REVIEW

Incorporating Professionalism into Medical Education:
The Mayo Clinic Experience
Paul S. Mueller

Division of General Internal Medicine and Program in Professionalism and Bioethics, Mayo Clinic, Minnesota, USA(Received for publication on December 18, 2008)(Revised for publication on February 4, 2009)(Accepted for publication on February 19, 2009)

Abstract
Professionalism is a core competency of physicians. In this article, the statements of professional societies (e.g., the Charter on Medical Professionalism), the expectations of patients andsociety regarding professionalism, and a framework for defining medical professionalism aredescribed. The framework’s foundation consists of clinical competence, communication skills,
and a sound understanding of the ethical and legal aspects of medicine. Rising from this foundation are attributes of professionalism: accountability, altruism, excellence, and humanism.
The capstone of the framework is professionalism, or the complete physician. Reasons forteaching professionalism to and assessing professionalism among medical students, physiciansin training, and physicians in practice are also described. These reasons include patient expectations; the association between professionalism and improved clinical outcomes (and the association between unprofessional behavior and adverse outcomes); accreditation organization
requirements; and observations that professionalism can be taught, learned, and assessed. In
addition, methods for teaching professionalism are described (e.g., didactic lectures, discussion
groups, simulation, and role-modeling). To ensure that medical students, physicians in training,and physicians in practice are competent in professionalism, they should be assessed for professionalism. Thus, approaches to assessing professionalism are also described (e.g., multiple
tools and observers). Professionalism assessments can be used for formative and summative
feedback, evaluation of professionalism education programs, and generating hypotheses for
professionalism research. Finally, the rich history and culture of clinical excellence and professionalism and specific programs for teaching and assessing professionalism at Mayo Clinic aredescribed throughout this article. Indeed, the Mayo Clinic experience validates professionalism
as a core physician competency. (Keio J Med 58 (3) : 133－143, September 2009)

Keywords: professionalism, medical professionalism, ethics, medical education, assessment
Introduction

ever, the medical profession has been criticized for perceived and real breaches of professionalism and ethics(e.g., promoting self-interests rather than the interests ofpatients). In response to this criticism, interest in preserving, promoting, teaching, assessing and researching
medical professionalism has increased.
The objectives of this article are to: (a) define “professionalism”; (b) describe the rationale for teaching andassessing professionalism in medical students, physi-

Medicine has been regarded as a “profession” for centuries. Indeed, over millennia and a wide variety of cultures and locales, oaths and codes of ethics have described physicians’ professional and ethical values andduties. Until recently, it was assumed trainees in medicine would assimilate and physicians in practice would
maintain these values and duties. In recent decades, how-Presented at the 1592nd Meeting of The Keio Medical Society in Tokyo, October 17, 2008.
Reprint requests to: Paul S. Mueller, MD, MPH, Division of General Internal Medicine and Program in Professionalism and Bioethics, Mayo Clinic, 200 First
Street SW, Rochester, MN 55905, USA, E-mail: mueller.pauls@mayo.edu
133

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Table 1 The Physician Charter on medical professionalism5
Fundamental Principles
1. Principle of primacy of patient welfare
2. Principle of patient autonomy
3. Principle of social justiceProfessional Responsibilities
1.
2.
3.
4.

Commitment to professional competenceCommitment to honesty with patients
Commitment to patient confidentiality
Commitment to maintaining appropriate relations withpatients
5. Commitment to improving quality of care
6. Commitment to improving access to care
7. Commitment to a just distribution of finite resources
8. Commitment to scientific knowledge
9. Commitment to maintaining trust by managing conflicts ofinterests
10. Commitment to professional responsibilities

