medical education in review
Professionalism: a framework to guide medical
education
Howard Brody1,2 & David Doukas3
CONTEXT Despite considerable advances in
the incorporation of professionalism into the
formal curriculum, medical students and resi-
dents are too often presented with a mechani-
cal, unreflective version of the topic that fails
to convey deeper ethical and humanistic aspi-
rations. Some misunderstandings of profes-
sionalism are exacerbated by commonly used
assessment tools that focus only on superfi-
cially observable behaviour and not on moral
values and attitudes.
METHODS Following a selective literature
review, we engaged in philosophical ethical
analysis to identify the key precepts associated
with professionalism that could best guide the
development of an appropriately reflective
curriculum.
Medical Education 2014: 48: 980987
doi: 10.1111/medu.12520
Discuss ideas arising from the article at
www.mededuc.com discuss
1
Institute for the Medical Humanities, University of Texas Medical
Branch, Galveston, Texas, USA
2
Department of Family Medicine, University of Texas Medical
Branch, Galveston, Texas, USA
3
Division of Medical Humanism and Ethics, Department of
Family and Geriatric Medicine, University of Louisville, Louisville,
Kentucky, USA
980
RESULTS The key precepts needed for a
robust presentation of professionalism can be
grouped under two headings: Professionalism
as a trust-generating promise (representing
commitment to patients interests, more than
a mere business, a social contract, a public
and collective promise, and hard work), and
Professionalism as application of virtue to
practice (based on virtue, deeper attitudes
rather than mere behaviour, and requiring of
practical wisdom).
CONCLUSIONS These key precepts help stu-
dents to avoid many common, unreflective
misunderstandings of professionalism, and
guide faculty staff and students jointly to
address the deeper issues required for success-
ful professional identity formation.
Correspondence: Howard Brody, Institute for the Medical
Humanities, University of Texas Medical Branch, 301 University
Boulevard, Galveston, Texas 77555-1311, USA.
Tel: 00 1 409 772 9386/2376; E-mail: habrody@utmb.edu
2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 980987

INTRODUCTION
A Year 3 medical student turned in to one of us (HB)
a required essay that began When I hear the word
professionalism, my first reaction is Yuk! In the of the professions teaches us important lessons that
resultant small-group discussion, several students
concurred with the writer: they too had come away
from their previous professionalism teaching sessions
with negative opinions. They had somehow gotten
the impression that professionalism as presented in
their curriculum had taught them merely prohibi-
tions of behaviour. When asked what they thought
professionalism ought to mean, they described a con-
cept which, in the instructors view, matched well with
the core ethical ideas the term is intended to convey:
dedication to the priority of the patients interests.
Our joint experience in teaching about ethics and
professionalism for a number of years reinforces
our concern that medical educators too often trans-
mit to students and residents an unreflective,
mechanical view of professionalism. This concern
was voiced by Coulehan1 and subsequently sup-
ported by empirical studies.26 One possible flaw in
this teaching is that the concept and practice of pro-
fessionalism may not be sufficiently grounded in
either ethics or humanities. Such teaching can be a
reduction of behaviours into a list of Do Nots
based on superficial appearance and comportment,
evaluated by checklists. The resultant negative per-
ception of professionalism in many students stems
from their impression that they are being asked to
memorise a list of rules that seems detached from
their intended ethical role as a healer.2,4,6,7 Instead,
we assert that professionalism ought to resonate pos-
itively with the ethical aspirations of learners and
prompt them to reflect more deeply.8
Some educators attribute the problem of how to
teach professionalism to the lack of scholarly con-
sensus over the definition of professionalism, or to
other problems of a conceptual nature.7,916 We
support continued scholarly inquiry, but disagree
that this is where the pedagogic problem lies. We
believe that, at present, we possess for teaching pur-
poses sufficient consensus on the most important
core ideas that ground professionalism. Overcoming
professionalisms negative impression requires that
we focus more on the aspirational signal and less on
the deleterious noise.
