Abstract
Despite a robust literature on the topic, a consistent definition of medical professionalism remains elusive. A single, generalizable definition is ineffective and tends to emphasize prohibited behaviors rather than aspirational concepts. As physicians are increasingly employed by corporate entities, the nature of healthcare work has changed, as well as professional expectations. This study explores how patients and family physicians understand medical professionalism and its drivers.
We recruited family physicians who completed the ABFM Continuing Certification Questionnaire in 2024 to participate in in-depth, semi-structured interviews. A trained qualitative researcher used Zoom to interview 27 demographically diverse physicians. We utilized modified snowball sampling to recruit patients through a key informant. All interviews were transcribed verbatim and analyzed utilizing NVivo software following an inductive content analysis approach.
Interview results coalesced into a model of professionalism that represents the clinic visit, the practice site, and the overarching system. Three main components of individual physician professionalism emerged, including foundational duties, relationship-based care, and communication. Patient trust in the overarching healthcare system and individual physicians was deeply influenced by the interconnected system.
This study presents key elements of physician professionalism while highlighting how deeply physicians are entangled within the larger practice and healthcare systems. Professionalism extends beyond—and is impacted by—more than individual attitudes and behaviors. Institutions must interrogate their own policies to support physicians in developing their skills in relationship-based care and communication.
- Doctor-Patient Relations
- Family Medicine
- FMLC 2025
- Medical Anthropology
- Patient Preference
- Primary Care Physicians
- Professionalism
- Qualitative Research
- Workforce
Introduction
Over the past two decades, conversations concerning medical professionalism have acknowledged the lack of a consistent and agreed-upon definition. A singular, generalizable definition is ineffective,1 “decontextualized” from the realities of practice,2 and tends to emphasize “prohibited behaviors” rather than “aspirational concepts.”3 Calls for “positive professionalism”4 and a professionalism that is “active, ongoing, and iterative,”5 are vague and narrowly conceptualize physicians as isolated individuals.
Beginning in medical education and stretching into practice settings, professionalism is commonly defined by legalization and aesthetics.6 Professional behavior, for example, is widely defined as not committing sexual assault, fraud, or inappropriate prescription of controlled substances.7 This leads to an understanding of professionalism that begins and ends with an “avoidance of negative consequences.”2 Historically, professionalism norms reflected dominant cultural expectations (whiteness, ableism, heteronormativity) that shaped who was judged as “professional.”8 This was reinforced by ACGME requirements that reduced professionalism to a series of boxes to be checked.
In a qualitative study conducted with internal medicine physicians, patient care emerged as a key aspect of professionalism.6 Knowing that patients rely on them motivated physicians to work long hours and perform other types of uncompensated labor.6 Cerdeña and colleagues similarly call for a professionalism that reflects “patient welfare, patient autonomy, and social justice.”8 The increasing emphasis on profits has cut into professionalism via the loss of autonomy,5,9 the increase in administrative and bureaucratic demands,10 and prioritizing productivity over patient and self-care.11
Few qualitative studies of professionalism within medicine exist, including in the family medicine specialty.1,2 Even fewer include the perspectives of patients, who are essential to the definition of professionalism, as patients are co-experts whose lived experience reveals system-level dynamics physicians may not see. This project seeks to understand how patient advisors and family physicians understand professionalism and its drivers.
Methods
A random sample of 325 American Board of Family Medicine (ABFM) diplomates who completed a continuing certification questionnaire in 2024 were invited to participate in January 2025. Through an iterative process to assure diversity in age, race, gender, practice type, and practice location, a final purposive sample of 27 physicians agreed to participate. A convenience sample of 11 patient advisors were recruited for in-depth semi-structured interviews via email through a key informant (TL) and interviewed in May and June 2025.
All interviews were conducted via Zoom by a trained qualitative researcher (AK, PhD anthropology) using a semi-structured interview script. Both scripts were informed by 11 previous pilot interviews with ABFM diplomates conducted in August 2023. Questions probed the meaning of professionalism, with an emphasis on gathering examples of positive and negative professional behaviors. Questions also explored institutional and systems-level supports and barriers to professionalism. Physicians received $150 and patients received $100 remuneration for their time and effort.
