Organizational Professionalism and Self-Assessment: Realization of a Necessity

Abstract
Background: The recent rapid developments in medical science and technologies have brought about powerful medical tools; however, the professional commitment has failed to keep pace. Professionals’ reluctance or failure to practice professional behavior has significantly challenged society’s trust in professionalism. Consistent assessment of the profession, at least through measuring the capabilities and encouraging the elimination of shortcomings, can serve as an effective tool to preserve or restore this trust. Numerous assessment methods are recommended to measure the level of professionalism among the members of the medical society. Sometimes, professionalism is defined using shared values and sometimes various lists of professional behaviors are suggested. However, no comprehensive definition has been proposed for professionalism. Professionalism is normally individual. This study sought to provide a comprehensive definition of professionalism and accordingly explains organizational professionalism. In addition, it tried to define profession assessment through a non-systematic review of online resources using Web of Science, Science Direct, and PubMed databases. Professionalism is a belief system or a driving force to create these lists to improve healthcare, according to which professionalism requires collective action. The philosophy underlying the common standards of physicians regarding the patient-physician relationship confirms the importance of teamwork and organizational professionalism. Following professional autonomy, assessment of the members of a profession is carried out via self-assessment. Meanwhile, the continuation of the self-assessment system entails patients’ trust in their physician and society’s trust in the profession of medicine. Furthermore, the medical profession should operate with more transparency, thus the society can feel that the self-assessment is  really effective. Thus, constant and dynamic self-assessment is started with the physicians and expanded through the clinical team. The profession should administer systematic professionalism in all dimensions of the health system. In addition, it should guard its self-assessment privileges obtained from society and seek the assistance of ordinary individuals in society, patients, and experts in fulfilling this task.
Keywords: Medical professionalism, Self-assessment, Self-regulation, Systemic professionalism

Introduction
Over the past several years, science and technology have provided medical professionals with powerful tools. The professional commitment is a requirement to preserve the trust between society and this profession must be developed along with them. However, it appears that the scientific developments and technical skills have proceeded the professionalism in this profession (1). Professionalism is a set of goals, behaviors, and qualities expected of a person in a profession, and includes knowledge, practices, skills, and positive judgments that a member of a profession must have to benefit others without considering their own interests.‏ 
Although the spirit of professionalism is seen in the Hippocratic Oath (2), the first codes of medical professionalism were written by Thomas Percival in 1800 AD, and the American Medical Association presented its codes of medical ethics in 1847. Since 1900, there have been other movements in the interpretation of professionalism, but in 2002, the American Internal Medicine Foundation, along with the American College of Physicians Foundation and the European Federation of Internal Medicine, gave a new form of professionalism and established its basic principles (3‏).
The principles of professionalism emphasize three dimensions:
1. The welfare of the patient, which relies on altruism and trust and the interests of the patient
2. Respect for the patient’s autonomy, which includes honesty with the patient.
3. Social justice and paying attention to the needs of a patient while paying attention to resource management and the needs of all patients (4).
Although society appreciates the development of science and technology, its expectations regarding the development of professionalism are growing as well (5). An informed society seeks accountability, transparency, and proper professional behavior (6). Professionals’ reluctance or failure to practice professional behavior can undermine society’s trust in professional commitment. In addition, it can threaten professionalism. Precise supervision of the profession and assessment of the behaviors of its members is one of the main requirements to maintain the profession and the professionals at a standard level and fulfill the public expectations.
A variety of assessment methods have been proposed to measure the level of professionalism among members of the medical society (7). Sometimes, professionalism is defined by shared values such as compassion, justice, honesty, respect, altruism, and providing services (8). Sometimes, from the assessment perspective, various lists of professional behaviors are suggested for these assessments (9). However, the assessment lists are merely tools to monitor the performance of the professionals and they cannot provide a comprehensive definition of professional commitment. Therefore, it is a misconception to assume that professionalism can succeed without a comprehensive definition of it. Another issue that should be taken into consideration is deciding who should supervise this profession. For instance, paragraphs M and R of chapter two of the code of the Medical Council of the Islamic Republic of Iran (IRIMC) state that participation in designing the supervision and evaluation by laws and guidelines and participation in their implementation are among the inherent duties of IRIMC (Reference: Code of IRIMC, ratified on 13/04/2004 by the I.R. Iran Islamic Consultative Assembly and ratified on 06/11/2004 by the Expediency Discernment Council of I.R. Iran (10).
This research sought to provide a comprehensive definition of organizational and professional commitment and utilize it to define a systematic view of the professional commitment and professional assessment method.

