Volume 8, Issue 6 - June 2025

Dear Yvonne,

This issue of The Academy is one of the more fun issues to edit, and this is for at least two reasons. First, it allows me the opportunity to write a bit more than usual. Second, it draws on the wealth of knowledge, expertise, experience, and engagement of those who presented new work at the recent APHC conference, “Building and Rebuilding Trust: Reflection and Action in Professionalism,” which took place at Rosalind Franklin University of Medicine and Science in North Chicago, Illinois earlier this month. The conference brought together a wide array of professionalism scholars, practitioners, and students from across the globe to discuss current and perennial questions about professionalism. Presentations and conversations occurred in person and online, with a wealth of exchanges, the impact of which are sure to be seen in the coming years by health professionals. Putting on an international conference is no easy feat and kudos – and a wish for some much-deserved rest – go out to the conference organizers: Dr. Elizabeth Kachur, Dr. Mary Horton, and Dr. Amal Khidir. Special thanks are also due to Dr. Michelle Schmude, and Dr. Tanja Adonizio, and Dr. Dennis Novack, for their leadership and work.

As is our custom, the articles that comprise this issue touch on the conference. The first article is a preface and initial portion of a four-part series rooted in one of the conference warm-up sessions. The four-part series engages the Swick Test and is authored by Dr. Frederic Hafferty. Those who attended the conference may have run into Hafferty at Fireside chat or in sessions, as well, but the warm-up exercise that has everyone talking will be the subject of this series. The second article is a reflective piece on what it is that binds persons with professions and serves as a foundation for professionalism; authored medical student, Sandra Guirguis, the piece explores her answer to that timely and time-honored question which informs many discussions of trust in the health professions. Spoiler alert: her answer is rooted in the oaths that bind professions and, in her own case, the Hippocratic Oath. The last – and I can assure you, least – of the three pieces is an editor’s recap on conference highlights with special attention paid to the new award that will benefit The Academy. I had the honor of attending the conference both as a presenter and, more relevantly, as Editor-in-Chief of The Academy, which allowed me the time to report on the conference. The results of that reporting are not a representative sample of the excellent work at the conference but a few comments on especially notable features. The issue also highlights important goings on in the professionalism world, as well as the usual announcements, and items of interest from APHC members.

Bryan Pilkington, PhD is Editor-in-Chief of The Academy: A Forum for Conversations about Health Care Professionalism

1. The Swick Exercise

2. The Hippocratic Oath: A Medical Student’s Reflection on Its Relevance Today
3. Conference Highlights
4. ABMS Conference 2025 Registration Now Open
5. The American University of Rome Summer Professional Development Program
6. Healthcare Professionalism: Education, Research & Resources Podcast
7. APHC Member Benefits

The Swick Exercise

By: Frederic W. Hafferty, PhD

Preface

What follows is Part 1 of a 4-part history of a class exercise (The Swick Exercise) that has played a fundamental role in my own professionalism journey. I want to outline its history not because I feel the exercise should be adopted by others [e.g., that it deserves some version of an eternal life – smile], but that the logic underlying the exercise is fundamental to what I see as the work of professionalism going forward. There is, and always will be, an interstitial space between what is formally defined, measured, and/or institutionalized (via codes, charters and curricula) as professionalism, and what trainees experience as they navigate the complexities of their learning environments and the organizational swirls of their workplaces.  For me, professionalism is the ongoing and necessary conversations about what it means to be a good doctor.  No conversation.  No professionalism. The Swick Exercise, shorn of any initial intent, became my portal into the interstitial “buzz” between what I was teaching about professionalism and what my students actually heard and were sharing among each other.   What I learned became a part of my own conversation in speaking out and writing about professionalism.

Looking ahead, in Part 3, we will take a retrospective look at what a series of students in their first 2 months of medical school had to say about professionalism via the Swick Exercise.  Today, professionalism has become “the P word,” a tarnished shadow of its earlier promises.  Some claim it has become weaponized against trainees (by faculty/administration), against physicians (by employers), and more darkly, as an instrument to further marginalize already minoritized populations. Others call for its outright banishment from the classrooms and on-call rooms of medical training, seeing it as too burdened, too corrupted, or too recklessly deployed as a cudgel of social control.  These data, now 20+ years old, document that students, from the onset of their training, and long before these current outcries, embraced certain professionalism principles while simultaneously harboring dark suspicions about other aspects of what they were being called upon to do and be in the name of professionalism.  In short, what was supposed to be unequivocally aspirational was being viewed (at best) as a “mixed blessing.”  Moreover, and under the threat of being “written up” for some ever-morphing unprofessional “transgression,” these rapidly-cynicized reservations remained largely invisible to those who stood firm in their pedagogical pulpits preaching misguided homilies about what it meant to be “true professionalism believer.”

