The Use of "Professionalism" as a Tool for Control

How professionalism in medicine is used to challenge who you are rather than how you care for others

Last week, I was reading a note from

Dr. Amber Hull

. She was discussing the process of finding her voice and how medical training “demands compliance and a silencing of defiance”. This week, she also wrote about her experiences questioning the foundations of medicine, specifically with regards to mental health, and how in doing so, she had been “threatened with “professionalism violation”, verbally accosted in front of my peers and quietly told to stay in line or else risk my future.” I applaud her because I know she must face many unjustified criticisms about her professionalism. She has the nerve to question the status quo and dogma of medicine and to talk publicly about sex, a topic that is important to a substantial proportion of her patients and a topic that most people could use reliable guidance on at one or more times in their lives. 

You may find it noteworthy that talking (or not talking) about sex is not on the list of professional responsibilities as defined by a physician charter on professionalism. Instead, it includes: 

• Commitment to professional competence

• Commitment to honesty with patients

• Commitment to patient confidentiality

• Commitment to maintaining appropriate relations with patients

• Commitment to improving quality of care

• Commitment to improving access to care

• Commitment to a just distribution of finite resources

• Commitment to scientific knowledge

• Commitment to professional responsibilities

I don’t think I’ve ever been called unprofessional for behavior related to direct patient care, or at least they don’t stick with me because they seem legitimate. Discussing professionalism with Dr. Hull got me thinking about the ridiculous reasons some of my colleagues and I were called unprofessional.

When I asked

Nessa Meshkaty, MD

about her experiences with being called unprofessional, she said, “If unprofessional means counterculture, that was me every second.” Most of her experiences with being called unprofessional were related to trying to advocate for patients with hospital administration. However, many reasons for calling someone unprofessional are much more superficial than that.

Mine was probably the least egregious amongst them. I was called unprofessional because I did not keep up with submitting my duty hours through a very clunky website. In my defense, my employer could have just had us swipe badges like every other employee in the hospital did, but they decided not to ask questions they didn’t want to know the answers to, and instead hoped we would fudge the numbers on said website. Also, residency is a time where you have to be a very keen manager about how many f***s you have to give, and given the choice between giving f***s about patients or my duty hours, it seemed like an easy choice. The powers that be would argue that you can care about both patients and duty hours, but asking an overwhelmed person to respond to each new task with, “Thank you, sir, may I have another,” is unhealthy and unfair. Honestly, I think that expectations that we are superhuman are, in fact, dehumanizing. 

There was one friend who was called unprofessional because she wore her hair down on shift, even though she put her hair up before performing any procedures. Another friend was called unprofessional as a medical student because her pant legs were frayed because she is short and she stepped on them. Nevermind that medical students have neither the time nor the money to find a seamstress for their clothes and that she had a 6 month old at home, so clearly had better things to do than worry about her pants. Another friend had strong feelings about the ethics of how clothes are made (rightly so), so she bought her work clothes from Goodwill. Those kind of clothes standout against the standard J. Crew wardrobe of medical students, but you will notice they have absolutely nothing to do with the principles above. In fact, there are probably large swaths of the population who feel more comfortable with her in that wardrobe than in the Standard Professional Uniform of doctors. One friend noted that anything that is not traditionally masculine is perceived as unprofessional because it’s outside the norm. “Nails, makeup, clothes, it’s all loaded. Business casual has a uniform for men, but women are too busty, too revealing, or too tight, etc.” 

“Professionalism” is also used as a cudgel if you have anyone outside of the hospital that depends on you. One friend told me:

I was told I was unprofessional for objecting to [filling in for a sick colleague]. I had missed half a day of clinic in second year (so was expected to make up the time). I had requested one week off in all of residency because my husband was going out of the country for work and I had no childcare. This is the only time in med school or residency that I’d ever asked off for childcare. My husband stayed home every sick day, every school closure, everything. 

They put me on a Saturday overnight call [during that week I had asked off], and told me it was unprofessional when I objected. I ended up begging my daughter’s friend’s parents to watch her. This was after they had already told me that I had been given that week off and they changed it with very little notice.  

Many of these incidents, particularly those regarding appearance may seem small, but they are shaming and convey the message that you don’t belong here as you are. Even the British Medical Journal, has noted that professionalism is frequently used as a tool to mask racist, sexist, and other discriminatory beliefs, including telling students that their queer identity or gender expression was “unprofessional”. So, it’s not just change how you look (which has little to nothing to do with professionalism anyway), but often change who you are. The impact of being called unprofessional can be long-standing. It often amounts to public shaming and can leave people feeling confused, lonely, embarrassed, and scared. 

This misapplication of “professionalism” is a tool for control. Labeling someone as unprofessional, especially in the context of medical school and residency limits future opportunities for the learner. Ambitious and motivated as medical students and residents are, threats to future opportunity, whether they are real or perceived, have a real influence on behavior. Use of professionalism is a way to shame you for being different, in an attempt to coerce you to act the same. It is an attempt to silence the squeaky wheel, and an attempt to gaslight you so you start to question if what matters to you should really matter to you. 

Historically, the healers in a culture–druids, medicine people, shamans, every culture had its word, except our modern Western culture, were not just one thing. As Martha Beck notes in her book Finding Your Way in a Wild New World, these healers filled the roles of, “mystic, doctor, therapist, artist, herbalist, naturalist, and storyteller.” We’re not meant to be one thing. We’re meant to use intuition, radical listening, and our very essences to heal. Who are they to tell us that who we are is “wrong” and that the things that matter don’t matter?  

Late Summer Shaman