Preventing incremental drift away from professionalism in graduate medical education.

Professionalism is a core competency of graduate medical education programs, stipulated by the Accreditation Council for Graduate Medical Education. We identify an underappreciated challenge to professionalism in residency training, the risk of incremental drift from professionalism, and a preventive ethics response, which can occur in residency programs in countries with oversight similar to that of the Accreditation Council for Graduate Medical Education. Two major, welcome changes in graduate medical education-required duty hours and increased attending supervision-create incentives for drift from professionalism. This article analyzes these incentives based on the ethical concept of medicine as a profession, introduced into the history of medical ethics in late 18th century Britain. This concept calls for physicians to make 3 commitments: to scientific and clinical competence; to the protection and promotion of the patient's health-related interests; and to keeping individual and group self-interest systematically secondary. Some responses of programs and residents to these incentives can undermine professionalism, creating a subtle and therefore hard-to-detect drift away from professionalism that in its worst form results in infantilization of residents. Program directors and educators should prevent this drift from professionalism by implementing practices that promote professionally responsible responses to the incentives created by required duty hours and increased attending supervision.