ProfessionnalFormation.org (PFO) is a resource that we hope will help guide you on your journey to becoming a professional.

All healthcare professional organizations have defined the elements of being a professional, and most of these definitions are similar. They emphasize putting the patient first, respecting patients' autonomy, commitments to excellence, caring, altruism, honesty, confidentiality and more. Yet once you graduate and enter practice or postgraduate training, you are not automatically a professional. You can act professionally according to the guidelines of your discipline, which is what the leaders of your discipline, the public, and especially your patients, expect. But the question we hope you will answer for yourself in your training is "how do I become the kind of person who is a professional?" The authors of the modules in PFO have many years of experience in helping students grow personally and professionally. They have been reflective about what has promoted their own growth. We believe that, in working through the content and exercises in PFO, you will become more aware of your own learning edges, and create for yourself intentional practices that will help you become the professional that you wish to be.

The tasks of personal and professional growth are difficult. Perhaps you are aware of the core values that guide you, but realize that you don't always act in ways that are consistent with those values, especially when stressed. Your profession expects you to behave in ways that, at times, seem almost superhuman. You are called on to be eternally patient, understanding, empathic, knowledgeable and level-headed in very challenging circumstances. You strive to respect patients' autonomy when they make decisions contrary to what you think is right. You have to subvert your own interests to the best interest of your patients, even when doing so might be detrimental to you. You have to be non-judgmental and compassionate even with patients of whose behaviors you disapprove. You must believe in the possibilities of redemption and healing even in patients, such as repeat substance abusers, whom you consider hopeless cases.

You are discovering and creating who you are and what you can contribute to the world. It can be difficult to transition from being competitive to being a supportive member of a community or team, and to make the transition from primary self-interest to thinking of your patients first. The work habits that have enabled you to be successful so far may not work as well as you continue to face learning a seemingly impossible amount of information, and encounter human suffering you have never before seen. The great majority of students overcome the challenges, but many embrace excellence in knowledge and skills at the expense of developing their abilities for empathy and compassion. Many succumb to the gratifications of overwork and success at the cost of their own emotional development and well-being. Some become detached from the core values that previously inspired them.

The authors of PFO don't want this to happen to you. We want you to become a professional in the true sense – a person who is professional because that is who you are – knowledgeable, skilled, capable of empathy and compassion, honest, altruistic, patient, mature, thoughtful, reflective and so much more.

In recent years, healthcare leaders have worried that their professions are in jeopardy. There have been radical changes in healthcare delivery, technology and public attitudes. These changes include the corporatization of healthcare delivery, a perceived emphasis on quantity over quality of care, high levels of burnout among health professionals, consumerism, universal access to medical information and advice, publicity about medical errors, and failures to self-regulate our professions and individual practitioners.

As a reaction to these changes, educational leaders have fashioned statements about the values, principles and commitments that define us as healthcare professionals. There have been numerous calls for programs in healthcare training that emphasize professional development and assessment..

One helpful statement emerged from a working conference cosponsored by the Association of American Medical Colleges (AAMC) and the National Board of Medical Examiners: The qualities of the good physician in this formulation were captured in eight categories: (1) altruism, (2) responsibility and accountability, (3) excellence and scholarship, (4) respect, (5) honor and integrity, (6) caring/compassion/communication, (7) leadership, and (8) knowledge and skills (NBME 2003).

Similarly, the leaders of medical professional societies have issued statements on the elements of professionalism. Perhaps the most widely cited is the Professionalism Charter, created by the leadership of the American Board of Internal Medicine, the American College of Physicians, The American Society of Internal Medicine and the European Federation of Internal Medicine (ABIM 2002).

