4-The Problem and Power of Professionalism

Widening the Lenses on Professionalism and Professional Identity Formation
The Problem and Power of Professionalism: A Critical Analysis of

Medical Students’ and Residents’ Perspectives and Experiences of
Professionalism
Daniela Maristany, MD, Karen E. Hauer, MD, PhD, Andrea N. Leep Hunderfund, MD, MHPE,
Martha L. Elks, MD, PhD, Justin L. Bullock, MD, MPH, Ashok Kumbamu, PhD, and
Bridget C. O’Brien, PhD
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Abstract
Purpose narrative and thematic analysis to identify advocacy. Participants described
Professionalism has historically been mechanisms by which professionalism deleterious consequences of
viewed as an honorable code to define empowered or disempowered individuals professionalism on their learning and
core values and behaviors of physicians, or groups based on identities. mental health. However, participants
but there are growing concerns that also described useful aspects of
professionalism serves to control people Results professionalism as a means of advocating
who do not align with the majority Forty-nine trainees (31 medical students for marginalized groups. Additionally,
culture of medicine. This study explored and 18 senior residents from multiple participants described how they
how learners, particularly those from specialties) participated in interviews; reconceived professionalism to include
historically marginalized groups, view the 17 identified as a race/ethnicity their own identities and values.
purpose of professionalism and how they underrepresented in medicine and 15 as
experience professionalism as both an people of color not underrepresented Conclusions
oppressive and valuable force. in medicine. Their stories, especially Trainees, especially those from historically
those of participants underrepresented marginalized groups, experience
Method in medicine, identified professionalism professionalism as a restrictive,
The authors conducted a qualitative as an oppressive, homogenizing force assimilative force while also finding
study with a critical orientation. In 2021 that sometimes encoded racism through value in and constructive adaptations
and 2022, they interviewed fourth-year various mechanisms. These mechanisms for professionalism. Understanding both
medical students and senior residents included conflating differences with the destructive and empowering aspects
at 3 institutions about their perceptions unprofessionalism, enforcing double of professionalism on individual and
and experiences of professionalism. After standards of professionalism, and institutional levels can help improve the
cataloguing participants’ stories, the creating institutional policies that framing of professionalism in medical
authors combined critical theory with regulated appearance or hindered education.
Professionalism remains a powerful represent professionalism5: consider it is necessary to understand how