If we are presently unclear on how best to teach
professionalism, the problem with respect to
2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 980987
Professionalism: a framework
education research is compounded. Knowing how
properly to assess and measure professionalism
requires the contributions of more disciplines than
are usually brought to bear, especially ethical and
philosophical perspectives. Although the sociology
have major ethical import, viewing professionalism
as a concept to be explained solely by sociological
models is inadequate.17 As valuable as it may be to
measure behaviour, if professionalism is more than
behaviour, all such assessment tools will fall short.
We concur with the observation of Cruess and Cru-
ess: As situated learning theory suggests, a balance
must be struck between teaching the cognitive base
explicitly and providing opportunities where learn-
ing can occur in an authentic context.18 For exam-
ple, one thoughtful study of unprofessional
behaviour among students (passing examination
information to their fellows) correctly identified the
culture of assessment as a background condition
affecting the behaviour. The authors, however,
failed to ask how assessing professionalism itself
might create problems for teaching the concept cor-
rectly.19
This paper proposes a keep it simple approach to
the cognitive base of professionalism that conveys
the most critical and central ideas in a way that
learners can readily grasp and value. This presenta-
tion, moreover, naturally leads to further inquiry
that prompts deeper ethical reflection. Our goal is
to clarify this core set of ideas for use in profession-
alism pedagogy, and thus indirectly to guide future
educational assessment and research. This paper
does not propose a detailed professionalism curricu-
lum because such curricula will necessarily vary
depending on the teaching setting and resources.20
The key precepts required to convey this core set of
ideas are grouped under two interrelated headings:
Professionalism as a trust-generating promise, and
Professionalism as application of virtue to practice.
PROFESSIONALISM AS A TRUST-GENERATING
PROMISE
The first set of precepts leads to the idea that pro-
fessionalism entails making a promise that ideally
builds public trust and can be very challenging to
fulfil. Once students see how challenging this task
is, they are better prepared for the second set of
precepts, which address the character formation
necessary to live up to such a promise over a profes-
sional lifetime.
981
H Brody & D Doukas
Professionalism as a commitment to the interests of
the patient
Professionalism represents a commitment to placing
the interests of the patient ahead of those of the
professional.
Most definitions agree that the goal of the profes-
sional interaction is the benefit of the patient and
only secondarily the benefit of the physician.
(Although a technical term for this attribute is self-
abnegation, we will use the more widely under-
stood, if less precise, term altruism.21) Such a
claim may seem both self-evident and vacuous, but
it is actually quite pregnant with important issues
that students and residents need to discuss.
At what point, for example, do the professionals
own interests have a legitimate claim in patient
care? How much is the professional expected to
sacrifice to benefit the patient? When do lifestyle
issues or moral commitments owed to other indi-
viduals supersede ones obligations to the patient?
These are issues with which students and residents
should grapple under faculty guidance and thus it
is helpful that this key precept stimulates such
questions.
Placing the patients interests first entails a list of
related behaviours
Placing the patients interests first logically entails a
list of related professional behaviours and obliga-
tions. Contrary to the perception of the medical stu-
dent described in the Introduction, definitions of
professionalism can also assume the form of lists
of desirable behaviours.22 For example, many defini-
tions grant technical competence equal status with
giving priority to the patients interests.23 However,
when learners understand that professionalism in
practice must be guided by the patients best inter-
est, they readily see that this beneficence-based duty
requires the physician to be technically competent in
order to truly be able to serve. Similarly, the priority
of the patients interests implies other professional
behaviours, such as respecting confidentiality, truth-
fulness and shared decision making.
When professionalism is presented as a laundry list
of behaviours (whether positive or negative), stu-
dents equate the learning of professionalism with
the memorising of such a list, which implies that
whether a behaviour is professional or unprofes-
sional can be determined by mechanically
982 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 980987
consulting the list.1,2,4,6,7 We suggest instilling in stu-
dents the core of what professionalism is and then
helping them to see how the core logically gener-
ates the list. It is still helpful to share the list with
students, but ideally as a set of illustrations with
which to expand the core precept.