Interviews were recorded and transcribed verbatim by Microsoft Word transcription services and reviewed by MB for accuracy. Interviews lasted an average of 67.5 minutes. Data was iteratively analyzed by two qualitative researchers (AK, MB) via inductive content analysis.12 For both sets of interviews, an initial codebook was created by AK, then tested by MB. A final codebook was developed through iterative discussions and applied to all remaining interviews. All coding disagreements were reconciled via discussion. Physician interviews were coded separately from patient interviews. Data source triangulation methods were employed to compare codes and develop a final model of professionalism.3 The qualitative software NVivo (v. 14) was utilized for data analysis and a coding comparison query,13 which calculates percentage agreement between two coders; all codes achieved greater than 90% agreement. Representative quotations have been edited for readability.
Verbal consent was obtained at the start of each interview. This study was approved as exempt by the American Academy of Family Physicians (AAFP) Institutional Review Board.
This article emerges from a presentation given to 8 family medicine leadership organizations in summer 2025. It reflects updates to analysis and incorporates audience feedback, where applicable.
Results
Physician and patient demographics are presented in Table 1. The majority of physicians and patients self-identified as women (55.56%; 90%, respectively) and white or Caucasian (48.15%; 58.33%). The average age of physicians was 48.6 years; the average age of patients was 53.8 years. The largest category of physicians (22.22%) reported working for a hospital or healthcare system owned practice.
The model of professionalism that emerged from interviews is presented in Figure 1. The bottom “gears” represent the three main pieces of health care: the clinic visit, the practice site, and the overarching healthcare system. The overarching healthcare system included contemporary institutions that drive health care, such as government policies, insurance companies, and practice administration. Interviewees also referenced histories of racism and sexism in medicine that continue to influence their interactions with the system. The top circles represent the three main components of physician professionalism that emerge during the clinical visit: foundational duties, relationship-based care, and communication. Patient trust in the overarching healthcare system and individual physicians is deeply influenced by the interconnected system, as outlined in our model.
The Context of the Clinic Visit Impacts the Professionalism of Physicians and Patient Trust
According to patient participants, the practice environment sets the precedent for the clinic visit, and nursing and other staff set the tone before a patient and physician meet. Patients reported that it reflects poorly on the professionalism of physicians when offices are short staffed; productivity demands lead to shorter visits, and patients carry additional administrative burdens. Patients in this study desired continuity with their doctor, but continuity was often at odds with access. In other words, patients encountered a challenging trade off: to wait extended periods of time to maintain continuity with their established physician, or schedule an earlier appointment with a physician unfamiliar with their case. This situation ultimately led to the erosion of confidence in the practice’s professionalism and reflected poorly on the physicians.
The larger health system, including insurance companies and state and federal policies, shape the community histories and public narratives that patients take into the clinic encounter with them and color their perceptions of physician professionalism. Particularly among minority patients, the history and ongoing experiences of medical harm remain present in their minds and bodies. As one patient stated, “Trust is a complicated thing and there are lots of reasons people have skepticism about health care … many reasons … current and historical.” While patients were acutely aware of the historical inequities of medical practice, the majority of physicians nostalgically viewed the past as a time of autonomous practice and community engagement.
In this way, the health system, the practice environment, and the clinic encounter are interlocked pieces, with systems (past and present) and practices exerting significant pressure on the patient’s visit. In short, the health system and practice environment were found to produce barriers to physician professionalism.
Foundational Duties Are Key to Professionalism, but Not Sufficient on Their Own
Foundational duties were determined to include basic job responsibilities and continual learning.
Job responsibilities include being on time for appointments, or addressing with patients the reason for being late. They also include completing charting, which, importantly, means keeping track of details of patients’ lives that would further build connection and confidence in the physician-patient relationship. Job responsibilities also include completing contractual assignments (eg, prescribing certain pharmaceutical brands) and can vary based on the practice type and ownership model.
Continual learning was deemed to include keeping up with medical knowledge, but more importantly, learning from patients who are experts in their own bodies, lives, and sometimes diseases. Continual learning commonly means expanding medical knowledge and developing new skills to directly serve patient needs. However, patients, particularly those navigating lifelong chronic diseases, reported wanting physicians to acknowledge what they do not know and engage in continuous learning.