cians in training (e.g., residents and fellows), and physicians in practice; (c) describe methods for teaching andassessing professionalism in the healthcare setting; and(d) describe professionalism education programs at
Mayo Clinic (Rochester, Minnesota, U.S.A.). Notably,
the ethics and professionalism principles and practices
described in this article derive largely from a Western
perspective. In addition, this article will focus on medical students, physicians in training, and physicians inpractice.
What is “Professionalism”?
The word “professionalism” is derived from the Latin
professio, or public declaration.1 One definition of profession is “a calling requiring specialized knowledge andoften long and intensive preparation including instruction in skills and methods as well as in the scientific, historical, or scholarly principles underlying such skills andmethods, maintaining by force of organization or concerted opinion high standards of achievement and conduct, and committing its members to continued study
and a kind of work which has for its prime purpose therendering of a public service”.1 The goals, behaviors,
and attributes that characterize a profession constitute“professionalism”.
Nevertheless, professionalism is an abstract concept.
When asked, “What is professionalism?” individuals arelikely to respond, “I know it when I see it” or list attributes of professionalism rather than recite a specific definition. Notably, professional societies have used similar
approaches to defining professionalism (i.e., these definitions typically include lists of attributes of professionalism). For example, the Association of American Medical Colleges (AAMC), in its “Learning Objectives for
Medical Student Education,”2 states that physicians mustbe altruistic, knowledgeable, skillful and dutiful—attributes of professionalism. The Accreditation Council for
Graduate Medical Education (ACGME)3 lists 6 generalcompetencies that physicians-in-training must possessbefore graduating from residency and fellowship training
programs, one of which is “professionalism.” In defining
professionalism, the ACGME lists attributes of professionalism including respect, compassion, integrity, responsiveness, altruism, accountability, commitment toexcellence, sound ethics, and sensitivity to diversity.4
The American Board of Internal Medicine (ABIM), theAmerican College of Physicians, and the European Federation of Internal Medicine, in the “Physician Charter,”5
describe professionalism as “a foundation of the social
contract for medicine” and lists 3 ethics principles and10 “commitments,” or attributes of professionalism(Table 1). Other groups have taken similar approaches
and one approach is not necessarily superior to another.
Rather, what is remarkable is that the various approaches
generally list similar sets of attributes of professionalism.6
Articulating Professionalism at Mayo Clinic
In a speech given at the 1910 Rush Medical College
commencement, Dr. William Mayo stated, “As we growin learning, we more justly appreciate our dependence
upon each other...The best interest of the patient is the
only interest to be considered, and in order that the sickmay benefit of advancing knowledge, union of forces isnecessary.”7 Attributes of professionalism can be foundin Dr. Mayo’s statement including the primacy of patient
welfare, altruism, competence, and teamwork. Indeed,from this quote are derived Mayo Clinic’s primary value,“The needs of the patient come first” and Mayo Clinic’s
mission, “Mayo will provide the best care to every patient every day through integrated clinical practice, education, and research.”8 Reflecting the institution’s history, primary value, and mission, Mayo Clinic leaders developed the Mayo Clinic Model of Care,9 which is defined by high quality and compassionate care deliveredin an integrated multispecialty academic setting. The primary value, “The needs of the patient come first” isachieved by embracing 7 patient care- and 7 practice environment-related attributes of professionalism (Table 2).
The Relationships between Patients, Society andthe Medical Profession
In order to be a member in good standing of the medical profession (i.e., licensed), a physician must manifest
professionalism. Using the Physician Charter as a guide,a physician should acknowledge specific ethics principles and commitments (e.g., competence) (Table 1).5
These principles and commitments highlight physicians’“fiduciary” duties to patients. Fiduciary duties recognize

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Table 2 The Mayo Clinic Model of Care9
Patient Care
1. Collegial, cooperative, staff teamwork with multispecialty integration. A team of specialists is available
and appropriately used.
2. An unhurried examination with time to listen to the patient.
3. A physician takes personal responsibility for directing patient care over time in a partnership with thelocal physician.
4. Highest quality patient care provided with compassion and trust.
5. Respect for the patient, family, and the patient’s local physician.
6. Comprehensive evaluation with timely and efficient assessment and treatment.
7. Availability of the most advanced, innovative diagnostic and therapeutic technology and techniques.
The Mayo Clinic Environment
1.
2.
3.
4.
5.
6.
7.

Highest quality staff, mentored in the culture of Mayo and valued for their contributions.
Valued professional allied health staff with a strong work ethic, special expertise, and devotion to Mayo.
A scholarly environment of research and education.
Physician leadership.
Integrated medical record with common support services for all outpatients and inpatients.
Professional compensation that allows a focus on quality, not quantity.
Unique professional dress, decorum, and facilities.

