Physician professionalism: definition from a generation perspective

Objectives The primary objective of this study was to determine whether consensuses on the definition of emergency physician professionalism exist within and among four different generations. Our secondary objective was to describe the most important characteristic related to emergency physician professionalism that each generation values. Methods We performed a cross-sectional survey study, using a card-sorting technique, at the emergency departments of two university-based medical centers in the United States. The study was conducted with 288 participants from February to November 2017. Participants included adult emergency department patients, emergency medicine supervising physicians, emergency medicine residents, emergency department nurses, and fourth- and second-year medical students who independently ranked 39 cards that represent qualities related to emergency physician professionalism. We used descriptive statistics, quantitative cultural consensuses and Spearman’s correlation coefficients to analyze the data. Results We found cultural consensuses on emergency physician professionalism in Millennials and Generation X overall, with respect for patients named the most important quality (eigenratio 5.94, negative competency 0%; eigenratio 3.87, negative competency 1.64%, respectively). There were consensuses on emergency physician professionalism in healthcare providers throughout all generations, but no consensuses were found across generations in the patient groups. Conclusions While younger generations and healthcare providers had consensuses on emergency physician professionalism, we found that patients had no consensuses on this matter. Medical professionalism curricula should be designed with an understanding of each generation’s values concerning professionalism. Future studies using qualitative methods across specialties, to assess definitions of medical professionalism in each generation, should be pursued.


Introduction
The rise of public dissatisfaction with physicians in general and the downward trend in positive perceptions of physicians' altruism create strained physician-patient relationships that in turn result in malpractice lawsuits. 1 Altruism is just one facet of professionalism, a skillset that has recently become a cornerstone of medicine and medical education. 2 A better understanding of professionalism may help reduce physician self-interest and corporate influence within medicine while improving patient trust, patient satisfaction and the patient-physician relationship as a whole. 3,4 Numerous efforts have been undertaken to improve the teaching of medical professionalism. The Accreditation Council for Graduate Medical Education named professionalism one of six core competencies, thus mandating all residency training programs to teach and evaluate professionalism. 5 Yet no single, universal definition of physician professionalism exists, instead, healthcare experts and educators have described professionalism using a number of behaviors and characteristics that include fidelity to patient trust, accountability, respect, compassion, integrity, sound ethics, altruism and truthfulness. 6,7 Previous studies identified concrete examples of physician behaviors that patients regard as professional, such as formally greeting patients with a handshake and taking notes while speaking to the patient. 8 There have been mixed results concerning the importance of wearing a white coat with regard to physician professionalism. 8,9 Individual backgrounds, cultures, socioeconomic status and age or generation affect how each person perceives medical professionalism. To date, emergency physician (EP) professionalism definitions are yet to be established.
The Silent Generation consists of individuals born from 1928 to 1945. This cohort is generally perceived as tending to work hard, not speak out, and conform to societal expectations. They were born during World War II and the Great Depression and reached adulthood in the comparatively prosperous 1950s and 1960s. 12 Baby Boomers are defined as the demographic cohort born from 1946 through 1964. Perhaps because these individuals were raised in a time of great social change and upheaval, they lean toward moderate and conservative viewpoints. 13 Baby Boomers are commonly viewed as competitive, dedicated and hardworking. They value individuality and loyalty to their jobs. 14 Generation X includes those born from 1965 to 1980, an era characterized by increased divorce rates. These individuals were often raised in single-parent homes and thus had less supervision and bonding time with their parents who were generally away working. This group was characterized as pessimistic and unsatisfied during their adolescent and young adult years. 15 Now in adulthood, they are described as a whole as being informal, independent, fun-loving, active and happy, and with an appreciation for work-life balance. 14,16 Millennials or Generation Y are those born from 1981 to 2000. Growing up, this group often had supportive "helicopter" parents who were closely, perhaps excessively, concerned with their children's success and well-being. This generation has been described as confident, socially sensitive, conventional, ambitious and achieving. 14,17 The values and characteristics associated with each generation of individuals may influence how they define and perceive medical professionalism. Literature that examines the link between generations and perceptions of medical professionalism is limited. Previous studies have explored how age can affect an individual's likelihood to consider certain behaviors as professional or unprofessional in healthcare settings. 18 Our study aims to identify the gap in the definition of EP professionalism (EPP) within and among generations. The primary objective of this study was to discover whether consensuses on the definition of EPP exist within and among the four different generations. Our secondary objective was to describe the most important characteristic related to EPP that each generation values.

