Professionalism and the Heisenberg uncertainty principle

Within medical education, discussions of professionalism are becoming more complex and simultaneously garnering increased attention (Arnold, 2002; Boon and Turner, 2004; Kao, Lim, Spevick, and Barzansky, 2003; Klein et al., 2003; Ludmerer, 1999; Lynch, Surdyk, and Eiser, 2004; Smith, 2005; Swick, Szenas, Danoff, and Whitcomb, 1999; Swick, 2000; Veloski, Fields, Boex, and Blank, 2005). At the same time, concerns about physician's professional behaviors (Relman, 1998; Morrison and Wickersham, 1998; Kohn, Corrigan, and Donaldson, 2000; Institute of Medicine Committee on Quality of Health Care in America, 2001) are resulting in mandates to assure competency in professionalism (ABIM, 2002; ACGME, 1999; AAMC, 1998). It is in this educational milieu that we must reflect on our approaches to measuring professionalism and the implications of those measurements for students, faculty and patients. The uncertainty principle, which Werner Heisenberg elaborated in 1927, is proposed as a focal point for such reflection. The Heisenberg Uncertainty Principle is "usually stated in the form: δxδpx >= h/4πi, where δx is the uncertainty in the x-coordinate of the particle, Apx is the uncertainty in the x-component of the particle's momentum, and h is the Planck constant" (Isaacs, 2000). Alternatively, in non-mathematical terms, it states that "the more precisely the position is determined, the less precisely the momentum is known in this instant, and vice versa" (American Institute of Physics, 2005). Apart from the fact that the professionalism movement is gaining momentum, how can this principle be of any relevance to current discourse on the role of professionalism in medical education? Many people view the Heisenberg Uncertainty Principle as implying that the act of making a measurement alters the system being measured. Although this view is erroneous from the standpoint of quantum mechanics (Styer, 1996), measurements of professionalism within medical education may be context dependent (Arnold, 2002; Epstein and Hundert, 2002; Fochtmann, 2004; Ginsburg et al, 2000; Hundert, Douglas-Steele, and Bickel, 1996; Swick et al., 1999) or modified by the knowledge that professional behavior is being rated (Holden, 2001; Rees and Shepherd, 2005). Position and momentum, like the specific elements of professionalism, may appear to be discrete and absolute entities. However, in actuality, "the position or momentum of a particle in quantum mechanics is not characterized by a single number, but rather by a continuous function" (Zaarur and Pnini, 1998, p. 58). By the same token, our conceptualizations of professionalism may appear to represent distinct categorical ideals, but in clinical practice these traits are more gradated and impossible to define in absolute terms (Boon et al., 2004; Epstein et al., 2002; Fochtmann, 2004; Ginsburg et al., 2000; Swick, 2000; Van De Camp, Vernooij-Dassen, Grol, and Bottema, 2004). Finally, as the preceding paragraph demonstrates, an emphasis on the detailed mathematics of a particular concept or its measurement can sometimes distract from rather than illuminate its importance to the field as a whole. Such may also be true of our current fixation on measuring professionalism competency in medical education. Few would question the importance of professional standards of behavior in maintaining the ethical ideals of the medical profession or in fulfilling obligations to patients. In recent years, however, changes in the structure of the health care system and in the delivery of clinical care have been paralleled by changes in physician-patient relationships (ABIM, 2002; Arnold, 2002; Berkman, Wynia, and Churchill, 2004; Castellani and Wear, 2000; Emanuel, Cruess, Cruess, and Hauser, 2002; Ludmerer, 1999; Lundberg, 1991; Relman, 1998; Smith, 2005; Stephenson, Higgs, and Sugarman, 2001; Van Eaton, Horvath, and Pellegrini, 2005). Traditional conceptualizations of professionalism have become more complex. At the same time, concerns about declines in professionalism have been raised in general terms and in association with reports of misconduct by individual physicians (Institute of Medicine Committee on Quality of Health Care in America, 2001; Boon et al., 2004; Kohn et al., 2000; Morrison et al., 1998; Papadakis, Hodgson, Teherani, and Kohatsu, 2004; Relman, 1998; Stern, Frohna, and Gruppen, 2005). In response, professional organizations have delineated more formal standards of professionalism (ABIM, 2002) and credentialing bodies such as the Accreditation Council for Graduate Medical Education (ACGME) and the Liaison Committee on Medical Education (LCME) have placed an increasing emphasis on the teaching and evaluation of professionalism in all phases of medical education. At face value, it seems entirely reasonable to increase attention to and evaluation of professional behaviors in medical education. Unfortunately, the actual implementation of such initiatives has been less straightforward and has potential pitfalls as well as benefits.