the power differential between physicians and patients.
Physician-patient interactions are not akin to transactions
between buyers and sellers of goods. While the seller is
expected to represent his or her product fairly, the buyer
is expected to be knowledgeable of the product before
buying it. In contrast, physicians possess specialized andhighly complex knowledge and skills, prescribing rights,
and other powers that patients do not have. Patients whoare ill or injured (and, hence, vulnerable) must therefore
trust that the physician is acting on the patient’s behalf.
With the attributes of professionalism and physicians’
fiduciary duties in mind, society’s expectations of the
medical profession can be listed: competence, the services of the healer, altruism, integrity, transparency, and accountability, and promotion of the public good. One canalso list the profession’s expectations of society: autonomy (i.e., to train, admit, monitor, discipline, and expel its
members), a functioning healthcare system, and sufficient resources to meet its responsibilities.5, 10, 11 The relationship between society and the medical profession isformally established and reinforced through licensure.
These expectations necessarily require that medical students, physicians in training, and physicians in practicebe taught and assessed for professionalism.
A Framework for Defining Medical Professionalism
Using the statements and positions of professional societies, and patient and societal expectations, a robust
framework for defining professionalism emerges; Arnold
and Stern12 propose such a framework that in turn can beused to develop curricula for teaching and tools for assessing professionalism (Fig. 1). This framework canalso be used to conduct research related to professionalism. The foundation of this framework is comprised ofclinical competence, communication skills, and soundunderstanding of the ethical and legal aspects of medicine. Rising from this foundation are accountability (individual physicians and the profession taking responsibility for physician behaviors), altruism (the interests ofpatients guide physician behavior), excellence (commitments to competence, life-long learning, continuous improvement, and the advancement of knowledge), and humanism (respect, compassion, empathy, honor, and integrity). The capstone of the framework is professionalism, or the complete physician.
Why Teach and Assess Professionalism?
Teaching and assessing professionalism does not occur
by chance alone
There are multiple reasons for teaching professionalism to and assessing it in medical students, physicians in
training, and practicing physicians (Table 3). One reason
is that teaching and assessing professionalism does notoccur by chance alone. In order for medical students andphysicians in training to become professionals and physicians in practice to remain professionals, the elementsof the framework of professionalism －clinical knowledge and skills, communication skills, ethics, accountability, altruism, excellence, and humanism－ should be
intentionally taught. This intentionality requires formal
curricula and authentic fostering of a culture of professionalism in learning environments. Likewise, professionalism should be intentionally assessed. Clear expectations and rich experiences alone will not guarantee thatprofessionalism is learned. Assessment motivates individuals to learn what is important (i.e., professionalism)and helps determine whether competency in profession-

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Fig. 1 A framework for defining medical professionalism.32

alism has been achieved.13
Patients expect physicians to be professional
A compelling reason to teach and assess professionalism is that patients expect physicians to be professional.
In one study,14 192 patients were asked to describe ideal
physician behaviors. Seven behaviors were identified:being confident, empathetic (“understands my feelings”),
humane (compassionate and kind), personal (i.e., viewing the patient as a person rather than a disease), forthright (“tells me what I need to know”), respectful, andthorough. Indeed, in another study,15 compassionate care
was the factor that most predicted patient willingness toreturn for or recommend (to others) care in the outpatientsetting, whereas delivery of care (especially that which
encouraged patients to ask questions) and compassionate
care were the factors that most predicted willingness toreturn for or recommend care in the inpatient setting.
Notably, internal surveys conducted at Mayo Clinic (theauthor’s institution) have had similar results: high patientsatisfaction and rating of quality of care are associatedwith physician caring, efficiency, listening, adequate explanations, thoroughness and staff courtesy and teamwork.
Medical professional societies expect professionalism to
be taught and assessed
Another reason to teach and assess professionalism isthat medical professional societies expect or require it.

As members of a profession, physicians have specializedcompetencies (including professionalism), duties and responsibilities, and the autonomy to train, monitor, anddiscipline its members. As noted previously, the AAMC
states that physicians must be altruistic, knowledgeable,
skillful and dutiful.2 Among the 6 general competencies
listed by the ACGME are “interpersonal and communication skills that result in effective information exchange
and teaming with patients, their families, and other
health professionals” and “professionalism, as manifested through a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.”3 Requiring competence in these domains not only requires that training
programs teach professionalism, but also that they assesslearner professionalism. Notably, within 15 months after
its release, the Physician Charter5 was endorsed by 90
specialty societies.1 6 Furthermore, the ABIM certification program has content related to ethics and professionalism.1 7 These efforts underscore the importance ofteaching and assessing professionalism.
Professionalism is associated with improved medical
outcomes
An important reason for teaching and assessing professionalism is that professionalism is associated with improved medical outcomes including increased patientsatisfaction and trust, increased patient adherence withtreatments, increased likelihood patients will stay with aphysician, fewer patient complaints, and less patient liti-

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Table 3 Reasons for teaching and assessing professionalism
1. Teaching and assessing professionalism does not occur bychance alone.
2. Patients expect physicians to be professional.
3. Medical professional societies expect professionalism to betaught and assessed.
4. Professionalism is associated with improved medical
outcomes.
5. Unprofessional behavior is associated with adverse medical
outcomes.
6. Accreditation organizations require that professionalism betaught and assessed.
7. Professionalism can be taught and learned.
8. Professionalism can be assessed.