Materials and Methods
This is a narrative review study aiming to clarify the definition of organizational professionalism and self-assessment to promote the knowledge and attitude of professionals of an organization.This study is not a systematic review and  therfore, first, the keyword of medical professionalism was searched on accredited scientific websites and search engines such as PubMed, Science Direct, Springer, Scopus, and MD Consult. A large number of articles were found (without advanced filters). Then, systematic professionalism, self-assessment, and self-regulation were included in the search to limit the results. Finally, advanced research was limited to the past 20 years. The articles that met the purposes of this study were selected.  Furthermore, the medical ethics books, especially on organizational professionalism and self-assessment, which addressed this subject, were separated and examined. In addition, the Iranian articles were searched on accredited Iranian websites such as Magiran and IranMedex. The articles in this regard were meticulously selected. The articles were assessed from a viewpoint of organizational professionalism rather than merely professionalism using the main principles of assessment. 

Purpose of the Study
This research was aimed at clarifying the concept of organizational professionalism and its role in promoting organizations, describing the components of organizational professional commitment, and facilitating monitoring professionalism in the organization by proposing professional assessment methods in organizations.

Results
Professionalism
A variety of definitions have been proposed for professionalism. Most of the definitions provide a list of desirable beliefs, behaviors, requirements, commitments, principles, values, virtues, and characteristics and search for the normative and descriptive components of professional commitment (11). The principles of professionalism are different from different points of view, but one point of view, which is perhaps the most complete, considers eleven items to be part of the principles of professionalism. Empathy, compassion, respect, altruism, and preferring the interests of patients over their own interests, commitment to excellence, care, responsiveness, sensitivity to the needs of the society, honesty, coherence and responsibility are the principles that are enumerated in this perspective (10).
Kohen refers to medical professionalism as a tool to fulfill the contract of the profession and society (12). Fridson defined it as a collection of organizations that authorize the members of an occupation to live with that career while supervising their own job (13). However, neither of them provided a fundamental definition of professional commitment. The fundamental interpretation of the nature of professionalism benefits organizations and individuals who seek to promote its power within healthcare. Defining professionalism using performance lists involves several problems (11).
1. Behavior checklist-based definitions lower the value of professionalism. A list of measurable behaviors is necessary, yet it is not sufficient for defining it.
2. When professionalism is defined with a behavior checklist, it risks misinterpretation since it is obtained by merely checking the elements of the checklist.
3. A list-based definition is applicable at the individual level, and it fails to account for group activities such as consistent development and meeting professional standards.
Professionalism is not defined by these lists, yet it is a reason to create these lists. It is a principle in the belief system or a driving force to create these lists to improve healthcare (11). It enables the members of this profession to come together in groups and learn about the joint competence standards and ethical values regarding patients’ expectations (14,15).
Furthermore, it makes them enter into joint contracts and monitor each other’s professional behaviors, which is the result of this belief system. This definition ensures the professionals that they are worthy of the public trust and the trust of their patients. 
Moreover, the definition of professionalism as a belief system aiming at promoting the healthcare system is crucial from several perspectives (12).
1. In this interpretation of professionalism, the technical-scientific competencies and ethical values are acknowledged to be equally important. However, the initial definitions that emphasized the value checklist defined professional commitment as ethical values and even replaced ethics with professionalism. It entailed the risk of excluding the technical skills from the contracts of the professional commitment (12).
2. This new definition is required to enable the professionals to grow together (16-17) and develop methods to hold each other accountable and acquire information about joint contracts. Thus, this definition emphasizes the legitimacy and effectiveness of self-assessment mechanisms (12-18).
3. In case, professionals view professionalism as a belief system to improve healthcare, it will encourage them to discuss and exchange their views, and establish and apply joint competency standards and ethical values to control the medical profession. In case professionalism fails, society might support other “isms” (12).