This statement asserts that a medical professional adheres to certain principles and commitments. In summary, these are:

Principles: primacy of patient welfare, patient autonomy, social justice

Commitments:

Professional competence Professional responsibilities Patient confidentiality Improving quality of care Appropriate relationships

Scientific knowledge Managing conflicts of interests Honesty with patients Improving access to care Just distribution of finite resources

The nursing profession has not had the same level of ferment and debate about professionalism as in medicine. The American Nurses Association Standards of Professional Performance describe a competent level of behavior in the professional role, including activities related to quality of practice, education, professional practice evaluation, collegiality, collaboration, ethics, research, resource utilization, and leadership. Registered nurses are accountable for their professional actions to themselves, their patients, their peers, and ultimately to society. (Fowler 2015 a) Nursing has instead focused on their code of ethics, which embodies many of the elements of professionalism above. (Fowler 2015b, ANA Code of Ethics )

Societies representing various disciplines have elaborated on the elements of professionalism their practitioners must uphold.  These statements can be found at the following links:

• Physician Assistants
  https://prodcmsstoragesa.blob.core.windows.net/uploads/files/PACompetencies.pdf
• Physical Therapy
  http://www.apta.org/Professionalism/
• Pharmacists https://www.aacp.org/sites/default/files/oathofapharmacist2008-09.pdf
• Social Work https://cswe.org/getattachment/Accreditation/Accreditation-Process/2015-EPAS/2015EPAS_Web_FINAL.pdf.aspx

Howard Brody and David Doukas have simplified the concept of professionalism by asserting that basically it has two elements:

• Professionalism is a trust-generating promise (representing commitment to patients` interests, more than a mere business, a social contract, a public and collective promise, and hard work).
• Professionalism is application of virtue to practice (based on virtue, deeper attitudes rather than mere behavior, and requiring of practical wisdom). (Brody 2014)

The AAMC Group on Educational Affairs described components of professionalism (Inui 2003), that we believe are relevant to all healthcare professions:

Whatever the definition of professionalism that is endorsed by your healthcare profession, it takes learning and personal growth along the way to becoming a professional. We have asked several students and one faculty member to comment on some of what they have learned that has contributed to their professional development. (Also see Appendix 1)

Elizabeth Kern, third year medical student

Stacy Karle, final year nurse practitioner student

Lily Feldman, second year physician assistant student

Nina Multak, PA, PhD faculty member

Professional formation is the process by which one grows into becoming a professional. This process involves external influences on your attitudes and behaviors, including your school's formal and informal education in professionalism, as well as socio-cultural expectations and media depictions of ideal healthcare practitioners. There is an equally important internal process, consisting of your constant reflection, growing self-awareness and intentional practices to promote your personal growth. There is a third process that is critical to your development: attention to your personal well-being.

Most healthcare education and training programs explicitly address professionalism. Faculty discuss the values and behaviors of the ideal professional in their respective fields. There are white coat ceremonies, sessions explaining and requiring commitment to an honor code, formal courses in ethics (PFO Module 2), small group discussions to deal with and support each other through difficult challenges, aspects of history taking / counseling and communication coursework that highlight professional behaviors, interprofessional education sessions and more. Competencies in basic and advanced communication skills - such as communication of empathy, working with difficult patients/clients, responding to errors and giving bad news - depend on the professionalism of the healthcare professional. Our sister resource, DocCom , presents 42 modules on communication competencies. Ideally, your institution has created a culture in which faculty and staff are role models for professionalism. There is an emerging consensus on the content of professionalism education, represented by the modules in PFO. All of these coursework and activities comprise the formal curriculum, designed and taught by healthcare educators.

There is also an informal or “hidden” curriculum represented by institutional culture, the attitudes and behaviors of leadership and role models, which in many cases do not represent the values and behaviors taught in the formal curriculum. This hidden curriculum can be corrosive to professional development. Its negative effects can be counteracted if students hold firm to their core values, reflect on what they are seeing, have an opportunity to discuss their impressions with peers and faculty, and make decisions about their own behaviors and attitudes. The hidden curriculum is discussed in detail in PFO Module 3.

There is no doubt, though, that the process of clinical education affects and can change students. Tom Inui, in his 2003 treatise on medical professionalism for the Association of American Medical Colleges, wrote about medical students:

“As they move through their undergraduate medical education experience, our students also move from being open-minded to being fact-surfeited, from being intellectually curious to being increasingly focused on just that set of knowledge and skills that must be acquired to pass examinations, from being open-hearted and empathetic to being emotionally well-defended, from idealistic to cynical about medicine, medical practice, and the life of medicine” (Inui, 2003).

While it may not be this stark in all health professions schools, the cognitive and emotional demands of health professions education can wear you down. How can you accomplish the personal and professional growth necessary to become the professional you want to be?