gation. In addition, professionalism is associated withoverall physician excellence including medical knowledge, skills and conscientious behaviors.4, 18
Unprofessional behavior is associated with adverse
medical outcomes
The results of several studies highlight concerns about
professionalism among physicians and therefore reinforce the need for teaching and assessing professionalism. In a survey1 9 of 1,627 physician executives, morethan 95% reported that they regularly encountered unprofessional physician behaviors including disrespect,yelling, insults, abuse, and refusal to complete duties.
These behaviors involved nurses, other physicians, administrators, and patients. Other surveys2 0-2 3 have revealed that a majority of nurses and many physicians
have witnessed or experienced unprofessional physician
behaviors. Furthermore, physician abuse of pharmacists
and trainees is not uncommon.2 4, 2 5 Respondents to one
survey2 3 believed disruptive physician behaviors werelinked to adverse events (e.g., medical errors).
What are the consequences of unprofessional physician behaviors? Evidence suggests that unprofessional
behaviors result in reduced employee morale and productivity, high employee turnover, reduced nurse satisfaction, reduced communication, teamwork and efficiency, higher costs and decreased learner satisfaction, burnout, and depression. Notably, if unprofessional behaviors
are not addressed, learners may come to regard such behaviors as acceptable and incorporate the behaviors
themselves.26, 27
Evidence also suggests that unprofessional behavior
among practicing physicians can be predicted during
medical school. One study28 found that physicians disciplined by the California state medical board had significantly higher odds of having manifested unprofessional
behavior (e.g., poor reliability and responsibility, lack ofself-improvement and adaptability, and poor initiativeand motivation) during medical school than non-disciplined physicians. A larger study2 9 involving 40 U.S.

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state medical boards had similar findings. These findings
suggest a need to monitor closely for and address unprofessional behavior during medical training and make efforts to remediate such behavior and expel the learner ifnecessary; doing so fulfills the profession’s responsibility of self-regulation.
Accreditation organizations require that professionalism
be taught and assessed
The Joint Commission, an independent, non-profit organization that accredits and certified healthcare organizations in the United States, has issued new and revised
standards that address unprofessional healthcare worker
behavior.3 0 These standards require healthcare institutions to have codes of conduct defining acceptable behavior and create and implement processes for managing
unprofessional behavior. Failure to meet these standards
risks accreditation and certification. In addition, The
Joint Commission recommends that institutions teachand assess professionalism (e.g., teaching etiquette, holding healthcare team members accountable for role-modeling professionalism, developing a system for surveillance and reporting, etc.). Needless to say, these accreditation standards require that healthcare institutions teachand assess professionalism.
Professionalism can be taught and learned
Another reason for teaching and assessing professionalism is that professionalism can be taught and learned.
Formal and informal curricula influence learner attitudes
and beliefs regarding professionalism, moral and ethicalreasoning, and behaviors. Evidence also suggests thattrainees learn most about professionalism from rolemodels.4 Role models can greatly influence attitudes andbehaviors. The “hidden curriculum,” the teaching andlearning that occurs outside of the formal curriculum －in clinic and hospital hallways, call rooms, and especially in patient rooms－ is a powerful influence on learners
and is largely delivered by role models.11, 13, 31
Professionalism can be assessed
A growing body of evidence indicates that professionalism can be assessed.4, 3 2, 3 3 As with any clinical topic,
the main reason for assessing professionalism is to determine if trainees learn and physicians in practice meetthis core competency. Furthermore, assessing professionalism conveys the message that professionalism is important and valued. Learners will attempt to master aclinical topic’s content if they know they must undergo
an assessment of their competence related to the topic.
Likewise, medical students and physicians will respondsimilarly to efforts at teaching and assessing professionalism: “They don’t respect what you expect; they respect

