Professionalism Is an Essential Element of Board Certification
By Cheri L. Canon, MD, ABR Governor
The Ethics and Professionalism Committee of the American Board of Medical Specialties (ABMS) has defined professionalism as “a belief system about how best to organize and deliver health care, which calls on group members to jointly declare (‘profess’) what the public and individual patients can expect regarding shared competency standards and ethical values, and to implement trustworthy means to ensure that all medical professionals live up to these promises.”1
At its core, the fundamental obligation of professionalism is that medical healthcare providers put the patient’s interests above their own. The ABR’s mission is focused on certification, and certification includes a public trust that is linked to behaviors that are implicit expectations of medical practice.
The public has assumptions regarding medical practitioners that relate not only to competence and expertise but also to professional behavior. Many of these requirements extend beyond mere technical ability, and some relate to what is broadly referred to as professionalism. At a 2019 symposium hosted by the ABMS and the National Board of Medical Examiners (NBME), Advancing Assessment of Professionalism in Continuing Certification, discussants agreed that “the public believes that licensing and certifying boards test and assess health care professionals to ensure they are competent and up to date in all aspects of patient care, including professionalism.”
In meeting the obligation to the public, the ABR has the responsibility to consider professionalism from several vantage points, including (but not limited to) behavior prompting negative actions by state licensure boards; improper conduct during exams; testing of relevant principles; requiring documentation of understanding and demonstration of an individual’s professionalism during training (usually represented by successful completion of an ACGME-accredited residency); and defining expectations for our staff and volunteers.
The Professionalism Committee regularly monitors and reviews reports from state licensing boards. This is similar to the other ABMS certifying boards and is based on the role of the licensing boards in supporting the public interest by granting medical licenses based on criteria that include sound practice, legal compliance, and ethical standards. The ABR often borrows from state boards because the latter have greater investigative capabilities and much of the documentation is publicly available. As with many professional review functions, the goal is a balance between sensitivity (censuring the practitioner for substandard behavior) and fairness (acknowledging that there is often nuance when attempting to make these determinations). The board also accepts reports of professionalism concerns from colleagues, other medical practitioners, and the public.
Improper conduct during the exams is, fortunately, extremely rare. This is presumably related to the integrity and high ethical standards characteristic of individuals who are accepted to and progress through quality training programs. The ABR’s concerns about exam security are not based on mistrust but are an affirmation of our obligations to the public and candidates. The value of the certificate, for the patient and the practitioner, is based on the validity of our determinations of knowledge and skill.
Standardized testing of principles related to professionalism is difficult. In the testing environment, these concepts are part of “noninterpretive skills” or “nonclinical skills,” and our volunteers often struggle with the challenge of writing a relevant question that appropriately assesses the understanding of principles that are often nuanced in their real-world application. The ABR acknowledges that concerns regarding an individual’s professionalism are more effectively identified and addressed during a multi-year residency. As a result, we rely on the training program’s attestation in this regard.
The Board of Governors also defines and oversees expectations for our staff and volunteers. This includes not only traditional issues such as monitoring conflicts of interest but also an expanded focus on fundamental expectations of how professionals treat each other. Professionalism is an essential element of board certification if we are to continue to garner the public’s trust.
- Wynia MK, Papdakis MA, Sullivan WM, Hafferty FW. More than a list of values and desired behaviors: a foundational understanding of medical professionalism. Acad Med. 2014; 89: 712-714.