There are several components of your personal development relevant to professional formation. There is an aspirational element, in which you accept and commit yourself to behaving in accordance with the values and behaviors expected of your profession. You must also examine your own core virtues and values, align your behaviors with them, and gradually merge these values with the values of your profession. In PFO Module 3 you will have an opportunity to explore your values and how they may guide your professional growth. Also, the PFO dashboard, which contains assessments and scales, keeps you aware of how your actions are consistent with your values. You must understand your character strengths, and work on developing them for the benefit of your profession and those you serve.

Your journey to become a professional begins when you profess your commitment to the core values, attitudes and ideal behaviors of your profession. As mentioned earlier, this may start with a white coat or other ceremony, in which you pledge, on your honor, to uphold the ideals of your profession. This can be difficult as you confront many challenges in your training and early work life. We know that sometimes trainees and clinicians don’t always keep their commitments to their professed values. There are a number of studies that describe widespread unprofessional behaviors by a variety of healthcare professionals, including faculty, students and staff. These behaviors have contributed to medical errors, unsafe working environments and high levels of cynicism and burnout (Feudtner, 1994; Christakis, 1993; Reddy, 2007; Campbell, 2007; Rosenstein, 2005).

Furthermore, unprofessional behaviors in superiors and peers can lead to ethical erosion in trainees. In one study, third-year medical students anonymously reported observation, participation in and perceptions of 27 unprofessional behaviors before and five months after clerkships. Student observation of (21 of 27) and participation in (17 of 27) unprofessional behaviors increased (P<.05). Students perceived unprofessional behaviors as increasingly appropriate (P<.05 for six behaviors). Participation in unprofessional behaviors was associated with diminished likelihood of perceiving a behavior as unprofessional (P<.05 for nine behaviors) (Reddy, 2007).

After you commit to the ideals of your profession, you can be intentional about growing personally and professionally. This involves reflecting on how your behaviors express your core values and choosing actions that conform to those values and the values of your profession. You must choose your role models carefully and admit when you make mistakes and learn from them. There are many goals to achieve. We outline some of these in the next section.

We reflect on our thoughts and actions in order to do better and to grow. Our reflections are based on how well our behaviors express our deeply held values, our aspirations, and our desire for acceptance and recognition of our peers and teachers. There are many areas of our complex selves of which we can become more aware, and self-awareness can help us make more informed and wiser choices. Many schools are now focusing on self-awareness and personal growth activities in their ethics, humanities and professionalism courses. (Novack, 1999) As with any educational activity, defined goals and objectives guide the way and help you know whether you are making good progress. We suggest the following, and will comment briefly on each. I will occasionally include brief examples from my own professional development.

Overall goals:

• Students should be aware of how their personal histories and current personal lives, values, attitudes and biases affect the care of patients, and should be able to use awareness of their emotional responses in patient care for their patients' benefit.
• Students should care for themselves physically and emotionally.

Objectives: In order to grow personally in the service of becoming a healthcare professional, students must learn to:

1. explain the virtues that guide their interactions with patients and colleagues, providing concrete examples;
2. discuss how their own character strengths and limitations, emotional triggers, attitudes and ways of thinking affect their relationships with patients/clients and colleagues;
3. navigate the balance between objectifying and over-identifying with patients/clients;
4. confront their fears of death and become comfortable giving bad news and talking with dying patients and their families; 
5. move from self-centeredness to patient-centeredness;
6. cultivate their commitment to social justice in thought and action;
7. become confident in what they know and don't know, admit when they don't know and ask for help;
8. learn from mistakes through reflection and discussion with others;
9. become helpful members and leaders of teams;
10. grow in their moral development;
11. enhance their capacity for empathy and compassion, and skills in communicating those;
12. develop emotional intelligence and emotional regulation;
13. balance self-criticism with self-acceptance and gratitude;
14. develop their moral courage;
15. maintain their well-being so they can be present for their patients/clients and colleagues.

Through the ages, philosophers and religious leaders have promoted many virtues that, if practiced, assure successful relationships between individuals and in communities. As we have seen above, Doukas and Brody define professionalism as virtue in action. Among these virtues are wisdom, love, respect, moderation, patience, courage, humility, mindfulness, acceptance, gratitude, altruism, justice, tolerance and forgiveness (https://en.wikipedia.org/wiki/Virtue, Seligman 2002)  Which virtues guide you?  How successful are you in practicing these virtues?  The virtue/concordance scales in the PFO dashboard can help you reflect on these questions over time.

