Research Report “Once When I was On Call. . .,” Theory versus Reality in Training for Professionalism Susan Eggly, PhD, Simone Brennan, MA, and Wilhelmine Wiese-Rometsch, MD Abstract Purpose To identify the degree to which interns’ reported experiences with professional and unprofessional behavior converge and/or diverge with ideal professional behavior proposed by the physician community. Method Interns at Wayne State University’s resi- dency programs in internal medicine, family medicine, and transitional medi- cine responded to essay questions about their experience with professional and unprofessional behavior as part of a cur- riculum on professionalism. Responses were coded for whether they reflected each of the principles and responsibilities outlined in a major publication on physi- cian professionalism. Content analysis included the frequencies with which the interns’ essays reflected each principle or responsibility. Additionally, a thematic analysis revealed themes of professional behavior that emerged from the essays. Results Interns’ experiences with professional and unprofessional behavior most fre- quently converged with ideal behavior proposed by the physician community in categories involving interpersonal inter- actions with patients. Interns infrequently reported experiences involving behavior related to systems or sociopolitical issues. Conclusions Interns’ essays reflect their concern with interpersonal interactions with patients, but they are either less exposed to or less interested in describing behavior regard- ing systems or sociopolitical issues. This may be due to their stage of training or to the emphasis placed on interpersonal rather than systems or sociopolitical is- sues during training. The authors recom- mend future proposals of ideal profes- sional behavior be revised periodically to reflect current experiences of practicing physicians, trainees, other health care providers and patients. Greater educa- tional emphasis should be placed on the systems and sociopolitical environment in which trainees practice. Acad Med. 2005; 80:371–375. Unprofessional behavior by physicians has been widely publicized, from fictional portrayals of arrogant, demeaning physi- cians on popular television to reports of illegal and unethical behavior contribut- ing to medical errors 1 and skyrocketing health care costs. Unprofessional behav- ior may begin before or during medical training; a recent study linked problem- atic behavior in medical school to subse- quent disciplinary actions by a state med- ical board. 2 The physician community has taken steps to address the issue, set- ting standards and delivering innovative curricula to train future physicians. Three of these are significant to the purposes of this project. First, although many definitions have been proposed, 3 the Medical Profession- alism Project, a collaborative effort by the ABIM (American Board of Internal Med- icine) Foundation, the ACP (American College of Physicians) Foundation, and the European Federation of Internal Medicine wrote a Physician Charter that has been widely adopted as the standard. Published in 2002 in both the Annals of Internal Medicine and the Lancet, the charter states: Professionalism is the basis of medicine’s contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining stan- dards of competence and integrity, and providing expert advice to society on matters of health. 4,5 The Physician Charter then specifies three fundamental principles and ten professional responsibilities that form the contract with society (see List 1). A fol- low-up article published 15 months later reported that the publication had been endorsed and reproduced in several jour- nals around the world, including the ma- jor journals for the fields of internal med- icine, surgery, obstetrics– gynecology, and dentistry, and had been translated into several languages. In addition, the fol- low-up article reported that several hun- dred U.S. and international newspapers had cited the Physician Charter in related stories and 65,000 reprints had been re- quested from around the world. 6 In a second major step toward addressing the issue of physicians’ professionalism, the Accreditation Council on Graduate Medical Education (ACGME) declared professionalism to be one of six general competencies all physicians should pos- sess and in 2001 began requiring that all residency programs document the teaching and assessment of their residents’ profes- sional behavior as part of the accreditation process. 7 Third, the major journals of nearly every medical specialty society have published descriptions of a range of curric- ula that teach and assess medical trainees in the area of professionalism. 6 Medical educators are acutely aware that their curricula for teaching all competen- cies are not delivered in a vacuum. 8,9 The nature of medical training inherently exposes medical students and residents to a social, economic, and political context that may or may not reinforce the princi- ples taught in the medical schools’ labs Dr. Eggly is assistant professor, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan. Ms. Brennan is research assistant, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan. Dr. Wiese-Rometsch is assistant professor, Department of Internal Medicine, Wayne State University, Detroit, Michigan. Correspondence should be addressed to Dr. Eggly, 5th Floor Hudson-Webber, Karmanos Cancer Institute, Wayne State University, 4100 John R., Detroit, MI 48201; e-mail: egglys@karmanos.org. Academic Medicine, Vol. 80, No. 4 / April 2005 371