force in medicine because it both a resident respecting an attending’s professionalism wields power to reinforce
identifies core values that unite members expertise while also striving to respect and/or undermine this commitment.
of the profession and establishes rules and the patient by advocating for a different
norms to guide physician behaviors.1 Few course of action. Interpretations of The use of professionalism to enforce
would contest the core tenets associated professionalism may be judged against White standards or ideals has been
with professionalism (commitment particular sociocultural standards described outside of medicine16–18
to excellence, integrity, respect for without contextual consideration and can be seen, for example, in the
all persons, patient-centeredness).2–4 or cultural interpretations.6,7 Recent negative professionalism connotations
However, in practice, tensions arise critiques of professionalism demonstrate around Black hairstyles19 and the need
between the values and actions that how viewing professionalism through for legislation to prevent workplace
dominant cultural norms disadvantages discrimination against natural hair.20,21
Please see the end of this article for information physicians and trainees from historically Within medicine, several commentaries
about the authors. marginalized groups.8–11 We use the note that current standards of medical
Correspondence should be addressed to Daniela term historically marginalized to mean professionalism are steeped in the
Maristany, 1701 Divisadero St., 5th Floor, San Francisco, people or communities that have been historical image of a physician (White,
CA 94115; email: daniela.maristany@ucsf.edu.
historically excluded from medicine male, Western),8–11,22 and AbdelHameid23
Acad Med. 2023;98:S32–S41. due to imbalanced power relationships, wrote of how the expectations of medical
First published online August 1, 2023 including but not limited to people of professionalism required her to suppress
doi: 10.1097/ACM.0000000000005367
Copyright © 2023 by the Association of American color, women, and people not identifying her identity as a Black woman.
Medical Colleges as heterosexual and cis-gendered.12,13 For
Supplemental digital content for this article is the medical profession to truly commit Studies of minority medical students’
available at http://links.lww.com/ACADMED/B454. to a diverse and inclusive workforce,14,15 and residents’ (hereafter referred to
S32 Academic Medicine, Vol. 98, No. 11S / November 2023 Supplement
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
collectively as trainees) experiences of illuminating how power differentials teaching, assessment, and culture
medical education have touched on contribute to experiences of of professionalism, racial/ethnic
concerns about professionalism but professionalism in medicine among composition of the students/residents,
have not explored this aspect of their learners from historically marginalized and geography. The institutional review
experiences in depth. Osseo-Asare and groups. Critical theory encompasses boards at all 3 institutions deemed the
colleagues’ interview study explored several theories (e.g., postcolonial theory, study exempt from review.
how race affected underrepresented in critical race theory, feminist theory)
medicine (URM) residents’ training and refers to inquiry that examines Eligible participants were fourth-year
experience, and professionalism surfaced how structures (sociocultural, racial, medical students at the 3 institutions
in residents’ descriptions of heightened political, and economic) and their and senior residents in family medicine,
attention to how their appearance and relationships to power affect experiences internal medicine, obstetrics–gynecology,
speech were perceived and feeling of different groups.34,35 Critical theory also pediatrics, general surgery, and
pressured to downplay their racial highlights the importance of centering neurosurgery. We chose fourth-year
identity to be seen as professional.24 the stories of historically marginalized students and senior residents to maximize
Concerns about professionalism voices. Given the absence of critical experience with professionalism in these
enforcing White cultural norms also studies on medical professionalism and stages of training. We included students
arose in studies of the experiences concerns about how professionalism and residents of all identities to enable
of minority trainees in Europe25,26 may contribute to inequities in medical comparison of stories and experiences.
and in a study of trainee experiences education, our study uses critical Participants received a $25 gift card.
with stereotype threat.27 These studies theory to explore how learners from
suggest that professionalism may be a diverse backgrounds and historically
particularly challenging aspect of medical marginalized groups (1) describe the Data collection
education for trainees from historically purpose and value of professionalism and Principal investigators at each institution
marginalized groups, though the studies (2) understand and observe/experience sent standardized recruitment emails to
do not compare experiences across professionalism, particularly its role in fourth-year medical student and senior
groups and as professionalism was not perpetuating racism and oppression. resident listservs. Interested learners
the primary focus of these studies, further We sought to illuminate mechanisms completed a demographic questionnaire
exploration is warranted. by which professionalism empowers or through Qualtrics, and the first author
disempowers individuals and groups in scheduled interviews with those who
While learners’ perspectives on the context of their identities. completed the questionnaire. The
professionalism are a primary focus first author conducted all interviews
of several research studies,28–32 only 1 via Zoom from November 2021 to
considered the context of race/ethnicity.33 Method November 2022. Interviews lasted
Alexis and colleagues conducted a Approach 45 to 60 minutes and were recorded
mixed-methods study of preexisting We conducted this study using critical and transcribed by a professional
survey responses from a diverse theory and a narrative approach to transcription service (Rev.com),
cohort of faculty, staff, and trainees at analyze stories detailing how trainees reviewed for accuracy, and de-identified.
1 academic institution and found that experienced professionalism wielding The authors used Dedoose (a platform
marginalized groups experience more power.34,35 “Wielding power” refers for qualitative analysis) to organize
scrutiny of their professionalism and to how professionalism is (1) used to coded data and link demographic
pressure to assimilate into majority reinforce or suppress behaviors, actions, information to interviews.
culture.33 These observations, by Alexis or identities (micro-view focusing on
and by the aforementioned authors individuals’ actions to advance their We piloted an interview guide with
about the minority trainee experience goals and interests); and (2) perceived or 2 to 3 trainees from each site, which
broadly, suggest that the experiences experienced by individuals as influencing resulted in adding 1 question about the
of trainees from groups historically behaviors, actions, or identities (macro- meaning of professionalism. Given the
marginalized in medicine differ from, view considering how cultural norms and limited changes, we requested consent
or at least are far more complex than, institutions shape behavior).36,37 from pilot participants to include their
the ideal notion of professionalism as interviews in our sample; all but 1
an enactment of integrity and respect. agreed. The final interview guide (see
The findings in these studies generate Setting and participants Supplemental Digital Appendix 1 at
additional important questions, such Study institutions included a private http://links.lww.com/ACADMED/
as how learners come to perceive medical school with 3 campuses in B454) began with a general question
professionalism as aligned with White the midwest, south, and southwest asking participants to discuss what
culture, how professionalism may (Mayo Clinic Alix School of Medicine), professionalism in medicine means
interfere with learners’ experiences, and a southern historically Black private to them, enabling the interviewer and
how, if at all, learners experience medical medical school (Morehouse School of participant to begin building a shared
professionalism as a helpful element of Medicine), and a western public medical understanding of professionalism
their training. school (University of California, San according to the participant. Next, we
Francisco [UCSF] School of Medicine). asked participants to recount times
Critical theory provides a lens for We selected these institutions to when they observed or participated
examining these questions and capture potential diversity in the in something they considered (1)
Academic Medicine, Vol. 98, No. 11S / November 2023 Supplement S33
the essence of professionalism, (2) restorying,39 a narrative analysis Overview of the stories
professional but others did not, and technique that involves analyzing the To contextualize our findings, we begin
(3) unprofessional, but others did not. transcript to understand the participant’s with an overview of stories and then
Then we asked them about times when experience and then summarizing the present themes from these stories.
professionalism was useful and when story to bring out key elements. Our Table 2 presents narrative elements of
it interfered with their training. To retelling included characters/setting, participants’ stories of professionalism
elicit stories speaking more directly problem/actions, outcome/moral (often (settings, characters, problems, actions,
to the intersection of identities and a quote expressing the story’s insight), and outcomes). While we centered
professionalism, we asked participants relationships, and manifestations of
primarily on differences across identities,