Professionalism means that health care can never be
merely a business
In a world in which all human relationships tend to
be recast as business arrangements, it is worth stat-
ing this key precept explicitly, even if it is merely a
restatement of the first.24 If health care were pri-
marily a business, making a profit could be seen as
its first principle, thereby contradicting the precept
that the good of the patient comes before the good
of the professional. Health care in todays world is
indeed a business: professionals are not indepen-
dently wealthy, and someone must pay the rent and
keep the lights on. However, health care should
never be viewed merely or primarily as a business. The
commercialisation and commodification of medi-
cine are among the most important threats to pro-
fessionalism today,25 and students are immersed in
a world that views every aspect of human life as
occurring in a marketplace.26,27 This aspect of pro-
fessionalism therefore deserves emphasis. For exam-
ple, Hafferty and Castellanis proposal that
entrepreneurial professionalism and lifestyle pro-
fessionalism merely represent further recognition
of professionalisms complexities in todays world
requires a greater examination of their ethical foun-
dations and implications.14
Professionalism is derived from the verb to
profess, which means to promise
In a classic article, Pellegrino stated that the verb
form was more informative than the noun.28 This
key precept relates the other precepts to the impor-
tant goal of public trust. Medicine requires public
trust, a concept that embraces the patients trust in
the individual practitioner. Patients will not give an
honest, exhaustive medical history, or allow their
bodies to be examined and probed, without this
trust, but without the information thus gleaned
from patients, practitioners will be helpless to com-
plete their tasks. Why should patients trust practitio-
ners, including those they have never previously
encountered? The answer this key precept offers is
that health professionals have promised the commu-
nity at large to place the interests of the patient
foremost.

The promise suggested by to profess is both a
public and a collective promise
Why should patients find this promise compelling?
What makes professionals worthy of the trust they
expect? In the end, professionals actual behaviour
will establish their trustworthiness. Yet most patients
are nevertheless willing at least provisionally to trust
practitioners. This trust is driven by the sense that
the promise made by practitioners to the commu-
nity is both public and collective.
Medical students best grasp this key precept when
they consider the ceremony at which a physicians
oath is sworn upon graduation. Firstly, the ceremony
is public; the class does not retreat behind closed
doors to recite the oath. Secondly, swearing the oath
is a collective action of the entire class; it is a promise
to the public and to each other. Individual students are
not asked whether or not they wish to recite the oath,
or whether they would like to alter the wording to cre-
ate their own versions. All participants take for
granted that the ceremony will lack meaning unless
all students swear the same oath at the same time.
The precept of a public, collective promise may be
a challenging one to convey to students in a society
so wedded to the ideal (or myth) of individualism.
Students may initially resist the idea that they are
bound by a collective promise that they did not
individually negotiate. Reflection, however, will
show them that if the promise is not both public
and collective, patients will have little reason to
trust a physician who happens to be on duty in the
emergency department and whom the patient has
never previously met. One pedagogic technique
that nicely bridges individualism with the precept
of the collective promise involves having students
write their own oaths or codes.29 The notion of a
public, collective promise leads directly to the fur-
ther precept of professionalism as a social contract,
which we address below.
Professionalism, properly understood, is hard work
A further problem with unreflective assessment
tools, in which professionalism is equated with the
checking by faculty staff of boxes that refer to obser-
vable behaviours, is that they create the impression
that meeting the minimum threshold is easy and
that only learners with serious ethical flaws will be
deficient in professionalism. This undermines the
important message that professionalism is an aspira-
tional goal which even the best physicians must
struggle to attain.