I was really impressed with the provider that I had before I moved here. The provider was actually very honest with me and said, I’m not that familiar with [your disease] and I know that you probably know more about it than I do, and I would really ask for you to help guide me with your treatment as much as possible. He … showed me that he really wanted to know more about [the disease] and he saw me as a patient and not just as an encounter.
While continual learning, much like job responsibilities, is foundational to the clinic visit, both are informed by and dependent on the communication in the physician-patient relationship. Medical knowledge and basic job duties are important, but neither will be truly in the service of the patient without relationship-based care and good communication.
Relationship-Based Care Provides a Framework for Engaging in Humanism, Ethics, and Values
Relationship-based care stresses bi-directional and reciprocal relationships as central to promoting the health of both patients and physicians. Both physicians and patients reported a deep desire for mutual respect, and patients, specifically, an explicit recognition of their expertise in their own bodies, experiences, and daily care. Patients want the physician, with their medical expertise, to act as a guide rather than an authoritarian figure. This approach is supported by personal connection rooted in an ethics of humanism. One patient, who at the time of interview was navigating not only her own health struggles, but those of her son, shared that:
How you connect with me is what … makes somebody a good professional…. I see being stoic, being emotionally disconnected from your patients, I know there is probably a mental health reason for some of that, but as a patient, sometimes I need you to be in it with me and that doesn’t look like you maintain[ing] a distance when I’m in crisis.
Physicians reflected the need to be personable and compassionate with all patients, because of their patients’ vulnerable and often painful states. Acknowledging and addressing vulnerability led to a stronger connection and built trust within the relationship:
I think for us, we’re working with patients that are pretty vulnerable, right? At their most vulnerable stage. So they’re not feeling well, they’ve got pain, they’ve had something that happened to them, right? So they’re already at a stage where they are vulnerable and you have to make sure you recognize that.
Discussions of humanism in the clinic often lead to conversations about personal ethical codes and value systems. Physicians found their ethics are often in tension with certain understandings of professionalism. Physicians mentioned gender-affirming care, abortion, vaccines, and other issues where politics, values, and medical care are often at odds as sources of that tension. While most physicians remained patient focused, developing their ethical code on what was best for their patients—in the spirit of relationship-based care—not all physicians did. Some physicians framed their patient care model through the lens of their own deeply held religious or political beliefs. A minority of physicians shared their unwillingness to discuss topics such as abortion or gender-affirming care with their patients. Other physicians noted how this reluctance could undercut the bi-directionality that is vital in relationship-based care and could compromise patient trust in the physician and overarching system.
Communication Was the Largest and Most Important Piece of Professionalism
Physicians reported that their communication is oriented toward themselves, the patient, and the clinic. This includes self-awareness and reflection, particularly around ethical decisions and scenarios. When faced with ethical scenarios, physicians expressed a desire to discuss and work through such issues with other physicians without fear of judgement. Physicians expressed a lack of time to self-reflect on ethics and values; lack of time was exacerbated by feelings of isolation that prevented communicating with colleagues and staff about such issues. Acute problems—broken computers, rooming mistakes, and other daily obstacles in the clinic—demanded strong communication between all team members. Physicians emphasized this dialogue as a key component to professionalism.
For patient-physician communication, both physicians and patients recognized the importance of listening to understanding one another. Patients also appreciated physicians who listened to more than just words, but to body language and emotions. For example, one patient was the caretaker for a child with a rare genetic syndrome that sent her to over twenty specialists, managed and coordinated by a family physician. During a particularly rough period in the child’s health journey, the caretaker and her husband went to an appointment with the coordinating family doctor.
My daughter was going through some tough things and me and my husband went into an appointment … just totally burned out. So, we have the appointment and she [our family doctor] kind of starts asking us questions; it was the PHQ 9 (depression) assessment…. I was familiar with the questions. I said, are you doing a PHQ 9 assessment? And she was like, yes, you and dad, you guys are not OK. And so, she brought in, in real time, a psychiatrist to come in and talk to us that day.