There is wide variation among us in our acceptance of and abilities to practice these virtues. Some of us hold onto resentments, which do no harm to the people we resent but can undermine our well-being. We often have to work at enhancing our abilities to practice core virtues. For example, forgiveness helps us let go of resentments and move on to more productive relationships. Tolerance and acceptance helps us work with patients, of whose behaviors we disapprove. Gratitude helps us balance our self-criticism, and appreciate the many gifts that we have. We can become aware of our virtues and how well developed they are or are not, and with self-reflection and discussion with others, develop our capacities to practice them.

We all create our worlds in unique ways. Our values, attitudes, biases, past experiences and emotions shape how we take in information and react to the world. When we meet new people we immediately make judgments and assumptions that may be proven wrong, but that nevertheless shape how we interact with these people. We often have unconscious biases that affect our behaviors. You can learn about your unconscious biases by taking various Implicit Association Tests (IATs) https://implicit.harvard.edu/implicit/ . Untested assumptions or biases interfere with history taking, counseling and therapeutic relationships. Patients/clients are much more likely to be adherent to medical advice if they trust the clinician and feel understood as a "whole person" (Safran, 1998). The most effective health professionals are reflective, examining their assumptions and biases in the moment, and can put them aside in the service of truly understanding a patient or client.

We all have character strengths that sustain us and help us be successful. We may be conscientious, generous, optimistic and empathic. Seligman asserts that if we use and develop our signature strengths, we will be more effective and satisfied with our work. (Seligman 2002) You can explore your personal character strengths at http://www.viacharacter.org/www/Character-Strengths-Survey)

We may have other qualities that get in the way of our being successful, such as procrastination or being judgmental. We all have emotional triggers, or "hot buttons" that are generally connected to fears and insecurities left over from our childhoods, such as "I'm not loveable enough," or I'm not good enough."  Our loved ones push our buttons most easily, but patients or clients, colleagues and supervisors may easily push those buttons as well – "You look too young to know anything about this!"  "Are you sure you know what you're doing?" etc. A component of personal growth is to disconnect those hot buttons, and to learn to not take things personally. Instead of reacting in anger at a slight, a mature clinician will engage empathy, knowing that others are speaking out of their own insecurities, or fear, depression, anxiety, or sometimes love. 

Our insecurities, and negative emotional states, often engender certain psychological defenses, and lead us to a need to be right, righteous, stubborn, pessimistic while blaming others, feeling powerless or feeling like a victim, and more. For example, trainees and clinicians may be tribal in their communication, disparaging ER clinicians, or other services (see PFO Module 3), or sometimes house staff have been heard to ask, "how many hits did you get last night?" joining with each other in feeling the burden of the work of admitting too many sick patients. Hopefully, you can see how your attitudes can shape your world view, and your relationships with others. Talking with colleagues about these feelings can often be therapeutic, since most trainees go through the same feelings and reactions as you. The notion of choice is key. You don't have to react reflexively to challenges.  You can choose to react in different, more adaptive ways.

Similarly, our ways of thinking can alter our perceptions and behaviors.  David Burns identified common forms of "twisted thinking" or cognitive distortions that can undermine our well-being and relationships with others, and proposed strategies for "untwisting" these cognitive distortions. (Burns, 1989) See also https://psychcentral.com/blog/10-forms-of-twisted-thinking/

Over the course of your professional life, you will have many opportunities to reflect on and discuss with others how your character strengths, emotional triggers and attitudes and ways of thinking can affect your patients and colleagues. Your growing self-awareness can help guide your personal and professional development.

There is a constant tension between objectivity and subjectivity in your growing professional identity. On the one hand, you learn many facts about human physiology, anatomy, biochemistry, pathology, etc., that can aid in your understanding of diseases. Healthcare students who dissect cadavers may find that dissection starts them on the road to objectifying patients, as the human body becomes separate from the person who inhabited it. On the other hand, you are taught to understand patients/clients as whole human beings within a biopsychosocial model of care. You learn to identify the pathophysiology and technical approaches to diseases, and also learn that people present with illnesses – their subjective responses to a sense of dis-ease. Patients' illnesses are comprised of their hopes, fears and concerns, and their symptoms are modified by their experiences, personalities and cultural expectations of “normal” illness behaviors. You are taught to understand suffering and to offer empathy and compassion.