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what you inspect.”34
Professionalism assessments can be used for formative
feedback (i.e., to improve a learner’s competence) orsummative feedback (e.g., a “grade”). Overall, assessments should be used to enhance professionalism in alllearners and practicing physicians, reward exemplars,
identify those with lapses in professionalism, and dismiss those who cannot achieve this core competency.1 3
In addition, professionalism assessments should be donein order to evaluate professionalism education programs
and generate hypothesis for research related to medical
professionalism. Finally, teaching professionalism without assessing it sends a conflicting message to learners,
practicing physicians, and patients.
How Does One Teach Professionalism?
How does one teach professionalism? One can start byteaching the foundational elements of professionalism:
clinical competence, communication skills, and an understanding of the legal and ethical aspects of medicine(Fig. 1). Being a professional requires specific knowledge and skills and generally all training programs strive
for clinical competence in their learners. Training programs should also teach communication skills (e.g., physician-patient, physician-allied healthcare staff, physician-physician, and so on) and ethics. Teaching communication skills and ethics makes sense for a number ofreasons. First, in order to assess patients properly, physicians must be able to communicate adequately and effectively with patients and, when appropriate, their surrogates (e.g., to discern patients’ healthcare goals and preferences, etc.). Indeed, the medical interview is one of themost common “procedures” performed by physicians.
Thus, being an effective communicator is essential forbeing an effective physician. Second, physicians typically work in multi-disciplinary teams comprised of not
only other physicians and learners, but also nurses, pharmacists, therapists, social workers and others. Effective
communication with these colleagues ensures proper patient care. Third, effective communication with patientsis associated with improved patient outcomes including
satisfaction, emotional health, symptom resolution andcontrol, physiologic measures (e.g., blood pressure), andadherence with management plans.35 Fourth, physicians
invariably encounter clinical situations that raise ethicaldilemmas (e.g., withholding life-sustaining treatmentsfrom patients who do not want them, etc.). Physicians
should be familiar with the ethical and legal aspects ofthese dilemmas and approaches for resolving them. Fifth,
ethics curricula can improve the moral reasoning of physicians.4 Indeed, for these reasons, many U.S. academic
healthcare centers have communication curricula andmost have ethics curricula.36
In addition to teaching foundational elements of professionalism, the attributes of professionalism －excel-

lence, humanism, accountability and altruism－ should
also be taught in order to foster the development of thecomplete and professional physician (Fig. 1). Yet, howdoes one teach abstract concepts such as these? Fortunately, a variety of methods can be employed (Table 4).
Didactic lectures and web-based learning modules areconvenient and popular methods of teaching. Using audio and video examples of professional and unprofessional behaviors during didactic lectures or embedding
them into web-based modules can be effective teachingtools. Notably, although the didactic lecture can be an efficient means of summarizing large amounts of information and improve knowledge and attitudes, didactic lectures do not necessarily improve patient outcomes. However, using interactive teaching methods such as casediscussions and hands-on practice sessions can improvelearner performance and patient outcomes.3 7, 3 8 Therefore, teaching and learning professionalism may be better achieved by using interactive methods such as discussion groups (e.g., the “challenging case”), role play, simulation using actor-patients, and team learning. Finally,
professionalism is perhaps best taught by role-modeling.4
Learners observe and adopt the attitudes and behaviorsof their role models. Medical teachers should use interactions with patients, colleagues, other members of thehealthcare team as opportunities to role model and therefore teach professionalism, especially excellence, humanism, accountability and altruism. Yet, role modelingalone is insufficient for teaching professionalism; itshould be coupled with discussion and reflection. For
example, a teacher who demonstrates to learners how todeliver bad, sad, or unexpected news to a patient should
follow-up the role-modeled behavior by discussing andreflecting on the behavior.13
A number of strategies exist that enhance teaching professionalism.3 9 First, a culture of humanism should beestablished; doing so conveys a message that the desire
to teach professionalism is authentic. Second, the curriculum should be practical and relevant; learners will bemost engaged in learning professionalism when it istaught in the context of their field of study (e.g., surgery
trainees should learn about professionalism issues related
to surgical practice). Third, learners should be engaged
in tasks that challenge and grow communication skills(e.g., breaking bad, sad, or unexpected news to patients).
Professionalism lapses, communication failures, andsimilar events should be recognized and used for formative feedback and teaching. As noted previously, rolemodeling is essential. Fourth, self-reflection should be
encouraged (e.g., journal writing, discussion groups,etc.). Indeed, “critical incident reports,” short narratives
written by medical students and physicians that describe
meaningful moments in clinical practice, can be an effective tool for teaching professionalism, especially if
coupled with group discussion and reflection.40 Fifth, the“hidden curriculum” should be intentionally addressed,

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Table 4 Methods of teaching and approached to assessing professionalism
Methods of teaching professionalism
1.
2.
3.
4.
5.
6.
7.

Didactic lectures.
Web-based curriculum.
Discussion groups.
Role-play.
Simulation using patient-actors.
Team learning.
Role-modeling with discussion and reflection.