how they felt their experience of power (critical lens on the story). We our narrative analysis also considered
professionalism is affected by their then organized stories by racial/ethnic narrators’ institutional context and
identity. To understand perceptions identity (URM, non-URM person positions (student/resident). Residents
of the effect of institutions on of color, and White). We engaged more commonly pointed to institutional
professionalism, we asked participants critical theory to identify discourses of actions that affected professional
how they viewed the medical system power and patterns related to identity, behavior, whereas students focused
(medical school, residency, and health including micro- and macro-level largely on interpersonal professionalism.
care organizations) as supporting or mechanisms by which professionalism Students also gave more examples of
inhibiting professionalism. wielded power in service to beneficial/ evaluations of professionalism and how
valuable purposes and negative/harmful perceptions of professionalism affected
We interviewed all volunteers from consequences, particularly for trainees clerkship grades.
each site and, based on our analysis with marginalized and minoritized
throughout data collection, decided identities. To structure our results, we Themes
our sample met our goals of including synthesized discourses and patterns
We present both themes about
participants with diverse identities into themes capturing professionalism
professionalism exerting an oppressive,
and our corpus of stories contained as a source of oppressive, exclusionary
homogenizing force defined by
sufficiently detailed descriptions to offer experiences and of valuable, empowering
historical White, male ideals and
insights into our research questions.38 experiences.
themes about professionalism serving
valuable purposes to extend agency
Data analysis Positionality and reflexivity to marginalized groups. Within these
Our analysis combined narrative Our research team included a clinician themes, we identify the mechanisms
and thematic analytic techniques39–41 educator fellow (now assistant by which professionalism exerts power
with critical theory34,35 to capture the professor), an internal medicine resident (Figure 1). We mention aspects of
micro- and macro-forces (mechanisms) (now nephrology fellow), education participants’ identities shared in their
shaping participants’ experiences of researchers, and clinician educators from stories and center the perspectives of
professionalism. Two investigators neurology and internal medicine. Team trainees with historically marginalized
(D.M. and B.O’B.) coded transcripts members identified as Asian, Black, identities. For longer excerpts, we note
with input from the full team. First, we Latina, White, women, and men. We participants’ self-identified gender, race/
identified and categorized participants’ reflected during regular group meetings ethnicity, sexual orientation, and level of
stories (as stories of exemplary on how our identities and biases affected training.
professionalism, conflicting views of experiences of professionalism and
professionalism, or identity intersecting engagement with the project.42 The
with professionalism). Often these Professionalism oppresses,
primary interviewer (D.M.) identified
stories occurred in response to one of homogenizes, and encodes racism
as a cis-gendered Latina/Asian woman
our questions, but some arose in other and was a clinician educator fellow Participants, particularly from historically
sections of the interview. For each throughout most of the project. Her marginalized groups, overwhelmingly
story, we categorized the level at which racial identity may have affected noted various mechanisms by which
professionalism was discussed (personal, participants’ comfort in discussing race professionalism exerted oppressive power
interpersonal, and institutional). We and professionalism. Her status as a and perpetuated White cultural norms
generated codes based on the other fellow may have made participants more as the standard of reference (Table 3).
question prompts (e.g., times when comfortable in sharing stories, though Notably, some participants, mostly
professionalism was useful in training her relatively higher training level may White trainees, had not considered
or interfered with training, perceived have deterred some. professionalism oppressive and had
purpose of professionalism, systems difficulty recalling when professionalism
supporting/inhibiting professionalism) had negative consequences or interfered
Results
and used thematic analysis40,41 to with their training.
generate subcodes and identify themes We interviewed 31 fourth-year medical
within the “useful” and “interfering” students and 18 senior residents. Mechanism: Difference conflated
categories. Seventeen participants (35%) identified as with unprofessionalism. Participants
URM, 15 participants (31%) as non-URM described differences in race, speech,
Second, we linked stories to participants’ persons of color, and 16 (33%) as White body type, sexual orientation/gender
self-reported identities and used (Table 1). identity, and personality conflated
picture, even though I thought I looked

Table 1 beautiful.—Ciswoman, Black, straight,
student
Participant Characteristics (n = 49) of Medical Students and Residents Interviewed
About Professionalism at 3 Medical Schools in 2021–2022
Mechanism: Enforcing
Demographic Number (%) homogenization. Beyond conflation
Institution
of difference with unprofessionalism,
Mayo Clinic 24 (49)
we identified several mechanisms of
how professionalism enacted racism
Morehouse 7 (14)
and directed trainees toward White
University of California, San Francisco 18 (37) heteronormative behaviors. Participants