Study design and setting
We conducted a cross-sectional survey study, using a cardsorting technique, at the EDs of two university-based medical centers in the United States (US). The study was conducted from February to November 2017. We included adults 18 years and older who were participants in the healthcare system, including ED patients, emergency medicine (EM) supervising physicians, EM residents, ED nurses and fourth-and second-year medical students. Only Englishspeaking participants were approached. We excluded participants who had alterations of consciousness, severe pain, HIV/AIDS and cancer, and those who were pregnant, under psychiatric hold, under police custody and/or handicapped. We also excluded participants who were unable to provide verbal consent. The institutional review boards of the University of California, both at the Irvine campus and the San Francisco at Fresno campus, approved the study under the Exempt Category 2, which entails the following: "interactions involving educational tests, survey, interview procedures, or observation of public behavior (including visual or auditory recording)." 19 We enrolled a total of 288 participants ( Table 1). The majority (70.49%) were Millennials, and predominantly female. Less than half of enrolled patients were Millennials, whereas more than three-fourths of healthcare providers were Millennials. Overall, we enrolled more female participants in the patient and healthcare provider combined group.

Study procedure and tool development
We reviewed available, published literature to identify 13 elements that potentially represent EPP. [20][21][22][23][24][25][26][27][28][29] For each element, we created three cards, using face validity from expert opinions, with each card describing a unique quality or behavior associated with the given element. We ensured the accuracy and uniformity of wording/interpretation of each card by testing the cards with EM supervising physicians, EM residents, medical students and patients. After the revisions were made, we piloted the instrument with 25 ED patients. After several iterations, we achieved a deck of 39 cards, with each card describing a quality or behavior related to EPP (Appendix). After participants verbally consented to participate, research associates asked them to independently rank all 39 cards from the most important behavior to the least important behavior contributing to EPP. They did this in a private room, without interference from the research team. Participants also completed a demographics survey, which consisted of gender, age, race, and questions about their religious affiliation. Study participants were also given the opportunity to describe an unprofessional encounter they may have experienced with a physician. We recorded all data in the secure Research Electronic Data Capture software, which is designed to store and manage online surveys and databases.

Data analysis
To obtain a 0.5 competency (0.25 agreement based on averaged Pearson correlation coefficients) and 95% validity, we needed at least 28 participants in each cohort.30 Descriptive statistics for participant demographics were provided. We used the quantitative cultural consensus method to examine the existence of a shared cultural model and to determine the aggregated rankings within each cohort. 30 The cultural consensus method is a statistical model that evaluates the degree of agreement within groups and estimates the 'culturally shared' belief where the answer was previously unknown. We used factor analysis of respondents, using minimum-residual algorithm (no rotation), to assess the degree of agreement within one cohort and obtain the individual-level competency scores. The method assumes that there is only a single factor solution. The ratio between the first and second eigenratios (E) indicate whether there is only a single shared dimension in the data. E 3 to 1 or greater indicates a shared cultural idea within the cohort. Competency levels for each individual were estimated as the first-factor loading from the factor analysis. A higher average competency score indicates a higher within-cohort consensus level. Negative competency (NC) scores indicate the presence of more than one sub-cultural group. Less than 5% NC scores were considered acceptable in each cohort. If the above two criteria were met, aggregated rankings of the cohort were estimated as the first set of factor scores. Finally, Spearman's correlation coefficient was used to examine the aggregated ranking between cohorts. We used SAS version 9.4 to conduct all data analyses (SAS Institute Inc 2013. SAS/ACCESS® 9.4 Cary, NC).

Results
The data showed consensuses on EPP in Millennials and Generation X when analyzing both healthcare providers and patients as one group (E 5.94, NC 0%; E 3.87, NC 1.64%, respectively), see Table 2. The Millennials showed higher consensus (average competency score = 0.59), followed by Generation X (average competency score = 0.53). Combining patients and healthcare providers in one group, Millennials and Generation X both ranked respect for patients as the most important quality. Being trustworthy and dependable and compassionate patient care were ranked in the top five for both generations. In contrast, complete medical records on time, adhere to doctor's religious and moral values, appropriate grooming, professional attire and wearing a white coat were ranked as the five least important qualities for EPP in all three cohorts (Table 3).  These two generations (Millennials and Generation X for the patient and healthcare provider combined group) showed a high correlation in aggregated ranking (0.998), see Table 4. In the Baby Boomers and Silent Generation group, however, no consensus was appreciable (E 2.34). When analysing healthcare providers and patients separately, we found significant consensuses on EPP in healthcare providers throughout all generations (Millennial: E 6.72, Generation X: E 4.23, Baby Boomers/Silent Generation: E 3.39; All NC: 0%). Millennials expressed the highest level of consensus, with a mean competency score of 0.62, while the average competency scores of Generation X and Baby Boomers/Silent Generation were slightly lower at 0.57 and 0.54, respectively (Table 2). In addition, correlations of aggregated rankings are high among the three cohorts (greater than 0.95), see Table 4. In the healthcare provider group, Millennials ranked respect for patients, whereas Generation X and Baby Boomers/Silent Generation ranked being trustworthy and dependable, as the most important quality for EPP. The five least important qualities were similar in Millennials and Generation X, as compared to the combined patient and healthcare providers group. However, the Baby Boomers/Silent Generation generations considered adhere to doctor's religious and moral values more important in contrast to the other two health care provider generation groups (Table 3). In the patient groups, no consensuses on EPP were found within any generation (Table 2).