To make rational decisions about diagnosis and therapy, you must be dispassionate. Being your own doctor or taking care of friends and family members can be dangerous, because your feelings will undermine your rationality. Similarly, if you too closely identify with a patient/client or sympathize too much, you could impair your decision-making. However, objectifying people and retreating into pure rationality risks emotional withdrawal and perceptions that you are "cold." Patients/clients need to feel that their healthcare providers care for them, are interested in them as people and have their best interests at heart. It is not always easy to navigate this balance between objectivity and subjectivity, but you must master it, so that you can be present for your those in your care. You must be able to offer empathy and compassion while remaining objective. Reflection and discussion with your peers and mentors can be helpful. PFO Module 8 discusses boundary settings in clinical care, which covers this issue in detail.

We all fear death. Fears of death can have myriad negative consequences in clinical care. It can lead to avoidance of necessary conversations about end-of-life issues and result in many miscommunications between caregiver and patient/client. It can lead to clinicians continuing to treat patients aggresively at the end of their lives without getting adequate input from them or their families. It can lead to patients feeling isolated because their caregivers seem unavailable to talk about their deepest worries and concerns. There is a growing body of knowledge and skills that you can learn to help you confront your own fears of death and to be more present for your patients or clients. It can be useful to practice in role-play or with standardized patients the skills of giving bad news, conversations about goals of care, and about palliative and hospice care. If you feel reluctant to talk with a patient/client who has a life limiting illness, take a breath and go ahead anyway. Ask if they feel comfortable talking about it. People with severe illnesses often want to talk and appreciate your just being there to listen.

Exercise 8 below can help you begin to achieve some self-awareness about your fears and feelings related to mortality.

Most of us began our healthcare education as young people. We are only a few years out of our adolescence when self-centeredness is the norm. We are still insecure about many things, wonder how much we can contribute, and still discovering and creating our identities. We want to be successful and we want to be accepted and admired by our family, peers and teachers. When we are young, our self-esteem depends on other esteem, and we seek the approval of peers and faculty. Many of our worries and desires center on our personal quests to succeed. In addition, we may be defensive and self-righteous. Yet the paths to becoming a healthcare practitioner demand that we shed our self-centeredness and take on altruism and compassion, putting the interests of our patients and clients above our own. This is actually not an easy task, and there are many challenges along the way. For example, a supervising physician may direct medical students to do a pelvic exam on an anesthetized woman patient, and they are unsure that the patient has given consent. They know that it would be a good learning experience, but worry about a lack of consent. Should they challenge the attending? How do they prioritize the patient's best interest as they go through various rotations?

I learned about putting the patient first in an instant. I was a beginning third-year student on my 1st rotation in surgery. It was 1970. The Vietnam War was still raging and I was a bit of a "hippy" with hair down to my shoulders. As I began to walk towards the operating suite to which I was assigned, one of my fellow students told me that I should switch out the cap I was wearing, with my hair flowing beneath it, with the kind of hood that was available that covered everything but my eyes. I looked into the operating suite and noticed that the surgeon had some hair showing underneath his cap and decided that what was good enough for the surgeon was good enough for me. Besides, I didn't want to look stupid. I went into the suite and was invited to hold a retractor. After a few moments, I noticed that the head nurse was gesticulating to me from the door and made motions indicating that I should put on the other hair covering. I simply smiled at her and shook my head "no." Clearly, she didn't want to make a scene and eventually left. The next day the clerkship director called me in to his office and told me that the chief of surgery was so angry with me that he wanted to "throw me out a window." If I did not go immediately and apologize to the head nurse, I would fail the rotation.

When I entered the office of the head nurse I was feeling righteous. I said that the surgeon had hair showing under his cap, and began to argue that students should be treated no differently. She simply cut me off and said, "suppose one of your hairs fell into the wound and caused an abscess, and suppose that the patient was your mother." I thought for a moment and said, "I'm sorry – you are right. I wasn't thinking. I won't do that again." I suddenly understood how my own self-centeredness could have harmed a patient.