Approaches to assessing professionalism
1. Commence at the start, and continue throughout, the learner’s career.
2. All levels of the hierarchy (i.e., medical students, physicians in training and physicians in practice)
should be assessed.
3. Individuals should know they are being assessed.
4. Use multiple assessment tools and observers.
a. Tests of knowledge, skills (e.g., communication skills), and reasoning (e.g., ethical dilemmas).
b. 360-degree reviews by faculty attendings, peers, allied healthcare staff (e.g., nurses), and others.
c. Objective structured clinical examination.
d. Patient assessments.
e. Critical incident reports.
5. Use for formative and summative feedback; professionalism “portfolio.”
6. Use for assessing professionalism education programs and conducting professionalism research.

particularly if it is at odds with the formal curriculum related to professionalism.11 Not addressing the “hidden
curriculum” conveys the message that what is taught is
not necessarily what is practiced (i.e., the professionalism curriculum is inauthentic). Finally, negative rolemodels and “disruptive” physician educators (e.g., those
who abuse learners) should be identified, provided feedback regarding their behaviors, offered remediation, and,if necessary, dismissed from teaching.4, 27
How Does One Assess Professionalism?
How does one assess professionalism? Not only “how,”
but also “what?”, “when?”, “where?”, and “by whom?”Using Arnold and Stern’s model (Fig. 1), foundational
elements of professionalism －knowledge and skills in agiven content area or specialty, learners knowledge inethics, moral reasoning and communication skills－
should be assessed. In addition, attributes of professionalism －excellence, humanism, accountability and altruism－ should also be assessed. Assessing these attributes
involves cognitive, behavioral and affective outcomes.
The observations should be relevant to, and based on the
expectations of, the specialty setting and the learner’s
developmental level.4
Multiple approaches to assessing professionalism
should be employed (Table 4). Professionalism assessments should commence at the start of, and periodicallythroughout, a physician’s career. Learners should knowthat they are being assessed and, ideally, all levels of thehierarchy －from medical students to faculty physicians－ should be assessed for professionalism. However, nouniversal tool for assessing professionalism exists.33 Instead, multiple tools should be used including tests ofknowledge and skills, 360-degree reviews (e.g., by faculty attendings, peers, allied healthcare staff, patients,and others), objective structured clinical examination(OSCE), review of patient complaints, and other methods can be used to assess professionalism.4, 13, 18, 33 “Critical incident reports” can also be used for assessment ofprofessionalism, especially for learners at the extremesof performance.4 1 Using multiple reliable tools ensuresthat professionalism assessments are valid.
Notably, physicians typically have few opportunities
for observing learner and colleague professionalism.
“Most practicing physicians observe each others’ behaviors only in the hallways and conference rooms －rarely
with patients.”32 In addition, faculty physicians may only
infrequently observe learners when learner professionalism is most challenged: during difficult clinical situations. In these situations, the best observers may be peers(e.g., fellow students, residents and fellows), allied
healthcare staff (e.g., nurses), patients, and patients’
loved ones. One can increase the number and variety ofobservers by involving these individuals in the assessment process. In addition, a variety of realistic settings(e.g., inpatient unit, outpatient clinic, research laboratory,etc.) should be used for observations. Using multiple observers in a variety of settings ensures the observations
are valid.4, 32
What do you do with the professionalism assessments?
First, the information should be gathered and collated aspart of a “professionalism portfolio” from which a clearer picture of learner professionalism is derived.4 2 Sec-140