Level of training of color carried social norms learned

4th-year medical student 31 (63) from everyday life into medicine,
Senior resident 18 (37) often in the form of stereotype threat.
Specialty (n = 18 residents) For example, a trainee who described
Family medicine 3 (17)
himself as a tall, Black man noted that
when interacting with a new team, he
General surgery 1 (6)
instinctively stood and spoke in a way
Internal medicine 7 (39) to seem smaller and less visible—“I’m
Neurosurgery 1 (6) always toning down who I am”—a
Obstetrics and gynecology 2 (11) habit learned outside of medicine to
Pediatrics 4 (22) avoid appearing threatening. Trainees,
Race/ethnicity largely Black and Latinx, had a greater
Asian or Pacific Islander 10 (20)
attentiveness to professionalism than
participants from majority groups
Black or African American 10 (20)
in medicine and held themselves to
Latinx 3 (6) higher standards to prevent negative
White 16 (33) stereotypes.
More than 1 race/ethnicitya 9 (18)
I modulate my voice a certain way,
Prefer not to respond 1 (2) just standing a little differently, always
Representation in medicine trying to make sure that I’m not being
Underrepresented in medicine (URM)b 17 (35) overbearing. I don’t know how much
of that is someone’s responded a
People of color, not URM c
15 (31) certain way and I’ve reacted or I’m just
Gender proactively doing that. I think a lot of
Ciswomen 28 (57) it is proactive.—Cisman, Black/Latinx,
straight, student
Cismen 21 (43)
Sexual orientation
LGBTQ (lesbian, gay, bisexual, transgender, queer) 8 (16) Stories passed between learners also
influenced participants’ perceptions
Straight 39 (80)
of professionalism standards. A queer
Unsure or prefer not to respond 2 (4)
student heard about a senior student
Abbreviations: Mayo Clinic, Mayo Clinic Alix School of Medicine; Morehouse, Morehouse School of Medicine; who disclosed their sexual orientation
University of California, San Francisco, University of California, San Francisco School of Medicine. to a patient. The patient responded by
a
Includes participants who self-identified as multiple races/ethnicities including Asian, Black, Latinx, Middle dismissing the student from their care, a
Eastern, and White.
b
Includes participants who self-identified as Black/African American, Hispanic/Latinx, Native American/Alaskan
dismissal supported by the attending. A
Native, Native Hawaiian/Pacific Islander, Filipino, Hmong, or Vietnamese. Latinx student heard from senior students
c
Includes participants who self-identified as a race/ethnicity other than White which is not included in the about professionalism remediation
definition of URM.
sessions where all remediated students
were people of color. Some participants
with unprofessionalism and standards you are interacting with comfortable. received feedback, either verbally or in
of Whiteness and maleness upheld as And I think that’s for Black women, that’s
writing, that conveyed instructions to
for Black men, that is for our Hispanic
synonymous with professionalism. As adhere to norms (e.g., certain levels of
population. That’s for anybody who
described in Table 3, spoken accents, code- looks different than what the majority formality, patterns of speech), which
switching, religious garments, painted demographic is … even my hair, I was participants described as “framed by
nails, how clothes fit on larger body types, terrified when I first started my locs a White male lens” (Latinx/White,
and both effusive or reserved personalities because you think, oh gosh, they’re resident).
served as fodder for professionalism going to think I’m grungy and dirty
concerns from patients and team members. because I have my hair like this. Is it
Mechanism: Double standards.
professional? My headshot that is on my
… you have to try to be extra Zoom, I was terrified for that hairstyle. Participants noted that one’s place in
professional, not only to try to show that Is it too masculine looking? Will I look the hierarchy, medical or racial, affected
you belong, but to make the people who like too much of a hard, Black female scrutiny of one’s professionalism.
Table 2
Narrative Elements of Medical Students’ and Residents’ Professionalism Stories
From 3 Medical Schools in 2021–2022
Narrative element Description
Setting Stories occurred in premedical/nonmedical (college or prior work environments), preclinical (lectures, small groups), and
clinical (clerkships, acting internships, internships, ongoing resident rotations) environments. While many stories involved
interpersonal interactions, some took place internally as reflections on whether future actions would be deemed
professional. Institutional settings (Mayo, Morehouse, UCSF) were most evident in stories describing rules/policies (e.g.,
dress codes, attendance policies, institutional response to activism), institutional norms (ways of giving feedback, using
professional titles), and formal professionalism training/assessments.

Characters Most stories involved a learner (often the narrator) interacting with 1 or more main characters (supervising attending or
resident, teacher, mentor, patient). Typically, characters held different degrees of power. Other central characters included
institutions, patients’ families, other medical students or residents, nurses, and allied health professionals.
Problems Problems at the core of most stories involved: differing definitions of what constituted professionalism between
characters with varying degrees of power, perceived professionalism violations (involving patient care, interpersonal
interactions, racism, sexism, microaggressions), and challenges of upholding professionalism expectations of multiple
parties simultaneously (for example, of the patient, attending, and institution).
Actions Characters’ actions toward others revealed complex power dynamics. Actions ranged from empowering/protecting those
in vulnerable positions (e.g., questioning potentially biased decisions, calling out racist and oppressive language/acts) to
reinforcing insecurities and inflicting harm (e.g., suggesting learners moderate personality, language, or appearance to
align with patients’/supervisors’ expectations; questioning trainees’ professionalism, and formally censuring trainees for
perceived lack of professionalism). Actions also included characters’ challenges to professionalism (by selectively taking
feedback on professionalism, seeking out role models who authentically expressed both their identity and professionalism,
and imagining alternate, improved ways to set professionalism standards when they were more senior).
Outcomes/conclusions Story outcomes described helpful and hindering effects of professionalism on learning, professional identity, and patient
care and were linked with participants’ identities. Helpful/valuable effects included establishing common expectations,
extending agency to marginalized groups, and supporting trainees in addressing racism/microaggressions. Harmful
outcomes included trainees feeling pressure to suppress elements of their identity, developing hypervigilance about how
actions will be perceived professionally, and feeling personally demoralized by critical feedback of professionalism.
Abbreviations: Mayo, Mayo Clinic Alix School of Medicine; Morehouse, Morehouse School of Medicine; UCSF,
University of California, San Francisco School of Medicine.
Trainee
Agency/
Wielding power Enforcing racism/encoding
advocacy/ Liberating/empowering Oppressive/homogenizing
dominant norms
legitimacy
• Establishing common • Difference conflated with

