trainee to perform a certain task or drive care decisions based on their level of competence.4 Trainees earn said trust by not only demonstrating clinical competence under direct supervision, but also exhibiting specific professional traits that may provide insight into their future behaviors as practicing clinicians.4 For example, Kennedy et al demonstrated that supervising physicians’ assessment of trustworthiness went far beyond clinical skills and extended into other dimensions. For example, discernment (awareness of limits in regards to skill and knowledge), conscientiousness (thoroughness and dependability), and truthfulness (absence of deceit).1 Through double-checking trainees’ clinical findings against their own clinical assessments and/or other documented, factual information and listening to language cues during clinical presentations, supervising physicians assessed trainees to determine their competence and ability to perform independent patient care.1

Medical educators have a responsibility to not only develop competent physicians who are dedicated to lifelong learning, but also, physicians of character who hold the values of the profession as their own.2,5 According to Forsythe,5 the public and those who prepare professionals for service understand that “who we are” can influence “how we practice.” Thus, the goal is for our trainees to develop their own internal compass rooted in the standards of medical professionalism that will guide them to make principled decisions, even during times of stress.5 In other words, we must support trainees in developing their professional identity, a sense of who they are as physicians.5

The pediatric competencies most relevant to professional identity formation and trustworthiness are:

  • Patient Care
    • Gather essential and accurate information about the patient.
    • Perform complete and accurate physical examinations.
    • Carry out management plans to completion.
  • Medical Knowledge
    • Demonstrate a commitment to gaining sufficient knowledge of basic and clinically supportive sciences appropriate to pediatrics.
  • Practice-based Learning and Improvement
    • Identify strengths, deficiencies, and limits in one’s knowledge and expertise.
    • Identify goals and perform appropriate learning activities to guide personal and professional development.
    • Incorporate formative evaluation feedback into daily practice.
    • Take primary responsibility for lifelong learning to improve knowledge, skills, and practice performance.
  • Professionalism
    • Professionalization: A sense of duty and accountability to patients, society, and the profession
    • Professional conduct: High standards of ethical behavior, including maintaining appropriate professional boundaries
    • Self-awareness of one’s own knowledge, skills, and emotional limitations that leads to appropriate help-seeking behaviors
    • Trustworthiness that makes colleagues feel secure when one is responsible for the care of patients

Behavioral Statements

Examples of professionalism that relate to professional identity formation and trustworthiness that are listed above provide general goals. In discussions with trainees, it may be helpful to identify specific behaviors or practices that exemplify professionalism in this domain, and others that would represent lapses of professionalism.

Examples of Exemplary Professional Conduct

  • Identifies personal and professional strengths, as well as areas needing improvement, through reflective self-assessment
  • Recognizes one’s own limitations and can develop a plan with appropriate mentorship to improve any deficiencies
  • Actively seeks out and incorporates feedback to further personal and professional growth
  • Adopts the ethical standards of the profession as their own and works to develop a sense of who they are as physicians, demonstrating an awareness of and a commitment to professional identity formation
  • Practices medicine with a commitment to their professional responsibilities, including honesty and integrity, even during times of stress
  • Forms therapeutic and trusting relationships with patients through effective communication
  • Maintains appropriate professional boundaries with patients and their families
  • Appropriately safeguards patient information and maintains patient confidentiality
  • Appropriately discloses medical errors with honesty and empathy
  • Demonstrates appreciation of multiple perspectives of a multidisciplinary team
  • Manages conflict in a professional and productive manner
  • Serves as a positive role model for trainees and fellow colleagues
  • Manages medical ambiguity