ond, the assessment data can be used for formative feedback. Third, it can be used for summative feedback.
Fourth, it can be used to reward exemplars and discipline
those with unacceptable lapses in professionalism.4, 3 2Finally, the data can be used to evaluate and improve
professionalism education programs and generate hypotheses for research on professionalism.4,3 3Teaching and Assessing Professionalism at Mayo Clinic
The most widely used means of teaching and fostering
professionalism at Mayo Clinic is its culture. This culture has been promoted since the Clinic’s founding andthroughout its history and is encapsulated in Dr. William
Mayo’s 1910 statement, “The best interest of the patientis the only interest to be considered”7 and more recently
in the Mayo Model of Care (Table 2).9 Essential elements of the Mayo Clinic culture are its unsurpassed expertise in all aspects of clinical medicine and its commitment to excellence. Patient care is efficient and cost-effective. Continuous professional development, quality,
teamwork, service, patient safety, and respect for diversity are viewed as professional obligations. Education
and research efforts are similarly pursued. Decisionmaking is typically multi-disciplinary and by consensus.
Professional dress, decorum, and etiquette are expected.
Recognizing that many patients and their loved ones visit
the Clinic under stressful circumstances, Mayo Clinic facilities are beautiful and well-appointed; rest areas, cafes,
meditation rooms, chapels, libraries, artwork, and plantlife are abundant. Regardless of their faith tradition, patients have access to spiritual care 24 hours a day. Indeed, in 1930, Dr. William Mayo stated, “The maintenance of the present spiritual status of the Mayo Clinic isof the greatest importance. We must not permit the material side to encroach upon our ideals…I believe the heartof the Clinic has been more responsible for its extraordinary usefulness to the people and the confidence that thepeople have in it than any other factor.”43 Likewise, ethics consultation is available 24 hours a day. All new
Mayo Clinic employees and physicians learn about theClinic’s rich culture and history of professionalism attheir orientations and, more importantly, from their colleagues and mentors throughout their careers. Furthermore, this rich culture is codified in Mayo Clinic policies
and procedures. Notably, external reviewers have confirmed the presence of the rich, vibrant, and living culture of professionalism at Mayo Clinic.44
In order to preserve and promote further this culture,professionalism teaching and assessment programs havebeen implemented at Mayo Clinic. These programs involve learners at all levels (including faculty physicians).
Mayo Medical School has multiple required professionalism and ethics elements for students including two
1-week-long intensive bioethics courses (one on the firstyear and one in the third year) and a leadership and pro-

Muleller PS: Professionalism and Medical Education

fessionalism curriculum in the first year gross anatomy
course.45 During the second year, students participate in
the “Advance Doctoring” professionalism reflective
writing program, which is similar to “critical incident reports” narrative writing programs described elsewhere.40
In the third year, students participate in the “Safe Harbor” professionalism program, which involves facilitatedsmall group discussions of clinical cases, personal reflections, and material drawn from the literature and arts.
Faculty, residents and fellows, and peers complete electronic professionalism assessments of medical students
during their clinical rotations.18 Finally, professionalismand ethics teaching is woven into courses and clinical rotations throughout the four-year curriculum. For example, during the pre-clinical nephrology block, students
learn about a variety of professionalism and ethics issues
faced by patients with kidney failure and nephrologists(e.g., just allocation of organs for transplantation, theethical aspects of withholding hemodialysis from dying
patients, and talking to patients about death and dying).
Taking this approach not only makes professionalismand ethics relevant for medical students, it also enriches
the discussions that occur and brings to life daunting
psycho-social and spiritual issues that clinicians face every day while caring for patients.
In addition, Mayo Medical School offers elective experiences in professionalism and ethics. This past year, agroup of Mayo medical students established an ethics
journal club sponsored by the Mayo Clinic Program in
Professionalism and Bioethics. At the journal club’smonthly meetings, journal articles on ethics-related topics (e.g., physicians’ duty to care for patients during apandemic) are discussed. Medical students also have theopportunity to devote 1 month of their elective time to abioethics “selective,” in which they, along with a faculty
mentor, design a curriculum related to bioethics that also
complements the student’s career interest. Activities during the “selective” might include a literature review, attending a bioethics conference, engaging in clinical ethics activities (e.g., ethics consultation), and conducting
an ethics-related project such as writing a paper or participating in empirical research. The result of these efforts at Mayo Medical School is a “professionalism portfolio,” a summary of which is incorporated into the student’s Dean’s letter which is sent to the residency programs to which the student has applied for additional
training.
The Mayo School of Graduate Medical Education(MSGME) also has multiple required professionalism elements for its learners (i.e., resident physicians and fellows). As noted previously, the ACGME identifies 6 corecompetencies that all graduates of residency and fellowship programs must possess; one of these competencies
is professionalism.3 As a result, each training program isrequired to deliver curricula and demonstrate learnercompetence in professionalism. To meet this goal, allKeio J Med 2009; 58 (3): 133－143