expectations unprofessionalism
• Extending agency to Professionalism • Dominant norms equated
marginalized groups with professionalism
• Supporting physicians/ • Stereotype threat
trainees in addressing • Double standards
oppression • Institutional policies
• Enduring racism/micro- enforcing discrimination
aggressions with poise • Lack of institutional support
• Signifier of belonging for advocacy
Figure 1 Proposed model for trainee experiences of professionalism: Interplay of experiencing the homogenizing power of professionalism and using
professionalism for positive, empowering means.
Many participants described senior especially related to timeliness and dress on students of color returning late from
attendings’ lapses in professionalism code. For example, in clinics with relaxed didactics.
going unreported because of their dress codes, medical students of color
I am Latino and White. And based on my
position and stricter enforcement of were reprimanded for casual dress while appearance, I have only ever gotten that
professionalism standards for trainees White students were not, and on hospital I’m White … so I’ve often been given the
of color compared to White trainees, teams, participants noted increased focus benefit of the doubt…. I tend to be more
Table 3
Mechanisms of Oppression: Ways Trainees Described Professionalism as Wielding an
Oppressive Force to Encode White Heteronormative/Majority Cultural Standards, as
Described by Students and Residents at 3 Medical Schools in 2021–2022
Mechanism Description of the mechanism Example or quote
Conflating difference with • Receiving indirect or direct feedback that aspects • Residents with accents labeled as more challenging to work
unprofessionalism of their identity or presentation, which strayed with by staff.
from the ideal of a White male physician, were not • Religious jewelry and beards viewed by attendings and
professional. patients as unprofessional.