2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 980987
Professionalism: a framework
A public, collective promise to dedicate oneself to
putting the patients interests first suggests on
reflection that the physician has undertaken a very
challenging task. Humans are probably pro-
grammed to be altruistic on occasions when, for
example, those with whom they feel close ties of
kinship are threatened by physical danger. By con-
trast, it is difficult to put someones interests ahead
of our own when we feel tired or threatened. It is
even harder to prioritise the interests of those with
whom we feel no natural identity, and towards
whom we may even feel animosity. Yet the promise
of professionalism requires that all such patients, in
all such circumstances, receive our best care, predi-
cated on our diligence in knowledge and skill acqui-
sition, our directed efforts towards the patients
benefit, and our public trust.30 Larson and Yao
make a similar point about empathy and point out
that bringing ones deeper attitudes into congru-
ence with surface behaviours requires considerable
emotional labour.31
Admitting that keeping the promise of professional-
ism is difficult accomplishes three critical pedagogic
tasks. Firstly, it establishes the importance of a pro-
fessionalism curriculum and justifies time and
energy devoted to the topic. Secondly, it takes the
faculty member off the pedestal and opens up real
dialogue with students as all reflect together upon
ways to deal with predictable challenges to profes-
sional behaviour. Finally, understanding how hard
professionalism is leads naturally to the next set of
key precepts that identify professionalism with vir-
tue. Virtue comprises our positive aspirations for
character that will achieve the goods of health care
by translating our deeper values, attitudes and
beliefs into effective behaviours.
Professionalism as an implied contract between
society and the profession
Professionalism can be viewed as an implied con-
tract between society and the medical profession, in
which mutual benefits are conferred, and which can
be renegotiated if conditions change.
At first glance the sociological literature on the pro-
fessions might appear to be distinct from an ethical
approach, as sociology attempts a descriptive
account, whereas ethics addresses the ought rather
than the is.14,32 The notion of a social contract,
however, provides an important meeting ground
between sociological and ethical accounts. Cruess
and Cruess have reminded us that the idea of the
social contract can usefully frame the way in which
983
H Brody & D Doukas
professionalism is taught.18,33 For example, without
the social contract, students will be unable to under-
stand the ethical importance and context of ade-
quate physician self-regulation.
The concept of the social contract reminds the stu-
dent that trust involves a two-way relationship. Ide-
ally, trust exists on the patients side and trust-
worthiness on the physicians. A dedication to profes-
sionalism, viewed as character, establishes the condi-
tions for trustworthiness.
Students often focus only on the dyadic nature of
the physicianpatient relationship and need to be
reminded of social context. This key precept
reminds students that the benefits conferred by soci-
ety on physicians, which include a comfortable level
of income that is sufficient to pay off student loans,
are conditional upon societys belief that it is receiv-
ing the hoped-for benefits from the profession. If
society decides that caregivers have strayed from the
path of virtue and are no longer trustworthy, the
privileges and authority now granted to health pro-
fessionals may be withdrawn. Furthermore, if society
makes it difficult for professionals to provide care
according to the appropriate ethical standards as
happened most dramatically in Nazi Germany the
professionals ought to demand that the contract be
renegotiated and may refuse to assume their
assigned social roles.
PROFESSIONALISM AS APPLICATION OF VIRTUE TO
PRACTICE
Professionalism as a subset of health care ethics
Professionalism is a subset of health care ethics and
represents an application of virtue to the health
professions.
Professionalism is a question of ethics, but much of
ethics today is addressed through rules and princi-
ples.34 Rules and principles may be highly useful
tools for ethical deliberation, but they have a major
weakness: they ignore the question of what sort of
person is deciding or performing the action. The
approach to ethics that focuses on what sort of per-
son one is becoming, or moral character, is com-
monly called virtue.35 As Pellegrino stated, virtue-
based ethics is a system that concentrates on the
moral agent and the kind of person he or she
ought to be, rather than on the acts themselves, the
circumstances, or the consequences they pro-
duce.23 As so little of ethics education reflects a vir-
984 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 980987
tue perspective, students may wonder why they are
being asked to adopt this seemingly idiosyncratic
approach when addressing professionalism.