new residents and fellows at Mayo Clinic must attend a
professionalism module during their orientation. The
content of this course includes respect for patient confidentiality, mutual respect, and so on. In addition, theMSGME is developing web-based professionalism andethics modules for the numerous residency and fellowship programs at Mayo Clinic. These modules will becompleted by learners at their convenience during theirtraining programs. A goal of the web-based curriculum is
to create modules that are specialty-specific (e.g., surgery-oriented professionalism and ethics modules forsurgery residents).
Notably, the internal medicine residency training program at Mayo Clinic Rochester takes a multi-faceted approach to teaching professionalism to internal medicine
residents. First, professionalism and ethics sessions (e.g.,commonly-encountered clinical ethical dilemmas, accepting gifts from pharmaceutical company representatives, etc.) are part of the “core curriculum.” Second,
professionalism and ethics issues are discussed frequently at the weekly morbidity and mortality conference(e.g., medical errors, medical futility, withdrawing treatments in dying patients, etc.). Third, all internal medicine residents at Mayo Clinic Rochester are required tocomplete professionalism OSCEs including modules on
breaking bad news, medical errors, confidentiality, andadvance directives. Patient-actors are used. While the
OSCEs are used for formative assessment, much learning occurs during these sessions as the learners assessthemselves and receive feedback for faculty observers
and the patient-actors.
The Mayo Clinic Rochester internal medicine residency training program also takes a multi-faceted approachto assessing professionalism among internal medicine
residents. The professionalism OSCEs were previously
mentioned. For formative feedback, faculty advisors review patient complaints and professionalism lapses with
their assigned trainees. A typical question during thesesessions might be, “How might have this situation gone
better?” In addition, education leaders at our institution
recently developed a novel method of assessing professionalism among internal medicine residents: electronic
360-degree assessments by peers, senior residents, faculty, and others. Notably, residents rated “highly professional” by faculty, peers, medical students, and allied
healthcare staff scored significantly higher on tests ofknowledge (in-training examination), mini-clinical evaluation exercise, and conscientious behaviors (completingrotation evaluations).18
Mayo Clinic also has required professionalism elements for its faculty physicians. All new staff physicians
at Mayo Clinic are required to attend and successfullycomplete a series of professionalism, physician-patientcommunication, self-awareness, and diversity modules.8, 46 The professionalism module covers the following topics: reflective listening, listing the attributes of141

professionalism, reviewing the data linking professionalism to favorable patient and learner outcomes, and recognizing and responding to professional and unprofessional behavior. Notably, attendees have rated this module highly. Periodically, all faculty physicians are required to complete web-based, interactive and otherforms of professionalism and ethics training modules inorder to maintain staff privileges. Finally, elective professionalism and ethics learning opportunities are available to Mayo Clinic faculty physicians. For example,
medical grand rounds sessions and continuing education
courses and symposia related to professionalism and ethics are commonly offered.
All Mayo Clinic faculty physicians undergo 360-degree reviews that include assessments of professionalism
by faculty peers, allied healthcare staff, and trainees.
Feedback from these assessments is used for formative
feedback during the physicians’ annual reviews. Lapses
in professionalism are not tolerated and are addressedusing a formal process; describing this process is beyond
the scope of this article. Notably, this process is in alignment with The Joint Commission standards regarding
disruptive and inappropriate behaviors among healthcare
providers.30
Several years ago, the PLEASE CARE professionalism program for non-physician allied healthcare staff
was implemented at Mayo Clinic. PLEASE CARE (anacronym for present, listen, empathize, action, summarize, excite, confidentiality, attitude, respect, and emotional intelligence) encapsulates Mayo’s primary value(“the needs of the patient come first”), describes how
one ensures ideal patient visits to Mayo and supports
Mayo’s service philosophy. Since its inception, nearly
3000 Department of Medicine allied healthcare staff(e.g., nurses, assistants, etc.) have completed the program, which consists of didactic lectures, video vignettes, and role plays. More than 95% of attendees
thought the program was beneficial and in every medical
specialty division in which the program was implemented, patient satisfaction increased significantly.47
Conclusion
Professionalism is a core competency of physicians.
Using the statements and positions of professional societies, and patient and societal expectations, a frameworkfor defining professionalism emerges: a foundation ofclinical competence, communication skills, and soundunderstanding of the ethical and legal aspects of medicine. Arising from this foundation are attributes of professionalism: accountability, altruism, excellence, andhumanism. The capstone of the framework is professionalism, or the complete physician. Indeed, professionalism is associated with superior clinical outcomes. Hence,
medical students, physicians in training, and physiciansin practice should be taught and assessed for profession-

142

Muleller PS: Professionalism and Medical Education

alism. Numerous methods can be employed to teach andassess professionalism. Professionalism assessments, inturn, can be used for formative and summative feedback
and professionalism “portfolios.” The Mayo Clinic experience validates the importance of teaching and assessing
professionalism among learners and physicians in practice and regarding it as a core physician competency.
Acknowledgment
The author thanks Dr. Michael D. Brennan, Director of
the Program in Professionalism and Bioethics, Mayo
Clinic, for his thoughtful review of this manuscript.
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