Discussion
In an attempt to define EPP, we were unable to demonstrate consensuses on the definition of EPP across all participants and generations. However, we were able to establish a greater understanding of the perceptions concerning EPP according to age and generations. Millennials tend to agree on what they value as professionalism whereas the other generations are still in controversy. If we only focus on which quality each generation considered to be the most important for EPP, Millennial providers valued respect whereas other generations valued trust and dependability. Given that today's healthcare providers come from all four generations, these generational differences can give rise to conflicts in the workplace. 31 In terms of patient care, the majority of healthcare providers in Generation X felt that being trustworthy and dependable are critical components of professionalism. While Generation X providers form their practice style to be trustworthy and dependable, patients from older and younger generations, non-consensually, seek other qualities, i.e., compassion, kindness and respect in their care. While these are all important components of professionalism, an unawareness of the differences in perceptions of EPP among generations may result in misinterpretations of patients and job dissatisfaction in providers. Our findings emphasize that generational differences in the perceptions of EPP exist and health care providers should be cognizant about these differences when treating patients. Understanding the patient's perspective will aid healthcare providers in building rapport and trust, eventually leading to more positive clinical outcomes. 32 Interestingly, we found that Millennials and Generation X share the same important value, respect for patients, although these two generations view respect differently. Older populations may not appreciate the equal respect and wish to be treated with more respect compared to others. In contrast, Millennials believe that respect must be earned and not simply given because of seniority status. 33 Previous studies have indicated differences in the perception of professionalism in patients of different age groups. 34 One study examined the perception of professionalism in medical students, residents and supervising physicians and found that each group ranked and valued professional behaviors differently, suggesting a generational influence on the perception of professionalism. 35 Literature examining how patients rank different behaviors related to physician professionalism is limited. We did not find consensuses on EPP among patients, regardless of their generations. However, we recognized a general trend in which patients from the Millennial, Generation X and Baby Boomer/Silent Generation groups ranked respect for patient, compassionate patient care and kindness, respectively, as the most important values for EPP (although these were not statistically supported consensuses). This serves as a reminder that each individual is unique and should be treated, as deemed appropriate, differently. Patients' personal experiences shape and will continue to change their perspectives of physician professionalism.
Results from Wiggins and colleagues demonstrated that patients consistently ranked behaviors related to communications skills as very important, and actions such as handwashing as less important. Behaviors related to physician demeanor, such as putting the patient at ease, were ranked as intermediate. 36 All generations in our study ranked physician appearance, including wearing a white coat, professional attire and appropriate grooming, as the least important qualities of EPP. This finding contradicts what has been taught and is expected from medical students during their training years. Perhaps less emphasis on students' appearance and more focus on their ability to show respect and humanism will be the future of professionalism-centred curricula.

Limitations
Our study has specific limitations that must be addressed. First, we have small sample sizes in certain participant groups, particularly in the Baby Boomer/Silent Generation groups. These smaller sample sizes may be a reason for nonconsensuses in these groups. Larger sample sizes are needed to determine significant consensuses in certain subgroups. Secondly, asking a participant to rank 39 cards could possibly be overwhelming, although an expert in the card-sorting technique suggests that participant's attention drops after ranking more than 40 cards. 37 Finally, we would need data from more than one region to represent the US as a whole, and for the results to be generalizable and well-represented.

Conclusions
Our study demonstrated that differences in perceptions of EPP do in fact exist among generations in this sample. More often, we see that health care providers share the same values and beliefs, but patients do not have uniform consensuses on the qualities of physician professionalism. Healthcare providers should be aware of this lack of consensus and customize their healthcare delivery to each individual patient. Medical professionalism curricula and evaluations should be designed with an understanding of generational differences in values of professionalism. Future studies using qualitative methods to assess the definition of medical professionalism, in each generation, should be pursued. Professionalism studies across various specialties are also warranted.