Examples of Lapses in Professional Conduct

  • Avoids opportunities to engage in reflective assessment, specifically regarding one’s own areas needing improvement
  • Avoids receiving feedback and/or fails to incorporate feedback into their practice
  • Fails to develop one’s own internal compass based on the ethical standards of the profession
  • Practices medicine with a lack of integrity
  • Treats patients with disrespect and/or lack of empathy, failing to establish a trusting doctor-patient relationship
  • Fails to maintain appropriate professional boundaries with patient and families
  • Demonstrates a lapse in patient confidentiality
  • Fails to disclose medical errors
  • Fails to disclose and/or manage conflicts of interest
  • Fails to appreciate the multiple perspectives of a multidisciplinary team
  • Avoids or poorly manages conflict
  • Models negative and/or unprofessional behaviors in the workplace
  • Acts dogmatically in the face of medical ambiguity

Teaching Professionalism

The transition from medical student to adept pediatrician is an evolutionary process in which knowledge and skills are acquired and professional values are incorporated into a clinician’s sense of self.5,6 This personal adoption of professional values is an essential component of professional identity formation and the development of a competent, trustworthy physician.5 The process requires time and experience and is influenced by trainees’ self-awareness, attitudes, and habits of lifelong learning, all of which can be molded with the appropriate guidance.4 Thus, teaching professionalism requires us to understand and mentor trainees through the process of professional identity formation.

Robert Kegan explored the process of how individuals undergo the evolution in their understanding of their relationships with other individuals and groups throughout most of their lives.7,8 Forsythe expanded on this concept and uses three of the six stages originally described by Kegan, specifically stages 2, 3, and 4, to explain individuals’ relationships with their profession.5,7 The following are the stages most relevant to professional identity formation. Stage 2 encompasses an individual’s ability to appreciate the perspective of another person, but only in the context of how that person’s views impact him or her personally.5,9 In stage 3, a learner views the world through multiple perspectives, and those perspectives can have an impact on their own personal identity.5,9 Here learners begin to identify with the profession by learning the implicit and explicit rules. They start to model the behaviors they witness, highlighting the importance of the hidden curriculum. In this stage, it is of utmost importance for senior physicians to demonstrate the professional behaviors they want their junior trainees to emulate. However, stage 4 is the critical transition in which individuals’ actions are led by their own expectations, not the expectations of others, and the values of the profession become integrated in their own personal and professional beliefs.5,9 In this stage, individuals understand “who they are” as professionals,5 and this newfound identity allows them to appropriately reconcile conflicts that emerge between personal and professional expectations with honesty and integrity.

All of the stages, but specifically stage 4, are critical to professional identity formation and thus, to the development of a physician who is trusted by the public and colleagues. Medical educators can modify and positively influence this developmental process by:

  1. Providing trainees with content-specific curricular experiences to enhance their development and explicit role modeling (i.e., pointing out what behavior they are modeling and why);
  2. Intentional skill-building in the areas of giving and receiving feedback, self-care, and conflict resolution; and
  3. Setting appropriate, stage-specific expectations for professionalism competencies of learners using a developmental approach.6,10

Learning Objectives for Trainees

  1. Explain the concept of professional identity formation and its impact on their individual professional development as a clinician throughout the entirety of their career.
  2. Describe the core elements of trustworthiness.
  3. Discuss how professional identity formation is linked to the concept of trustworthiness.
  4. Articulate those professional responsibilities most important to establishing and maintaining a trusting relationship with patients and society.
  5. Identify lapses in professionalism and the implications of those lapses on the trust-based doctor-patient relationship and society’s trust in the profession as a whole.
  6. Learn to self-regulate their own professionalism through continual self-assessment and address any deficiencies or lapses as a part of their lifelong commitment to professional development.

Reflective Exercises

These exercises can be used for individual reflection on professionalism issues or can be modified and discussed as part of a larger group meeting.

  • After holding a discussion about the professional responsibilities of physicians, ask your trainees to reflect and write, in one page or less, about their own professional identity formation, where they think they are in the process, and how this affects their relationships with colleagues, patients and families, and the profession.
  • Ask your trainees to reflect on their own personal ideals and how they align with the professional responsibilities of physicians.
  • Ask your trainees to describe a time in which they observed exemplary professional conduct that led to an effective, trusting encounter between a physician and their patient.
  • Using any of the vignettes below, ask your trainees to describe a similar real-life situation. Ask them to identify the conflicting values and what they learned from the situation.

