Revisiting Medical Professionalism and ABFM's Guidelines for Professionalism, Licensure, and Personal Conduct in a New Era

In June, the American Board of Family Medicine (ABFM) published revised Guidelines for Professionalism, Licensure, and Personal Conduct (Guidelines) after more than a year of careful study and deliberation. Our goal was to improve the clarity of the process by which board-certified family physicians come to be reviewed for consideration of revocation of their certification and to provide greater flexibility to the members of the Professionalism Committee of the ABFM Board of Directors as they consider individual cases. This article provides our rationale, briefly linking the tradition of medical ethics and professionalism to the practical aspects of how ABFM considers professionalism.

Medical professionalism represents a belief system through which physicians profess, to each other and the public, that they will uphold a set of shared ethical values and competency standards that patients and the public can expect of them. The origins of medical professionalism date back to the Hippocratic Oath¹, often publicly recited at medical school graduation, in which new physicians swear to uphold a set of principles of medical ethics. In modern day, the original oath has been eclipsed by more updated documents, such as the Declaration of Geneva, the Oath of Maimonides, and the American Medical Association Code of Medical Ethics.^2⇓–4 In each of these, physicians agree to place the interests of patients above their own, maintain standards of competence and integrity, and consistently demonstrate trustworthiness with patients, colleagues, coworkers, and the public. In exchange for honoring this social contract, they have the privilege of autonomy and self-regulation.

Professionalism continues to serve as the foundation of excellence in clinical care. Within its context is an implicit pledge that physicians commit to ongoing personal development, lifelong learning, professional development, and applying current knowledge in practice.⁵ While there has been much discussion about definitions of professionalism, there are generally 3 major components — a common ethical framework, specific behaviors that must be followed, and the development of professional and specialty identity.^6,7 More recently, a new charter on medical professionalism was published through the American Board of Internal Medicine Foundation.⁸ Endorsed by108 professional associations and organizations, this charter focused on 3 principles: the primacy of patient welfare, respect for patient autonomy, and promotion of social justice in the health care system, while also acknowledging the challenges imposed by the contemporary impact of the corporate mentality on a profession dedicated to serving others.

Patients have high expectations when they place their care in the hands of physicians, and they rely on there being organized, consistent, and fair processes by which the profession conducts an ongoing assessment of individual physicians that result in a judgment about whether the conduct was acceptable, remediable, or requires further action. While much of this begins at the local level, medical licensing boards and certifying boards each provide important functions in this regard. Individual state medical license boards review physicians' qualifications for licensure and render a decision about their legal right to practice medicine in a jurisdiction, as well as assessing any behaviors considered to create potential safety concerns for patients or the public and consider license limitation, suspension, or revocation. Typically, physicians and often public members sit on these boards, and professionalism is a major component of this assessment.

The role of certifying boards regarding professionalism is not in opposition to the role of the state licensing boards. Rather it should be viewed as complementary or enhancing. Certifying boards set standards for ethical practice within their respective medical specialties, which may exceed those of licensure. Like the medical license boards, certifying boards then have systems for systematically reviewing individual cases. Professionalism has always been a major component of ABFM Certification. As a practical matter, medical licensure forms the foundation of ABFM's assessment of professionalism. While neither a sensitive nor specific diagnostic test, if a physician does not have an unlimited medical license, this is often sufficient cause for a finding that a physician is not meeting the higher standards of certification in a medical specialty. In addition, ABFM may also address breaches in professional behavior and personal conduct which are not addressed by medical license boards.

Cases are identified through self-reporting to ABFM, regular reports from the Federation of State Medical Boards and other governing bodies, media alerts, and third-party complaints. The ABFM Professionalism Committee and its staff review cases to determine compliance with ABFM's Guidelines for Professionalism, Licensure, and Personal Conduct. ABFM relies on medical boards and similar governing bodies for data collection, provision of due process protections, investigation of complaints of unprofessional conduct, collection of witness testimony, and ultimately adjudication of complaints. However, this process has its own challenges in that substantial variation is observed in the decisions made by 71 existing medical licensure boards about how similar behaviors or actions are sanctioned.

Ultimately, it is the role of the certifying boards to determine if the physician's conduct is consistent with being recognized as board-certified in their specialty. All appeals in which a licensing board's decision or the physician's conduct results in a decision to remove certification are carefully considered by members of the ABFM Professionalism Committee who thoughtfully balance their dual role of supporting the public and Diplomates. The committee is composed of practicing family physicians plus representatives of other specialties and a public member. Deliberations focus on 3 questions: (1) Has the physician provided care that is safe or unsafe? (2) Has the physician demonstrated honesty, integrity, and behaviors associated with professionalism and trustworthiness with patients, colleagues, coworkers, and the public? and (3) Has the physician practiced at the level expected of a board-certified family physician?