We should have listened.  We should have led better.  It really was all there for us to see.

Part 1:  Swick & his Normative Definition of Professionalism

In 2000, physician and medical educator Herbert Swick published what long has been part of my very short list of impactful articles on medical professionalism. Titled Toward a Normative Definition of Medical Professionalism,¹ Swick sought, in his own words, “to create a persuasive definition based upon refined reflection about the nature of professions and the nature of physicians' work.”  Although not his first professionalism foray,^2-4 Swick here sought to answer a clarion call within medicine’s nascent modern day professionalism movement - to better define professionalism.⁵  In taking on this challenge, Swick’s article is notable because it would become – in short order – a key part of another historically important professionalism document, the Physician Charter.⁶ Following the ABIM Foundation’s pivot from its earlier Project Humanism to its highly impactful counterpart – Project Professionalism, both the Charter’s overall focus and its element foci drew heavily from Swick’s writings in general and his 2000 article in particular.⁷

Swick’s decision to adopt a normative approach to conceptualizing professionalism is notable for other connections as well.  Directly reflecting his foci on “the nature of professions and the nature of physicians’ work,” Swick drew upon the writings of sociologist Eliot Freidson, organizational sociologist Steven Brint (on the changing role of experts in society), and philosopher cum-sociologist William Sullivan (who would later co-direct the Carnegie Foundation’s Preparation for the Professions Program, a comparative study of professional education in engineering, the clergy, nursing, medicine, and law.⁸  In addition, Swick cited work by: (1) Preston Reynolds who as a medical resident was making important contributions to the ABIM Foundation’s Project Professionalism; (2) physician leaders and educators Richard and Sylvia Cruess, whose widely impactful work on professionalism included foci on the social contract and on professional identity formation; and (3)  physician-educator Mathew Wynia whose career spanning work on the nature of professions would include a pivotal partnership with Maxine Papadakis, Bill Sullivan, and myself in drafting an important institutional-level definition of professionalism for the American Board of Internal Medicine.⁹  Within a burgeoning professionalism literature, both the Cruesses and Wynia would go on to publish two of the three most important sociological framings of professionalism written by non-sociologists.  The Cruesses, with their own list of ten “conditions of professionalism,” created a stunning synthesis of sociology and ethics in their examination of what it meant to be both a profession and a professional.¹⁰ Wynia, with roots more in the individualistically framed world of ethics, drew heavily from sociological critiques of professionalism, as he created an archetypal model of professionalism as a societally stabilizing force.¹¹  The third article in this non-sociologist trilogy, by a Canadian trained theorist Tina Martimianakis, painstakingly traced the evolution of sociological writing on professions, including how Marxist, Feminist and anti-racist scholars had begun to untangle how professionalism, as a social construct, was sustaining gender and cultural inequities.¹² Their collective insights notwithstanding, all three would largely disappear within a medical education professionalism literature that increasingly came to operationalize professionalism at the level of individuals, be it their motives and/or behaviors while largely ignoring issues at the level of the profession itself including its collective responsibility to organize work in service to the public.¹³

Swick’s sociologically-informed normative approach to professionalism also captured my attention for another reason. In 1998, my dean had instructed me to develop a professionalism module for entering first year medical students - with additional touch points throughout their first and second years. While I understood the “why now” as well as the “why me” (given my previous – albeit more sociologically focused – work on professionalism, medical ethics, medical socialization, and on the other-than-formal aspects of the medical school curriculum), I was not prepared for what I began to learn as I rolled out these modules.  I thought I would be delivering a catechism of core values and key attributes as captured in the AAMC’s Medical School Objectives Project¹⁴ coupled with student feedback exercises covering a range of issues (e.g., dutifulness, altruism) followed by class-based discussions that would affirm what organized medical education had put forth as core to what it meant to be a good doctor.  Instead, I began to see that students were pushing back as they harbored rather deep and abiding hostilities to any notion they were “obliged” to serve, around the concepts of altruism and selflessness, and against the notion that some “external” body (a teacher, school, or profession) might require them to adhere to principles they felt they already had internalized (e.g., “I’m already ethical and virtuous”).¹⁵ As I struggled to understand these reservations, I learned that my dean’s support for the four non-class-based modules would be short lived, and that any further (still required by him) formal professionalism curriculum would need to be totally subsumed within my own (Fall) first-year course.  How then might I continue to explore that interstitial space between what was formally being taught as professionalism and what students actually thought about the catechism I was preaching?  Swick’s article, already part of my core reading list, was about to take on a new role.