Organizational Professionalism
Professional commitment comprises a sense of identity and attachment to a special profession. Inclination and interest in working in a special profession are associated with three dimensions, namely emotional, consistent, and normative; and professional commitment is defined as the sense of identity with a profession, the need for consistent service in a profession, and a high sense of responsibility regarding that profession. Organizational commitment is regarded as an emotional and mental attachment to an organization, according to which an extremely committed individual develops his/her identity in relation to the organization, participates in that organization, and takes pleasure in being a member of it; i.e., attachment to individual roles in relation to organizational values and goals for the sake of the organization itself rather than its instrumental values (5). Accordingly, professionalism requires collective action. The underlying philosophy in the common standards of physicians considering the patient-physician relationship confirms teamwork (8-19). There is a collective responsibility in teamwork, and the poor performance of one member must arouse the concern of all members.  The following constitute the most crucial characteristics of a diagnosis and treatment team (1-20):
Prioritizing patients, management skills, transparent values, responsibility to promote quality, taking care of all members, encouraging individual or group learning, developing a culture of anti-nitpicking, commitment to the principle of outsider inspection, and taking on the responsibility of good performance.
Efficient teams enjoy the following (1-20):
Explicit guidelines, efficient systems, reliable information, accurate evidence, clear reports, individual and team development programs, appropriate clinical audits, and bilateral and external assessment.
The complexity of new healthcare, personality diversity among the members, and the need for a structured management framework to meet society’s needs confirm the necessity of organizational and professional commitment to providing better services and meeting society’s expectations of the profession.
Goals of Organizational Professionalism
Organizational professionalism in the field of medicine includes the following (1,20):
1. Adjusting the professional values with the values of society
2. Defining clear standards based on the evidence
3. Managing the poor performance of the members of the profession
4. Establishing a systematic process to consistently assess and report professional competency
5. Conducting effective regional assessment following the qualities of the clinical teams
6. Strengthening the medical education and reeducation of physicians
7. Reforming the standard assessment body (i.e., GMC)
A systematic view of professional commitment supports environmental and organizational changes to overcome the obstacles to professionalism, improves the quality and safety of healthcare, and encourages the physicians’ professional behaviors (21).
Nearly all physicians participate in the clinical team processes and the clinical performance of each team is influenced by the performance of each member. Accordingly, all members must abide by the ideals of their team and profession. The accountability of each individual should be reinforced based on accountability to the team.
The GMC published the Good Medical Practice (GMP) in 1995, which was a development in the field of professional commitment. This document comprised principles that all physicians were required to observe. These principles were used as a basis for education in schools and the clinical supervision of physicians. This document also addressed the requirements of teamwork (15). Under GMP, each team must protect patients against damages. Thus, health professionals should learn how to deal with the poor performance of a colleague that can endanger patients (15). Physicians should earn scores in the periodic professional assessments. In addition, blocking the re-registration of physicians with poor performance is one of the responsibilities of organizational professionalism (1,20). The profession must be strict about the misbehaviors of its members.

Self-Assessment of Medical Profession
Professional commitment consists of three pillars, i.e., competence, ethics, and service. These three pillars are the basis of autonomy in medicine (8,19). Competence is derived from the body of sciences and skills, whose benefits are constantly boosted by research. Ethical behavior is the combination of values and standards, and service is a commitment to put patients first (22).
Autonomy privides the physicians with respect and freedom in decision-making, which motivates them to improve their performance. This autonomy enables the profession to define its educational, assessment, and disciplinary standards. Moreover, the independence of the medical profession emphasizes three claims (8,19):
1.There is a level of science and skill in medicine that nobody but the professionals can assess.
2. Physicians are accountable and reliable to deliver conscionable work without supervision.
3. There is trust in the profession to assess all unethical and defective performances.
Following profession autonomy, the assessment of members is carried out via a self-assessment system. Assessment of competent physicians and their re-registration by GMC is to accomplish this goal. Self-assessment of profession creates a link between society and professionals. This system has it flaws as well. For instance, it was argued that we cannot trust the capacity of physicians and protect patients from poor performance. When there is a conflict of interests between physics and patients, the interests of physicians might be prioritized. They were of the opinion that there should be a greater assessment carried out outside of the profession and the judgment must be carried out by an independent, external view (23,24). Sometimes, physicians were accused of being narcissistic, non-accountable, inefficient, and excessive social/class difference (20).
The continuation of the self-assessment system entails patients’ trust in their physician and society’s trust in the profession of medicine. In addition, the medical profession must operate with more transparency such that society can realize that self-assessment has been truly effective. This is the only path through which the efficient self-assessment resulting in the promotion of the profession can be accomplished (25).
Inter-profession self-assessment in Iran is merely carried out regarding guild and professional violations and not the general crimes. This issue has been explicitly stated in paragraphs V and Z of Article 3 of the Code of IRIMC (10).
Therefore, constant and dynamic self-assessment starts with physicians, is expanded by the clinical team, and continues to include all professionals nationwide (19). To preserve the independence of the profession and its reasonable management, professional commitment must be perfectly capable of adjusting to the changes.
Self-assessment of a profession is not a “right”, it is a privilege granted to it by society due to its trust in that profession (20). Thus, in case this trust is breached, as was the case in the Medical Councils of several countries such as England, these privileges will be revoked and granted to a governmental organization (26). Canceling the authority of the medical council organization in this regard and granting it to independent organizations is a proposition that society can offer to retain its rights in these situations.