• Indirect questioning of one’s professional actions, • Black students speaking informally with Black patients to
tied to an identity outside the majority in medicine. establish rapport received critical comments from attendings.
• Black women trainees with larger body sizes told their scrubs
(required during COVID-19 pandemic) fit “like pajamas” and
are unprofessional.
• Queer medical students told by attendings their painted nails
are unprofessional.
• Queer resident who expresses sexual orientation more openly
is dismissed as less serious/professional.
• Students with personalities not matching tenor of senior
resident/attending viewed as less professional or cautioned to
modulate personality.
Stereotype threat/ • Transferring what one knows to be true about race • “I know that automatically I will be judged more harshly for
transposing learned outside of medicine into experiences in medicine. things that are perceived as unprofessional compared to my
behaviors outside medicine • Holding oneself to higher standards of counterparts…. I will need to overcompensate in professionalism
professionalism to avoid negative stereotypes just to survive really, not even to be on the same playing field,
about Blackness and unprofessionalism or people but to survive. When I go to clinic or go to the hospital, I am
of color and unprofessionalism. always really conscientious of I am supposed to wear a suit.”
(Ciswoman, Black, straight, student)
Shared stories • Hearing stories either directly or indirectly from • “It was one of the earliest things that I remember in med school
peers or senior students/residents about … you hear all of these stories pouring in and it just leaves you
experiences with professionalism, including more tense and less inclined to push any boundaries … even
cautionary tales of what not to do. though I haven’t necessarily had an overt negative experience
with it [professionalism], it’s still just a constant worry.” (Cisman,
Asian/White, gay, student)
Double standards • Different levels of scrutiny or punishment of • “I’ve definitely seen residents and attendings, not keep to that
professionalism depending on one’s identity, same standard. And usually I do see more individuals who are
specifically one’s place in the medical, racial, or not people of color who kind of push the boundaries on how
gender hierarchy. they show up to work. And I feel like if people of color were
• Different interpretations of the same professional to come in that same … I feel like they would definitely be
action based on race, seniority. called out.” (Ciswoman, Latinx, straight, student)
Institutional polices • Institutional polices affecting trainees’ abilities to • On institutional policies requiring drug screens of pregnant
advocate for patients. patients that disproportionately affect certain races: “And
• Institutional dress policies that enforce racist, so, I feel like professionalism is lost when you’re working in
heteronormative standards. a system that is inherently unprofessional, because it’s not
• Discordance between trainee and institution respectful. And I think the way that that’s reconciled on the
professional values: Institutions not supporting provider standpoint is often by leaning into bias.” (Ciswoman,
advocacy/antiracism work. White, bisexual, resident)
assumed to be in the in-group, the White enforced certain clinical policies (e.g., Consequences of homogenizing force of
medical male system … when I challenge, searching patient rooms for drugs or drug professionalism
it’s seen as more as a positive or a growth
screens for pregnant patients who use Black trainees in particular described
in that direction. Whereas … [the] other
person [of color], it was seen as more of a substances), or failed to protect trainees the consequences of the homogenizing
negative or a combative stance.—Cisman, against racist patients. forces of professionalism, including
Latinx/White, straight, resident an inability to be one’s authentic self,
… when that [institution opposing student
advocacy] happens … then anything that tendency to become guarded, and
Mechanism: Institutional policies. you’re doing or anything that you’re saying hypervigilance about perceptions of
Institutional policies complicated has to be very carefully crafted and you’re their professionalism. Standards of
trainees’ abilities to enact their personal worried about rocking boats or making professionalism made participants
versions of professionalism. Participants people angry. And I think possessing a question, “is something that I’m doing
felt their definitions of professionalism minority identity there, where there’s a lot going to be seen as unprofessional because
of fighting for your own comfort, safety in
conflicted with the definition of their spaces as queer students. It’s just the harm
I’m just being who I am?” (Black, student).
institution when institutions discouraged of silence is really great when you’re the Participants became increasingly cautious
or did not actively support political people who are trying to push up against after receiving critical professionalism
engagement or antiracism work, it.—Cisman, Asian/White, gay, student feedback, especially feedback conflating
Table 4
Mechanisms of Professionalism Exerting an Oppressive/Homogenizing Force and
a Positive/Empowering Force at Multiple Levels, as Described by Students and
Residents at 3 Medical Schools in 2021–2022
Examples
Level Oppressive/homogenizing Positive/empowering
Personal/individual • Preemptive modulation of one’s actions to avert professionalism • Creating one’s individual definition of professionalism;
criticism (from learned behaviors and stereotype threat). making notes of ways one will act differently when
• Fostering hypervigilance around perceptions of professionalism. higher in hierarchy.
• Feeling unable to express oneself or one’s identity due to • Finding role models with similar identities who embody
professionalism concerns. professionalism.
Interpersonal • Stories from peers/more senior trainees about others who • Establishing shared team expectations for behavior.
received professionalism criticism. • Extending agency to patients or trainees.
• Receiving critical feedback on professionalism from superiors. • Creating space for trainees to discuss challenging
• Having one’s professional persona questioned by patients. situations.
• Witnessing differential scrutiny or remediation of • Addressing microaggressions or discriminatory remarks
professionalism based on race, seniority, and gender. by patients.
• Using tenets of professionalism to endure racism/
microaggressions.
• Using the aura of professionalism to lend credibility.
Institutional • Institutional dress codes that center White, heteronormative • Institutions setting policies about patient conduct;
standards. clinics reprimanding patients who act in racist or
• Lack of institutional support for antiracism work. disrespectful ways.
• Trainees being required to abide by institutional clinical policies • Institutions supporting advocacy, antiracism work, and
that they feel are racist or discriminatory. community engagement.
personality with professionalism, which patients and team members, and many then also respectful of the patient” (Asian,
impacted participants’ mental health. described it as a set of guiding behaviors student).
or principles. Yet participants also
… it was communicated to me almost as if
recognized that in practice, the behavioral Mechanism: Supporting physicians/
friendliness was perceived as unprofessional.
And I think for me that was very shocking manifestations of professionalism varied trainees in addressing oppression.
how professionalism can be perverted … it considerably. URM participants were Participants described frequent
made me a little bit more cautious and more particularly aware of the contextual nature microaggressions and discrimination in
shy on rotations. Usually, I’m very happy- of professionalism across specialties, their clinical work, most often with patients,
go-lucky, connect with everyone, but it just institutions, or even 2 separate clinical and their stories captured 2 ways that
made me feel terrible. And it also made me teams. Participants of color (URM and professionalism can be used to challenge
very suspicious … almost a hypervigilance
or a hyperawareness of how I am perceived
non-URM) described professionalism oppression. The first was through advocacy
specifically as a Black woman in medicine as useful to establish team behavioral and antiracism work, which several
… my perception was, “Oh, other people expectations. Students described the participants viewed as synonymous with
get to be friendly and get to show their utility of defining professionalism professionalism. The second was through
personalities.” But for me as a Black woman, standards for each specialty as they moved direct action. They saw professionalism as
I myself, I’m perceived as being less serious between clerkships. a tool to address racist remarks and felt that
or perceived as being immature in some
addressing such remarks, in the appropriate
way.—Ciswoman, Black, straight, student
Mechanism: Extending agency to clinical scenario (e.g., not an emergency
marginalized groups. When asked situation), demonstrated consummate
Professionalism serves valuable to share examples of the essence of professionalism. A White student found it
purposes professionalism, participants routinely highly professional that a clinic dismissed a
Participants also described told stories about physicians or trainees patient who made a racist comment about
professionalism wielding power in a who extended agency to someone lower a clinician. A Latina resident described
positive, supportive way. Participants’ in the medical hierarchy, most frequently the medical team engaging in formal
stories revealed how they modified or patients or other trainees. A resident professionalism standards—using the
molded professionalism to align with highlighted her communication skills in title “doctor”—when a patient continued
their identities and how they used various establishing an open dialogue with parents calling a younger female resident
mechanisms to subvert oppressive and of a sick newborn. An obstetrics resident by her first name. Participants also
reductive ideas of professionalism (see described working with a patient to honor highlighted the role of superiors using
Supplemental Digital Appendix 2 at her autonomy to achieve a nontraditional professionalism to speak out against
http://links.lww.com/ACADMED/B454). birth plan. Students described instances racism because “not everyone has the
after microaggressions or challenging power to be able to speak up and get away
Mechanism: Establishing common patient interactions where senior residents with it because we need to be well-liked
expectations. Nearly all participants or attendings worked to “just hold[ing] for our evaluations … to see a leader do
defined professionalism as involving space after something like that happened, that, I feel like that’s a great example of
respect and effective communication with in a way that was supportive to us and professionalism” (Black, student).
Mechanism: Enduring racism/ me … is seeing other people of color who Considering professionalism’s power
microaggressions with poise. were attendings and residents acting like on a micro- and macro-scale has
themselves, whatever that is … just acting
Participants, notably only those of color, important implications for assessment
in a way that was clearly, at least seemed
described professionalism as a tool to be authentic and unapologetic. And of professionalism, where emerging
to endure or withstand interpersonal just this is who they were and paying data demonstrate disparities in
racism while maintaining a professional homage to whatever culture they claimed. professionalism evaluations between
veneer. Participants described using And I feel like that gave me confidence to, URM trainees and non-URM trainees.45
professionalism to “still be respectable” it’s okay to not fit that structure and still Our findings suggest multiple ways
or “falling back on my training” when be professional.—Cisman, Black, straight, that professionalism assessment may
student
interacting with racist patients or staff be affected. Different definitions of
and emphasized using professionalism professionalism between trainee (e.g.,