Students will best understand a virtue approach
when they are reminded of how hard it is to keep
ones public promise to put the interests of patients
first, as the maintenance of public trust requires. To
do this not only on good days, but also on bad days
when we are tired and irritable and no-one is watch-
ing, requires more than simple rules; it requires that
we devote ourselves to becoming certain sorts of persons.
If students engage in honest reflection, they will
agree that little in their previous lives has taught
them to be the sorts of persons who routinely put the
interests of others first, even if to do so requires
some significant sacrifice. If students see that profes-
sionalism, properly understood, requires them to
grow into the sorts of persons who not only engage
in that hard work, but who do so willingly and
cheerfully, they then understand what character and
virtue have to do with their education.3638
Virtue is sometimes misunderstood because of a
focus on the listing of specific virtues, such as altru-
ism, compassion and honesty, as if these, too, could
be understood separately and memorised as a list of
desirable behaviours. We recommend instead focus-
ing on the core idea of virtue as it relates to lifelong
character formation.
Virtue as transcending behaviour
The virtuous person behaves in certain ways that can
be observed and measured, but virtue transcends
behaviour. This key precept may be less important
for trainees than for faculty staff and those involved
in assessment and accreditation, but students still
need a sense of it if they are to understand the com-
plex relationship between professionalism and com-
monly employed lists of professional behaviours.
In one sense, virtue is ultimately about behaviour.
There would be little point in saying that altruism is
a virtue if the virtuous person never actually
behaved altruistically, but merely entertained noble
ideas. One goal of learning and improving ones
own virtues is to be confident that when faced with
typical stresses and crises, one will default to the
right way to behave and will not be led astray by
temptation or fear.
By contrast, part of the reason why the develop-
ment of these virtues is indeed a lifelong commit-
ment derives from the fact that merely behaving

in certain ways is never enough. Albeit that get-
ting trainees to behave in accord with a list of
professional attributes is a good way to start the
process of character development, it is not the
intended moral destination. Making virtuous
behaviour ones default requires that virtuous atti-
tudes percolate deep into ones being. An ongo-
ing challenge for evaluators is to use behavioural
measures of professionalism appropriately, with
full awareness of their limitations, and not to
employ them in ways that send the wrong message
to students and residents.
Cohen seems to advocate restricting the domain of
professionalism solely to observable behaviour, rele-
gating deeper values and attitudes to the realm of
humanism.24 However, Cohen immediately adds:
In the absence of humanistic grounding, profes-
sionalism lacks authenticity; it is a thin veneer. . .24
As Cohen clearly calls for both professionalism and
humanism as he defines them, we think it better to
require a professionalism curriculum that addresses
both observable behaviours and deeper attitudes,
and find in virtue the required integration among
these concepts. Medical education must do more
than teach to the test of expected behaviours, and
must also promote the cultivation of virtue as a life-
long quest in the face of numerous challenges.39
Virtue requires integrating a set of values, attitudes
and behaviours
Virtue in professionalism requires integrating a set of
values, attitudes and behaviours into the core of ones
being, and applying practical wisdom to determine
how the virtuous professional would respond to a
given clinical situation; this is the sort of wisdom one
ordinarily gains from observing trusted mentors.
If professionalism is applied virtue ethics, and most
students have not been introduced to virtue ethics,
a short course in virtue is required as a part of pro-
fessionalism education. This key precept represents
the essentials that students must grasp. Being a vir-
tuous professional requires doing the right thing
(whatever puts the patients interests first and fore-
most) in the right way and with the right attitude,
and doing so consistently and reliably as an expres-
sion of deeply formed character; it requires getting
medical virtues like altruism right into the marrow
of ones moral bones. However, the virtuous physi-
cian is more than altruistic; he or she also exempli-
fies those aspects of character that promote the
patients best interests (such as compassion, perse-
verance, integrity and practical wisdom).40
2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 980987
Professionalism: a framework
Being virtuous requires more than having incul-
cated good values; it means having the practical wis-
dom to discern precisely how the virtuous
professional should respond to any given concrete
situation.41 As one aspect of good character, this
practical wisdom is a skill that must be cultivated
over a lifetime.