The Physician Charter articulates social justice as a core principle of professionalism. "The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in healthcare, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category." (ABIM Foundation, 2002) Other disciplines also include social justice in their professionalism statements as well. In a country with widening income and health disparities based on social status, race, ethnicity, gender, gender identification and geography, there are many wrongs to be righted, and many health care professional students might ask, "what role do I need to play in all this?"

Most healthcare education is focused on taking care of individuals, yet even in the care of individuals, we make decisions that can affect all.  When we order unnecessary tests, or prescribe expensive medications when a generic will do, we contribute to healthcare expenses increasing for all. Individuals have often suffered from the misfortunes of their genetics, as well as poverty, violence and deprivation in their communities. Listening, understanding, empathizing, and accepting people as they are will help us relate to them and help them overcome their barriers to regaining health. Many trainees and clinicians volunteer in their communities, such as in clinics for the homeless. As an extension of our personal growth from self-centeredness to patient-centeredness, we extend our focus to the community of all. As caregivers and professionals, we are responsible for our patients/clients, but also have a responsibility to the health of our society. If you agree with this professional commitment, it requires attention to your capacity for altruism, compassion, and the giving up of certain biases and judgments. This commitment to social justice is covered well in Module 5.

If we know the limits of our knowledge and skills, we should be able to seek help without feeling embarrassed. There is a lot of pressure in clinical care to be knowledgeable. Some supervisors will grill students on rounds, asking many substantive questions, sometimes making belittling comments if a student doesn't know something. You might become afraid of admitting that you don't know something. This culture of needing to appear smart all the time can be very burdensome. Students may feel humiliated when they don't know a fact on rounds or in class. Trainees may feel embarrassed at their lack of knowledge and not ask for help, making decisions in care that they aren't sure are correct, or losing precious time while they try to look up the correct answer themselves. They may get away with this for a while, but this behavior can sometimes have disastrous consequences. Putting your patients’ best interests first will guide you to seek help when needed. If you don’t know something, admit that and promise to look it up, and teach the team about it later. Often your supervisors or peers are happy to help out, and when you are in a supervisory position, it will be important to encourage your team members to ask for help if they are uncertain about something. Moreover, if you don’t know something as a supervisor, admit that. It will be a good example for your trainees.

When I was a young attending physician, I had a heavy dose of the “imposter syndrome,” and sometimes when an intern asked a question on rounds and I didn’t know of the answer, I would turn to the senior resident on the team and ask what he or she thought. I would then add other information that I did know, and it would seem I knew all the senior resident knew and more. That worked for a while, but one time the senior resident gave me the wrong answer, and I didn’t figure that out until the next day by which time the patient had been transferred the ICU. The patient subsequently died. There were many factors in this patient’s death, and I don’t know if treating him 24 hours earlier would have saved him, but over 30 years later I still feel guilty about this. After that incident, I always said, “I don’t know” when I didn’t know something, and asked for a consult, or other appropriate follow-up.

We are all human; we all make mistakes. Ask any senior health care professional about the mistakes he or she has made, and you will find that there are often many. Fortunately, most of them were minor and did not harm patients, but some were tragic. Clinicians often feel guilty for many years after a mistake that harmed a patient, especially if they have not discussed the mistake with others. With a new emphasis on patient safety, healthcare systems are creating cultures and systems to help prevent errors and to respond appropriately to errors when they occur. Sometimes mistakes are only mistakes in hindsight.  There was an unexpected bad outcome, but most clinicians would have taken the same original course of action.

After publishing an article that discussed mistakes, I received a letter from a physician who told me about feeling guilty about a mistake he made as a medicine intern, over 25 years previously. Immediately after the adverse outcome back then, his resident had scolded him severely and told him he was incompetent.  Soon afterwards he switched to a psychiatry residency, feeling that he didn't have the skills to be an internal medicine physician. He never talked about that incident with anyone, until he wrote his letter to me.  I called him and went through the details of that mistake.  It turned out that he had made a reasonable decision at the time given the information he had, and that the resident had clearly overreacted. 

Sometimes errors occur because of hubris, inability to admit a deficit in knowledge or skills, distraction, lack of well-being, sloppiness, or other personal issues. Working on your self-awareness and personal growth can help prevent these kinds of errors. It is always important to admit when you've made a mistake, go through the appropriate institutional channels for reporting and admitting the mistake to the patient and family, and discuss with your colleagues so that you can learn. This topic is discussed in PFO Module 6, and in Exercise 8 below.