Next: Part 2: The Exercise.

REFERENCES

1.  Swick, Herbert M. 2000. Toward a Normative Definition of Medical Professionalism. Acad Med 75 612-16.
2. Swick, Herbert M, DE Simpson, TJ Van Susteren. 1995. Fostering the Professional Development of Medical Students. Teaching & Learning in Medicine 7 55-60.
3. Swick, Herbert M. 1998. Academic Medicine Must Deal with the Clash of Business and Professional Values. Acad Med 73 (7): 751-55.
4. Swick, Herbert M., Philip Szenas, Deborah Danoff, Michael E. Whitcomb. 1999. Teaching Professionalism in Undergraduate Medical Education. JAMA 282 (9): 830-32.
5. Cruess, Richard L, Sylvia R Cruess. 1997. Teaching Medicine as a Profession in the Service of Healing. Acad Med 72 (11): 941-52.
6. ABIM Foundation.  The Physician Charter: https://abimfoundation.org/wp-content/uploads/2015/12/Medical-Professionalism-in-the-New-Millenium-A-Physician-Charter.pdf
7. Cruess, Richard L, Sylvia R Cruess. Personal Communication
8. Sullivan, W., and M. Rosin. 2008. A New Agenda for Higher Education: Shaping a Life of the Mind for Practice. San Francisco: Jossey-Bass.
9. Wynia, MK, MA Papadakis, WM Sullivan, and FW Hafferty. 2013. More Than a List of Values and Desired Behaviors: A Foundational Understanding of Medical Professionalism. Acad Med 89 (5): 712-14.
10. Cruess, Richard L, and Sylvia R Cruess. 1997. Teaching Medicine as a Profession in the Service of Healing. Acad Med 72 (11): 941-52.
11. Wynia, MK, SR Latham, AC Kao, JW Berg, and LL Emanuel. 1999. Medical Professionalism in Society. N Engl J Med 341 (21): 1612-16.
12. Martimianakis, Maria Athina, Jerry M. Maniate, and Brian David Hodges. 2009. Sociological Interpretations of Professionalism. Medical Education 43 (9): 829-37).
13. Hafferty, FW. 2018. Academic Medicine and Medical Professionalism: A Legacy and a Portal into an Evolving Field of Educational Scholarship. Acad Med 93 (4): 532-36.
14. AAMC. Report 1. Learning objectives for medical student education: guidelines for medical schools. Medical School Objectives Project. Washington (DC): Association of American Medical Colleges; 1998.
15. Hafferty, Frederic W. 2002. What Medical Students Know About Professionalism. Mt Sinai J Med 69 (6): 385-97.

Frederic W. Hafferty, PhD is a medical sociologist and Senior Fellow, Accreditation Council for Graduate Medical Education.

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From witnessing the delicate beginnings of life in delivery rooms to observing the fragile moments surrounding end-of-life care as a medical student, I’ve come to appreciate the necessity of an ethical framework in protecting the patient-physician relationship. The Hippocratic Oath, named after the fifth-century BC physician Hippocrates, is one of the earliest known normative guidelines for the conduct of medical professionals. While medicine has undergone drastic changes due to cultural and technological advancements over the past 2500 years, the components of the Hippocratic Oath still reflect aspects of modern medical ethics and professionalism. As I prepare to become a physician, I reflect on the role the Hippocratic Oath plays in shaping the culture and expectations of the profession through its tenets of mentorship, respect, confidentiality, and emphasis on doing no harm.
The beginning of the oath encompasses a vow to pass down the art of medicine to the physician’s sons and those of his teacher, compelling a culture of mentorship that remains a crucial part of medicine today. This is evident in multiple areas of medicine and has become ingrained in the culture, as medical students are often required to have a mentor in their chosen specialty. Medical students are not only instructed but also evaluated by residents during their clinical rotations. Interns are taught, corrected, and mentored by senior residents who, in turn, have a similar relationship with their attendings. This practice of passing down the skill to the students, or more novice physicians, has become an implicit, if not explicit, role of the physician. This emphasizes that medicine is a lifelong commitment to learning and teaching and that it is the responsibility of the medical professional to foster an environment conducive to that.