Students can understand these aspects of basic vir-
tue ethics by reflecting on their own experiences.
For example, Year 1 medical students struggle with
the basic skills of history taking and physical exami-
nation. They often ignore the patient while focusing
on their memorised checklist of tasks. Yet they
understand that, with further practice, they will be
able to perform a smooth, competent history and
physical examination, while also attending fully to
the patients words and feelings. Faculty staff can
make an analogy between this experience and how
the practitioners approach to the patient in a mor-
ally complex situation improves with practice.
Even students who have had no experience with
clinical mentors in school have probably encoun-
tered practitioners in their own and their familys
lives, and have seen both positive and negative role
models. Getting students to focus on their own
vision of the sort of practitioner they most wish to
resemble in their future career, and the sort of prac-
titioner they most wish to avoid becoming, allows
them to reflect upon the importance of practical
mentoring in the development of the virtuous pro-
fessional.
These key precepts about virtue help to immunise
students to two common misuses of professional-
ism, which unfortunately feed cynicism rather than
professional development.2 One misuse is that of
professionalism as a bludgeon, a term that refers
to the use of professionalism as a threat or
weapon with which to punish students who dont
follow the administrations rules. The other misuse
involves reducing professionalism merely to a req-
uisite competency that can be exhaustively evalu-
ated solely according to a checklist of concrete
behaviours.1,7 Unfortunately, professionalism in
education must do double duty.42 A small number
of trainees will indeed behave in grossly unprofes-
sional ways and must (according to the social con-
tract) either be remediated or terminated for the
safety of the community. For this group, profes-
sionalism must serve as a minimal threshold of
acceptable behaviour. However, this message com-
municates the wrong view of professionalism to
the much larger group that ideally will see
985
H Brody & D Doukas
professionalism as a positive, aspirational goal and
not as a minimal threshold. The double duty and
the aspirational ideal must both be explained to
students so that the messages sent by the school
remain clear.
CONCLUSIONS
The key precepts we propose for education in medi-
cal professionalism may be summarised as: (i) pro-
fession is a public, collective promise providing the
basis for trust, based on an implied social contract
committed to the patients best interests, and (ii)
professionalism involves hard work that implicitly
requires knowledge and technical competence, but,
more importantly, requires the application of virtue
ethics.
A professionalism curriculum that emphasises these
precepts, we suggest, will resonate more effectively
with medical trainees and will help to prevent a
number of common misunderstandings that cur-
rently hamper the effectiveness of professionalism
teaching. The precepts also ought to guide educa-
tional research to ensure that the right attributes
and outcomes are assessed, and that the assessment
instruments do not inadvertently teach students the
wrong message about professionalism by stressing
superficial behaviours over deeper character devel-
opment.
A great many important concerns about the ethics
and history of professionalism remain to be
addressed. We wish by proposing our list of key pre-
cepts to foreclose none of that ongoing scholarly
exploration. We merely wish to indicate how a robust
curriculum for medical students and residents, suffi-
cient to cover the basic concept of professionalism
and to warn of some common misuses of the concept,
can be constructed out of material already available,
while the deeper inquiry continues.
Contributors: both authors made substantial contributions
to the conception, design and writing of this paper. Both
authors participated in the review and critical revision of
the various drafts and approved the final manuscript for
publication.
Acknowledgements: none.
Funding: none.
Conflicts of interest: DD is president and chief executive
officer of the Academy for Professionalism in Health Care.
HB is a past chairman of its board of directors.
Ethical approval: not applicable.
986 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 980987
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