Chapter 10 Vignettes — Identity Formation and Trustworthiness: A Foundation of Professionalism

The vignettes that follow were developed for use in a small group setting to help stimulate discussions about issues regarding professionalism. Medical educators are encouraged to expand upon these to reflect local issues and experiences.

Vignette 1 — Appropriate Escalation of Care

An intern is working overnight on a general pediatrics unit and becomes clinically concerned about a newly admitted patient. The intern is unsure of the next steps to take and discusses the patient’s condition with a fellow intern; and together, they decide to continue to monitor the patient without any acute intervention. They do not alert the supervising senior resident or the attending of their concerns. An hour later, the patient clinically deteriorates and has to go to the intensive care unit.

Points to consider during discussion:

  • What is your initial reaction to this scenario?
  • What would you do if you were the supervising resident or the attending?
  • How should the intern’s failure to escalate his or her concerns be addressed?
  • How do the actions of the intern potentially affect how he or she will be supervised in the future?
  • What are possible reasons that the intern chose not to escalate care?
  • Should anything be discussed with the patient and their family?

Vignette 2 — Honesty in Patient Care

The medical team is rounding and your co-resident colleague is presenting. When your colleague reports the exam findings, they state the exam was normal and reassuring. However, you know that they arrived late this morning and was unable to examine their patients prior to the start of rounds.

Points to consider during discussion:

  • Do you have a responsibility to say something to your colleague? Supervising resident? Attending?
  • How should the behavior of your co-resident colleague be addressed?
  • When is the appropriate time to address their behavior?
  • How do you think the actions of your co-resident colleague potentially affect how they will be supervised in the future?
  • What are the potential consequences of not addressing the behavior?

Vignette 3 — Missing Opportunities for Improvement

A medical student gives long presentations on rounds that do not focus on the pertinent negatives and positives. As the supervising resident, you decide to provide one-on-one feedback to the medical student to help him improve his presentation skills. However, the medical student is dismissive. When you discuss the medical student with your fellow interns, you find out that they tried to give him similar feedback and he was dismissive of their comments as well.

Points to consider during discussion:

  • Is the dismissive nature of the medical student considered unprofessional? Why or why not?
  • Considering the prior attempts at feedback, what should the supervising resident do?
  • What are possible barriers preventing the medical student from receiving feedback?
  • What guidance should be provided to the medical student to facilitate his continued professional development?

Vignette 4 — Informed Consent

A febrile neonate receives a lumbar puncture as a part of his or her medical work-up in the Emergency Department. It was a difficult lumbar puncture requiring multiple attempts by two Emergency Medicine attendings, which leads to the development of a hematoma at the LP site. When the patient is admitted, the mother expresses to the admitting resident that she is upset because no one explained the complications associated with a lumbar puncture.

Points to consider during discussion:

  • What is your reaction to this scenario?
  • What is a physician’s responsibility when providing informed consent?
  • Do you think the mother’s relationship with the medical system and/or individual clinicians has changed due to this incident? And if so, how?
  • How would you address the mother’s concerns?
  • Do you discuss the case with the Emergency Medicine attendings?

Vignette 5 — Patient Confidentiality

The daughter of a well-known celebrity is a patient in your hospital. Your colleague is a true fan of the celebrity and has been to all of the celebrity’s concerts. Your colleague disclosed to you that the patient is located on the 4th floor, and your colleague is simply going to walk around on that floor to try to run into the celebrity for a quick autograph. Your colleague is not providing any medical care to this patient.