skills to mask their emotions, deflect speaking less formally with a patient from
Discussion
inappropriate comments, and stay calm. a shared racial background to establish
Our study describes how medical rapport) and supervisor (viewing the
Mechanism: Signifying of belonging. students and residents, especially those narrowed patient–provider distance as
Several trainees of color described from historically marginalized groups, unprofessional) may lead to trainees
professionalism lending them navigate professionalism in medicine from backgrounds less represented
“credibility” with patients or allied and experience professionalism as both among academic attending physicians
health professionals. The expectations an oppressive and empowering force. receiving lower professionalism ratings.
of professionalism (from both internal Our study builds on prior work on The burden of worrying about how
standards and policies) provided a how trainees experience race in their their own professionalism standards
benchmark, and working toward that training23–27 and provides an important differ from those of their assessors may
standard demonstrated to oneself, addition to studies of trainee perspectives also negatively impact performance
coworkers, and patients that the trainee of professionalism by centering the stories in other core competencies. Study
belonged in medicine. Some used the of learners from historically marginalized participants pointed to double standards
metaphors of acting or wearing a costume groups and applying critical theory to of professionalism, noting that non-
to explain the transformative power of examine power structures. Our narrative White students were more scrutinized in
professionalism on others’ perceptions. evidence supports the growing concern8,10 issues of timeliness and dress. Addressing
that professionalism, as enacted and these disparities will require change on
Professionalism is a way to sort of experienced in practice, encodes racism
signify to patients that I am a medical the micro-level (teachers understanding
professional in training in ways that other
and oppression within medical education. how identity affects their standards and
aspects of my identity might not … sort Our findings also complicate and assessments of professionalism) and
of like a costume to put on to sort of gain contextualize that argument, as we note macro-level (institutions reevaluating
some sort of clout or authority when you how participants found valuable ways to professionalism standards and who
walk into a patient’s room.—Ciswoman, use professionalism. guides professionalism remediation).
Asian/White, straight, student
In Table 4, we outline how Our study also has implications for
professionalism exerts power on multiple teaching professionalism. Advocacy
Mechanism: Challenging homogenizing levels. The macro-level (institutional) has been increasingly recognized,
effects. Participants described subtle ways highlights how institutions exert by trainees and institutions, as a key
they challenged professionalism as an power through resource allocation element of medical professionalism.46,47
oppressive force. Trainees were selective in and explicit policies/rules. The micro- Correspondingly, many of the
which professionalism-related behavioral levels (personal and interpersonal) participants in our study described
feedback they chose to incorporate. They demonstrate how professionalism acts extending agency to marginalized
also found ways to enact professionalism as a form of biopower, a term coined groups as an example of exemplary
authentically while staying true to by Michel Foucault to describe how professionalism or explicitly stated
their identities by seeking role models power is not only exerted by 1 entity that advocacy was a core part of
in senior positions who accomplished but a pervasive force carried out by professionalism. Yet participants also
those dual aims. Participants noted how all individuals in a society.37,43,44 In the cited concerns about their perceived
they planned to conduct themselves mundane interactions between trainees professionalism as a hindrance to
professionally when they became more and patients or attendings, the unwritten engaging in advocacy if their institution
senior. Linguistically, many participants norms of professionalism are reinforced, appeared indifferent or hostile to trainee
hedged when discussing racism in without a specific rule or decree. Trainees advocacy. To effectively teach trainees
professionalism, often engaging phrases also exert power upon themselves by to be advocates and professionals,
such as “it’s not something you can ever self-regulating to dress, speak, and stand medical schools and residencies will
prove,” “just perceptions that you have,” in ways that accommodate mainstream need to reconcile trainee perceptions
or “it’s hard to say in a small sample professionalism ideals. As we evolve with institutional attitudes toward
size” to avoid directly invoking racism in professionalism to be more inclusive, advocacy. As others have pointed out,
professionalism while still questioning we will need to understand and address this reconciliation will be best served by
professionalism’s power. the multiple mechanisms by which engaging trainees in the programs and
I was really trying to fit that picture of professionalism exerts power within methods used to teach and develop their
professionalism, and what really helped medical education. professionalism.48
Our findings also highlight the support this growth by incorporating Previous presentations: An earlier version of this
importance of acknowledging discussions of identity, especially racial article was presented at the 2022 Kern National
Network Conference.
intersectionality and positionality in identity, into formal professionalism
trainee experiences of professionalism. curricula and acknowledging how
D. Maristany is assistant professor, Department
Intersectionality was originally professionalism can limit individuality of Medicine, University of California, San Francisco,
conceptualized to describe the interplay and self-expression. San Francisco, California; ORCID: https://orcid.
of racism and sexism in Black women’s org/0009-0000-3928-3608.
experiences,49 and while our study Our study has limitations. While K.E. Hauer is associate dean for competency
noted many signifiers of difference we intentionally sampled from 3 assessment and professional standards and
professor, Department of Medicine, University

