SPECIAL COMMUNICATION A Behavioral and Systems View of Professionalism

Even after the passage of comprehensive legislation, vigorous debate continues about how to reform the US health care system. Patients, payers, politicians, and physicians all agree that something must be done to improve health care delivery, but the consensus ends there. Great enthusiasm exists for performance reporting and payment linked to patient outcomes, but evidence that these mechanisms significantly improve patient care is not uniformly positive. Missing from public discussion is the role professionalism and professional values can and should play in supporting health system improvements. Health care is a fundamentally human activity that occurs in the course of innumerable interactions that ultimately must be guided by an overarching ethos or value set, and those values need to be cultivated alongside performance metrics and payment strategies intended to instill greater accountability in the system. A growing body of social science literature calls attention to the limits of financial incentives as a motivator and identifies pride of purpose and intrinsic motivation as more powerful forces underlying human behavior. Particularly in a field as complex and as high stakes as health care, professionalism has long been recognized by economists and medical ethicists as an essential mediating force in patient care. Professionalism may not be sufficient to drive the profound and far-reaching changes needed in the health care system, but without it, the health care enterprise is lost. There are many reasons the concept of professionalism and core professional values typically are not an explicit part of discussions about health reform. Patients and consumer groups are unclear about the meaning of the word professionalism. They often view it negatively, as a set of guildlike privileges and entitlements focused entirely on the physician. Physicians may feel bludgeoned by admonitions to “be professional” in systems that foster and reward unprofessional behavior. Medical students have long been aware of the