Patients want physicians to be curious, to ask them questions, and to remain open-minded and non-judgmental. Most of the patients in this study were navigating complex, chronic health conditions. Due to their personal lives or physician turnover, they often had to explain and re-explain their medical history to someone new. One patient explained what a lot of other participants experienced when meeting a new clinician:
Doctors who have a condescending or poor perception of their patients … don’t want to hear the patients understanding of what’s going on, they just want to hear the symptoms and then they’ll look at it through their own lens.
The importance of remaining open minded, non-judgmental, and curious permeated all interviews. Physicians desire this from other physicians and patients desire this from physicians. The professionalism on display throughout the practice, together with the personal professionalism of physicians, builds trust with patients The perceived lack of professionalism at both the practice level and at the larger healthcare system level undermines patients’ perceptions of physician professionalism.
Discussion
Through interviews with 27 ABFM diplomates and 11 patient advisors, we developed a model of professionalism that incorporates both systems-level and individual-level factors. The healthcare system, the practice environment, and the clinic visit all impact both physician professionalism and patient trust. Physician professionalism includes foundational duties (charting, being on time), relationship-based care (a bi-directional and personal, authentic connection with patients), and communication (with an emphasis on listening). Systematic and individual factors cannot be disentangled from discussions of professionalism or patient trust in healthcare.
Relationship-based, bi-directional care requires organizational support. Relationship-based care is challenged by systems that incentivize volume over connection. To support both patient trust and physician professionalism, organizations must develop and maintain their own professionalism standards. This includes institutional policies that promote individual level professionalism, including compensation models that prioritize quality care over profit margins.14 Other measures of quality care, such as continuity and comprehensiveness, can support or “nudge” physicians to achieve better patient outcomes, lower costs, and a decrease in physician burnout rates.15 Furthermore, organizations across the healthcare landscape can redefine the meaning of productivity and efficiency to focus less on documentation and billing and more on building therapeutic relationships.16,17 Medical associations and professional organizations can pressure and support clinics, insurance companies, and government policies to redirect efforts towards what benefits both patients and physicians.18
The frameworks of relationship-based care19 and relational leadership20 can be utilized to develop physicians’ ethical codes and value systems in ways that honor their own identities and the needs of patients. Relationship-based care can ground decision making and treatment by directly engaging in the ambiguity of differing viewpoints, particularly when patient care does not align with a physician’s political or religious beliefs. Beginning in medical school and through residency, physicians should be encouraged to regularly interrogate their values and remain open and curious about other’s values. Hospitals and other clinic settings should prioritize a culture of transparency and non-judgement in discussing value systems and ethical scenarios.
Communication was a key theme that emerged from both patient and physician interviews. In a clinical setting, communication is actually a proxy for deeper constructs such as safety, trustworthiness, transparency, and power-sharing. In other words, communication is much more than an interpersonal skill and ongoing practice.
There are several limitations to this study. Physician participants were diplomates of the ABFM; professionalism and clinical experiences may look different within other specialties. Patient participants had extensive lived experience engaging in healthcare systems; professionalism may look different to patients who have fewer interactions with the healthcare system. Finally, the goal of qualitative research is depth, nuance, and a degree of transferability, not generalization.21
Conclusion
In this study, physician and patient participants described both system and individual components of professionalism. It is impossible to disentangle physicians from the systems they are embedded within; thus, a multi-pronged approach is required to promote professionalism. Institutions must interrogate their own policies and physicians must develop their skills in relationship-based care and communication.
Future research should investigate how physicians can work towards improving the professionalism on display in their practices and how they can maintain trust with their patients when the system acts as a barrier to trust. Additional research should explore patient-defined professionalism as a distinct construct to deepen understanding of trust, equity, and relational care. Furthermore, future research should explore how a culture of relationship-based care and communication can be developed and fostered from medical school through residency and into practice.
Conflicts of Interest
Annie Koempel, Madeline Byrd, and Robert L. Phillips Jr are employees of the American Board of Family Medicine. Robert L. Phillips Jr is also an employee at the Center for Professionalism and Value in Healthcare. Additionally, Tanya Lord is employed by Peer Support Community Partners and serves on the board of the ABFM.
Corresponding Author
Annie Koempel, PhD, RD, American Board of Family Medicine, akoempel{at}theabfm.org
Acknowledgement
We are deeply grateful to all study participants for sharing their time and expertise.
- Received for publication February 5, 2026.
- Accepted for publication April 8, 2026.
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