Fortunately, loss of certification in family medicine is quite uncommon—ABFM records show that it only happens for 0.09% of all certified family physicians. Furthermore, all those who have a break in certification for professionalism reasons can regain certification; over 50% do so after restoration of unlimited license status. Nevertheless, acting on serious breaches of professionalism by physicians is important for patients, the public, the specialty, and the privilege of self-regulation offered to the profession. Consistent with a continuous improvement approach in all that we do, ABFM leaders, staff, and board members regularly re-evaluate the conduct identified in the Guidelines and their rationale, as well as the input of members of the Professionalism Committee and other Diplomates, to reconsider our approaches to assessing the professionalism standards of board certification.

As the first major revision in over a decade, the revised Guidelines*, while remaining consistent with prior rules on licensure and personal conduct, including significant changes that include:

• A new section identifying Special Circumstances that may apply to certain licensure limitations or participation in Physician Health Programs that would provide the Committee some flexibility in determining the physician's certification status;

• Clarification regarding licensure limitations that are not the result of an adverse action (eg, related to a disability);

• A new section to define the professional conduct expected of family physicians and identify categories of professional and personal conduct which may violate the Guidelines even in the absence Licensure Policy violations;

• New language to address model disciplinary language or near-universal conditions applied to all physicians, such as limitations for self and family treatment;

• New language to address special medical license types (eg, visiting physician, visiting professor, camp physician, consultative medicine, and telemedicine);

• New guidance on applying for reinstatement after the loss of certification or eligibility;

• New guidance to help clarify expectations regarding participation in continuous certification during the appeal period.

These revisions provide more contemporary guidance for evaluating medical professionalism at the individual physician level and creates a more flexible structure for Professionalism Committee review of appeals of potential violations of ABFM Policies. We believe that they are fairer: they allow a more individualized review of the facts and context of each action before a withdrawal of certification by considering not just the limitation but the medical board's findings of the underlying conduct or other relevant circumstances before determining whether withdrawal of certification is appropriate.

Beyond the original professionalism oaths described at the beginning of this editorial, traditional definitions of professionalism typically center around a list of prohibited behaviors rather than aspirational concepts or positive exemplars. While assessment of professional lapses is important, ABFM believes that it is also important to acknowledge and promote positive professionalism. The acts that physicians do regularly demonstrate their service to their patients and society. We endorse a shift in overall focus that includes recognizing the daily expression of positive professionalism among family physicians who show up every day, consistently doing the right things for their patients despite many challenges. We have seen this in abundance during the Coronavirus disease 2019 (COVID-19) pandemic. We seek to honor their professionalism and commitment to their patients: we must celebrate each other for individual and collective demonstrations of professionalism and publicly declare that family physicians are meeting society's expectations. In doing so, we have the opportunity to establish our own public narrative that acknowledges the selfless acts displayed by family physicians daily for both patients and the good of society, whether it is in commitment to care of the uninsured; to addressing inequities in health care for patients of a different race, gender, social class, or abilities; making contributions to their communities; or teaching the next generation of health care professionals.

Finally, our work in the realm of understanding and assessing professionalism will begin to promote a built environment that enables professionalism in medicine.⁹ Recent attention has been paid to the concept of organizational professionalism and a set of competencies and behaviors that organizations can use to define professionalism that is distinct from individual professionalism.⁷ The impact of organizational professionalism, and its relationship to individual professionalism, is never more apparent than in the visible impact of corporatized medicine on the erosion of professional autonomy and the corresponding replacement of self- and peer-regulation with the identification and policing of unprofessional behaviors by organizations and institutions.¹⁰ As with individual professionalism, ABFM believes that organizational professionalism can also be influenced to evolve in ways that better promote and support an environment that is more satisfying for physicians and ultimately safer for patients. We look forward to working with each of you in this ongoing effort.

*The revised Guidelines for Professionalism, Licensure, and Personal Conduct were approved by the Board of Directors on April 26, 2021, and became effective on this date. The above summary is intended to help understand the process and revisions but should not be used as a substitute for compliance with the actual Guidelines. These Guidelines can be found on the ABFM Website here and in your MyABFM Portfolio.