The oath expounds on the idea of doing no harm. It specifically mentions keeping harmful things away from the sick, directly tying itself to modern core principles constructing medical ethics, namely, beneficence and nonmaleficence. During my clinical rotations, I’ve witnessed that these core principles regularly guide everyday decisions physicians must make concerning patient care. Physicians, despite having the most knowledge and skills to harm, vow only to use their skills toward healing the patient. The literal translation, including “deadly drug” and “destructive pessary,” may have some contradictions to the way medicine is practiced [2]. However, I argue this is not an indication that the oath is categorically irrelevant today, but rather that its relevance varies across different cultures. For instance, in most modern-day nations, the use of abortion is restricted to cases of rape or direct harm to the mother, not upon request. This is in agreement with the Hippocratic Oath, since ending a pregnancy in these cases benefits the health of the mother [3].  Furthermore, even in most of the countries with more permissive laws on abortion, there often is a “conscience clause”. This allows physicians to opt out of performing abortions if it contradicts their personal beliefs, meaning the law accommodates the physician’s values, leaving room for an element of the oath to guide patient outcomes today on such a heavily contested subject.

Extending this logic, the participation of physicians in designing the method for physician-assisted suicide (PAS) is highly controversial and may seem directly contradictory to the oath. Again, while physician-assisted suicide is legal in some countries, it is still illegal in the majority of the world. Even when PAS is offered, it is heavily regulated and not considered a widely accepted aspect of the physician’s role. The oath also deliberates the “deadly drug,” as aforementioned, most likely referring to capital punishment, another medical dilemma that exists in modern day. While physicians may have historically been involved in innovating methods of execution, their participation is not commonplace globally today. In the United States, for example, the AMA prohibits physicians from participating in capital punishment [1]. While execution methods such as firing squads, hanging, and beheading are performed in other parts of the world, physicians typically do not play a role in the process. Therefore, adherence to the oath’s tenet of doing no harm, even in the case of capital punishment, is still widely practiced.

Elsewhere in the oath, the physician promises to respect the households they enter. While home visits are occasionally a part of providing care, the household of the patient takes on a more symbolic meaning today, representing the patient’s emotional space and intimate domain. A physician enters that confidential realm every time a patient is under their treatment and must conscientiously navigate that. When allowed to interact with the patient in such a way, the physician must be careful not to take advantage, upholding the professionalism that honors the patient’s dignity. This corresponds to the part of the oath that mentions that one ought to be “free from all voluntary injustice and corruption” [2]. In addition, respecting a metaphorical household of the patient means providing culturally competent care and considering the social determinants at play in the health of each individual patient, a precept that is heavily integrated into medical education today.

Furthermore, the oath paves the way for the principles that inspire the modern laws on confidentiality, namely HIPAA, which legally mandates the confidentiality of patient information. Here, the physician vows to keep matters pertaining to the patient’s health private. Although the technicalities of patient data have evolved with modern-day technology, the fundamental principle of patient privacy still stands. 

Ultimately, the principles delineated in the Hippocratic Oath pave the way for expectations of a future physician’s professionalism. Despite changes in medicine that reflect changing times, the oath plays a vital role in contemporary codes of ethics in medicine. Given the gravity of saving human lives, an oath is not only warranted but necessary as a reminder of the profession’s roots and the standards physicians are held to.

REFERENCES

1. Capital Punishment | AMA-Code. (n.d.). https://www.ama-assn.org/delivering-care/ethics/capital-punishment
2. Cavanaugh, T. (2017). Hippocrates’ oath and Asclepius’ snake. In Oxford University Press eBooks. https://doi.org/10.1093/med/9780190673673.001.0001
3. World Population Policies 2017 Highlights: Abortion laws and policies – A global assessment | Population Division. (n.d.). https://www.un.org/development/desa/pd/content/world-population-policies-2017-highlights-abortion-laws-and-policies-%E2%80%93-global-assessment

Sandra Guirguis, B.A., is a fourth-year medical student at Hackensack Meridian School of Medicine and a Master’s student in Biomedical Engineering at Stevens Institute of Technology, with a strong interest in diagnostic radiology.

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APHC’s conference on trust and professionalism, which took place earlier this month, was a slam dunk – a metaphor I use with some lament, as the Knicks are no longer in the playoffs. There exist a variety of perspectives on and insights about the conference and this short article merely notes some highlights according to one of those many perspectives. Thus, I open with an apology if you favorite session – the one you attended or the one you offered – is not reflected in this brief discussion.