Main Principles of Self-Assessment (19)
1. Announcing Values and Standards (Desirable Medical Performance):
Some countries design and publish general manuals for professional conduct in organizations to achieve the desired values and standards (27-30). One instance is the design, approval, and publishing of the general manual of professional conduct by IRIMC.
2. A Reliable Qualitative System:
To prove that self-assessment is efficient and effective, the system should be tested by clear criteria and standards, which requires strict evidence of competence.
3. Patients’ Involvement:
Considering the importance of the view of patients to self-assessment, GMC has recently increased its unprofessional assessment team members by up to 25%. Patients’ understanding of physicians’ behaviors enables them to detect unprofessional behaviors (31).
4. External Peer Review:
This review is a major motive for effective action and it must constitute a great part of the self-assessment. This method can be used for assessing individuals, clinical teams, and institutions (32).
5. Diversity in Unity:
Every school of medicine and clinical team establishes its own standards and habits. The diversity of new ideas gives rise to different methods to achieve development and professional excellence with the same goals. The important issue in this diversity is the unity in different sections of the profession (33).
Without effective consistency, the system cannot be seen as a whole, the relations of its different components cannot be examined, and it is not possible to assess the system’s performance.
A framework of specific goals and coordinated colleagues will lead to optimal self-assessment.
6. Managerial Role of Professors:
A role model is a powerful force in medicine. Every day, the behavior of clinical instructors displays their proficiency, ethics, and commitment, which is known as professional commitment.
What the instructors do and how they do it is as effective as what they say (34-36), for instance, their relationship with patients, students, and colleagues, identification of limitations in their performance, clinical audit for improving their performance, constructive peer assessment for professional development, self-criticism, acceptance of poor performance by themselves and others, and compassion for colleagues in difficult conditions.
Their management style is important for performance quality, medical education, and professional self-assessment. Thus, assessment of behaviors and interpersonal skills must have a high priority in medical education (37-40).

Suggetions

Conclusion
Nowadays, it seems that society holds high expectations of the medical profession. The increase in these expectations indicates the success of this profession. Patients expect professionals to be accountable, have up-to-date knowledge, establish good relationships, and prioritize patients’ interests. Making efforts to meet the just needs of society gains more respect and trust for physicians, and encourages them toward professional conduct. The members of the health team should not consider the professional commitment an extra burden, rather they must adhere to the concept of an intellectual system, which aims at improving the quality of health services, and think of it as their driving force. Considering that organizational professionalism and team commitments are one of the inevitable cosequences and also requirements for the development of professionalism. Each member of the team must consider him/herself responsible for the profession, patients, and their peers. Accordingly, the profession must administer systematic professionalism in all dimensions of the healthcare system to accomplish this goal. It must preserve the granted privilege of self-assessment. To do so, it should seek the assistance of ordinary individuals in society, patients, and professional experts, which can strengthen society’s trust in the medical profession and physicians. This trust can lead to the ever-increasing development of the medical profession. In addition to preserving the privilege of self-assessment, this trust can enhance the development of physicians in this profession.