that were seen as less professional, geographically and racially diverse
of California, San Francisco School of Medicine,
participants with multiple marginalized institutions, our sample does not San Francisco, California; ORCID: https://orcid.
identities were more cognizant of how represent all institutional cultures. org/0000-0002-8812-4045.
their professionalism was perceived. Our sample is skewed toward Mayo A.N. Leep Hunderfund is associate professor
Professionalism burdened certain identity and UCSF participants and toward of neurology and medical director, Office of
groups disparately: while all Black students, despite attempts to recruit more Applied Scholarship and Education Science,
Mayo Clinic College of Medicine and Science,
participants noted a heightened awareness Morehouse trainees and more residents. Rochester, Minnesota; ORCID: https://orcid.
of how their actions were received, several Participants were predominantly straight org/0000-0002-7784-504X.
White participants struggled to identify and cis-gendered. Study volunteers
M.L. Elks is professor of medical education
how identity affected their professionalism may have been especially attuned to and senior associate dean of educational affairs,
or state times in which professionalism professionalism issues or had strong Morehouse School of Medicine, Atlanta, Georgia;
had negative effects. views of professionalism, positively ORCID: https://orcid.org/0000-0003-2239-025X.
or negatively. This possible bias was J.L. Bullock is a research fellow, Division of
The consequences of professionalism’s beneficial to yield vivid, detailed stories, Nephrology, Department of Medicine, University of
Washington, Seattle, Washington; ORCID: https://
homogenizing force have implications for which was the goal of our study. Lastly,
orcid.org/0000-0003-4240-9798.
trainee well-being. While trainees from interviews by 1 researcher allowed for
historically marginalized groups were uniformity but also may have been A. Kumbamu is assistant professor of biomedical
ethics, Mayo Clinic Alix School of Medicine,
more likely to feel affected by or aware of affected by the interviewer’s individual Rochester, Minnesota; ORCID: https://orcid.
professionalism, they were also more likely perspective. org/0000-0003-2538-2618.
to need to use professionalism to withstand B.C. O’Brien is professor of medicine and
racist remarks by patients or colleagues. education scientist, Department of Medicine
Though trainees largely portrayed this Conclusion and Center for Faculty Educators, University of
use of professionalism as positive, prior California, San Francisco School of Medicine,
Trainees’ experiences of professionalism San Francisco, California; ORCID: https://orcid.
research suggests there may also be are complex and influenced by their org/0000-0002-3050-0108.
negative effects. For example, enhancing intersecting identities. Our study
one’s ability to remain composed and demonstrates that trainees from References
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Widening the Lenses on Professionalism and Professional Identity Formation

The Problem and Power of Professionalism: A Critical Analysis of

Professionalism remains a powerful represent professionalism5: consider it is necessary to understand how

primarily on differences across identities,

picture, even though I thought I looked

University of California, San Francisco 18 (37) heteronormative behaviors. Participants

Level of training of color carried social norms learned

professional titles), and formal professionalism training/assessments.

• Establishing common • Difference conflated with

professional. patients as unprofessional.

and emphasized using professionalism professionalism between trainee (e.g.,

professor, Department of Medicine, University

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