The brightest highlight, for me, was the conversations. Professionalism, as it is described in one of the articles in this issue, lives in that space, and so I was very, very pleased to engage so many participants in short and longer talks. This was a bit tricky as a virtual participant, but the excellent set up for the hybrid conference allowed for in-session chats, networking conversations in zoom rooms, and… with the communities of practice building… follow up texts and phone calls. The conversations around trust and professionalism were uplifting in many ways. In a time when very different aspirations and goals are modeled and aimed at by some of the most powerful persons across the globe, it was a refreshing joy to chat with students earnestly working to form themselves into the kinds of health professionals we need in the future, teachers thinking of how to put their students in the best situations to succeed, and conference organizers bending over backwards to facilitate such important and impactful conversations.

A second highlight was the keynote addresses. They were all excellent and thought-provoking. Lauren Taylor’s research on trust won the day, for me, but each keynote will repay review. A third highlight was the fireside chat. Drs. Reynolds and Hafferty took us through a conversation (built on a previous conversation) about trust and professionalism: it is not every day that you have professionalism scholars of such renown causally and openly working through work germane to a conference’s theme. The penultimate item on my highlight list was a talk entitled, “Pedagogy and Passion: Cultivating Virtuous Professionals Who Champion Health Equity.” There were, to be sure, a plethora of excellent talks and a list of highlights could include many; however, this talk by Joe Kotva struck me as illustrative of the kind of professionalism work by teachers of health professionals that can address concerns about trust in healthcare. Kotva’s insightful session on how to cultivate necessary virtues was clear and compelling, as so many presentations were, but Kotva brought a sincerity and openness to the challenges embedded in traditionally accepted paradigms that, were he playing ball, might have gotten the Knicks over the hump. Of note was his not-so-subtle critique of principlist approaches in bioethics and the harm that they can cause for professionals. The care and concern illustrated for future professionals as they form their own professional identities amid a variety of negative – but also of well-appearing – influences was most welcome.

The final highlight – easily the top of the list, and readers will see why – was the new award for the article of the year! Tom Koch’s "Practitioners as Resource Stewards,” which appeared a few years ago in the APHC’s Professional Formation Update, precursor to this publication, has been selected as the inaugural winner of the APHC’s professionalism article of the year award. Thanks to Fred Hafferty, whose generous contribution underwrites the award, and to Michelle Schmude and the leaders of APHC for their work to allow Hafferty’s generosity to benefit The Academy. Future winners of the award, which is to be given yearly, will receive free registration at the annual conference, among other benefits.

Congratulations to Tom Koch! And happy writing to all those who look to submit in the future. Our inbox awaits…

Bryan Pilkington, PhD is Professor of Bioethics in the Department of Medical Sciences at the Hackensack Meridian School of Medicine.

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AMBS Conference 2025 Registration Now Open

Registration for ABMS Conference 2025, which will be held Sept. 17–19 at The Westin Pittsburgh, is now open.

As the premier health care conference on board certification, with a focus on assessment, lifelong learning, improvement, and professionalism, ABMS Conference 2025 offers an opportunity to share innovative collaborations, evidence-based research, and best practices that accelerate the transformation of certification and delivery of high-quality care.

Visit the ABMS Conference 2025 website to learn more about registration, hotel and travel, as well as this year’s program.

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Professional Formation and APHC collaborate on a podcast, Healthcare Professionalism: Education, Research & Resources.

Over 125 podcast episodes have been released with over 17,000 downloads.

Released every other Saturday morning, recent episodes include Rachel Pittmann discussing Telehealth Etiquette and Amal Khidir talking about Designing the Faculty Development Professionalism Program with Multi-cultural Perspectives.

You can access the podcast episodes on your favorite platform or at: https://bit.ly/PF-APHC-Podcast

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As a member, you have access to special benefits that include:

• Belonging to a community of like-minded professionals
• Participating in the monthly Professionalism Education
  Roundtables with authors, faculty, and researchers, plus accessing past recordings
• Accessing 15 Professional Formation modules for individuals for free
• Enrolling in the APHC Faculty Development Certificate program known as LEEP (Leadership Excellence in Educating for Professionalism), which was launched in 2020 and offers longitudinal mentoring for a select group of
  individuals seeking to deepen their knowledge and skills in
  professionalism education, assessment, and research
• Posting your research, articles, podcasts, webinars, conferences, and books in the newsletter distributed to about 15,000 people
• Receiving a 20% discount on educational videos created by the Medical Professionalism Project, which also allows you to obtain MOC and CME
• Registering for APHC conferences with discounts
• Participating in APHC committees, which include the conference program, membership, and education committees

Our annual membership fees are very inexpensive and are valid for one year from the payment date. Select from seven types of membership, including the institutional membership for four people. See the descriptions.

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Editor-in-Chief: Bryan Pilkington | Managing Editor: Yvonne Kriss

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