Points to consider during discussion:

  • Would you say anything to your colleague in response to this plan?
  • What is considered a breach in patient confidentiality?
  • Whose responsibility is it to safeguard the privacy of the patient and their family?
  • If your colleague were to run into the celebrity, how do you think this would affect the family’s trust in the medical institution and/or their physicians?

Vignette 6 — Disclosure of Medical Errors

A patient is admitted in the PICU for bacteremia and sepsis. IV antibiotics are ordered, and a higher-than-typical dose of Vancomycin is ordered and given to the patient before it can be corrected. There is no resultant harm to the patient.

Points to consider during discussion:

  • Considering there was no harm to the patient, do you think the medical error should or should not be disclosed and why?
  • Whose responsibility is it to disclose medical errors?
  • Is there an appropriate time to disclose the medical error?
  • How do you think the disclosure of the medical error will affect the relationship between the patient’s family and the medical team and/or the institution?
  • What would be your course of action if you notice that the dose of IV Vancomycin continues to be improperly ordered?

Vignette 7 — Hidden Curriculum

There is a hospital-wide quality improvement initiative to decrease the rate of central-line related blood-stream infections. As a part of the hospital-wide initiative, the medical teams are being asked to discuss central-line care on rounds when relevant to the patient. When you bring this to the attention of your attending physician, they report a lack of belief in the quality improvement process and would prefer not to participate. They prefer to leave the care in the hands of nursing.

Points to consider during the discussion:

  • What is your initial reaction to your attending’s response?
  • Describe the hidden curriculum. Is the hidden curriculum present in this situation? If so, how may it affect the trainees?
  • How does a physician balance their day-to-day responsibilities with their professional responsibilities to improving the overall quality of care?
  • Whose responsibility is it to address the attending’s behavior?
 

Summary

Professionalism is built upon the concept of trustworthiness. In essence, a trustworthy physician is a physician who has embodied the key elements of clinical competence, discernment, conscientiousness, and honesty while demonstrating a strong commitment to their professional responsibilities. As medical educators, we have a responsibility to cultivate these professional traits in our trainees. The goal of becoming a trusted professional (i.e., one who can safely and effectively practice without supervision) is a true developmental process that requires a focus on professional identity formation, the utilization of appropriate teaching methods, including targeted reflection, role modeling, and skill building, as well as setting clear expectations for accountability that aligns with the developmental level of the trainee.

References

  1. Kennedy, T et al. Point-of-Care Assessment of Medical Trainee Competence for Independent Clinical Work. Academic Medicine, 2008; Vol 83, No. 10: S89-93.
  2. MacKenzie CR. Professionalism and Medicine. HSSJ (2007) 3: 222-227.
  3. ABIM Foundation, American Board of Internal Medicine; ACP-ASIM Foundation, American College of Physicians –American Society of Internal Medicine. Medical professionalism in the new millennium; a physician charter. Ann Intern Med 2002; 136: 243-46.
  4. Hauer K, ten Cate O, Boscardin C, Irby D, Iobst, W, O’ Sullivan P. Understanding trust as an essential element of trainee supervision and learning in the workplace. Adv in Health Sci Educ (2014) 19: 435-456.
  5. Forsythe GB. Identity Development in Professional Education. Academic Medicine 2005. Vol 80. No 10. S112 – 117.
  6. Stern DT, Papadakis M. The Developing Physician – Becoming a Professional. New Engl J Med 2006. 355: 1794 – 9.
  7. Kegan R. The Evolving Self: Problem and Process in Human Development. Cambridge, MA: Harvard University Press, 1982.
  8. Kegan R. In over our heads: The Mental Demands of Modern Life. Cambridge, MA: Harvard University Press, 1994.
  9. Ludwig S. The Pediatric Milestone Project: Domain of Competence - Professionalism. Academic Pediatrics 2014; 14: S66–69.
  10. Arnold L, Stern DT. What is Medical Professionalism? In Stern DT. Ed. Measuring Medical Professionalism, New York, NY: Oxford University Press, 1006: 57 -79.