Healthcare is more and more delivered by teams. Patient centered medical homes (PCMH) depend on teams. PCMHs are a new model of primary healthcare delivery that are promoted and supported by insurance payers as one that helps achieve the Triple Aim of improved patient outcomes, improved patient experience and improved value.

PCMHs are based on the understanding that it is rare that a single healthcare provider has all the skills and knowledge necessary to effect maximal healing and wellness. Nurses, social workers, pharmacists, physical therapists and many others have critical contributions to make. While it is tempting to focus on becoming a hero, who makes a challenging diagnosis and selects an optimal treatment that cures a person with a life-threatening disease, this is too narrow a focus for delivering optimal care. As you go through your training, you begin to understand and appreciate the value and contributions of other team members, and learn to seek their help and trust their abilities. Sometimes you must do your part as a member of the healthcare team, and sometimes you are called to lead the team. In both roles, there are skills that enable you to function effectively. A component of your personal development is your growth in the social domain, becoming comfortable and confident in your communication with team members.  That communication is grounded in respect and trust. Interdisciplinary team care is covered in depth in PFO Module 7.

There are many scholars who have studied human development and some who have studied phases of moral development, including Kohlberg, Kegan, Ericson, Piaget, Maslow and others. Kohlberg identified six stages of moral development that can be more generally grouped into three levels of two stages each: pre-conventional, conventional and post-conventional (Kohlberg, 1971).

Level 1 (Pre-Conventional)
1. Obedience and punishment orientation
2. Self-interest orientation

Level 2 (Conventional)
3. Interpersonal accord and conformity to social norms
4. Authority and social-order maintaining orientation

Level 3 (Post-Conventional)
5. Social contract orientation
6. Universal ethical principles

Moving from one stage to the next depends on your increasing understanding of medical ethics (PFO Module 2) and how to "unpack" ethical dilemmas in clinical care. As you grow in your confidence, self-discovery and security in your identity, you become less focused in your own self-interest in moral reasoning and less worried about what your colleagues or supervisors would do or think and how you would be perceived by others. You will pay more attention to your commitments to the ideals of your profession and what is fair and just according to universal ethical principles. In putting your patient's or client's interest first, you will also be able to offer accurate empathy and compassion.

Virtually everyone who enters health profession education has some capacity for empathy and compassion. Studies suggest that, in part, our capacities are based in neurobiology. There is wide variation among individuals in the numbers of the brain cells (mirror neurons and spindle cells among them) that are associated with empathy. In addition, some are raised in families where feelings and emotions are often discussed, and others raised in families in which feelings are suppressed and rarely discussed. Empathy consists of the ability to imagine what it must be like for another who is experiencing distress and to be able to communicate that. Compassion depends on empathy, but also includes a motivation to do something to relieve another's suffering. Most healthcare training programs now teach empathy and a variety of effective techniques to communicate that empathy. Attentive silence, reflecting patients' emotions, legitimizing statements, asking about patients' worries and concerns, and stating your understanding of what the patient has expressed are all skills that can communicate empathy. Many schools also include teaching about compassion and enhancing one's ability to be compassionate. If you stay open to listening to your patients, asking about their experiences and concerns, putting aside your biases, judgments and assumptions, and practice communicating your understanding and caring to patients, you will grow in your abilities to be empathic and compassionate. Your clinical care will become more effective as a result, and you will find more fulfillment in your practice.

The concept of emotional intelligence has gained popularity and credibility since Daniel Goleman's best-selling book in 1995. Goleman asserts that emotional intelligence is as (or perhaps more) important than the more traditional intelligence quotient. Emotional intelligence is the ability to recognize your own and other people's emotions, label them appropriately, and use this understanding in interpersonal relationships. It also involves the capacity to manage one's emotions ( Goleman, 1996). Perhaps the most important and practical aspect of this concept is your ability to regulate your emotions. This is an essential skill in clinical care and in life. This involves intentionally pausing for a few seconds before you react emotionally, thinking about the likely reasons for the other person's statement that triggered you, how he or she might react to your intended reply, and the consequences of that reaction. You may decide to react in a different, more conciliatory, or helpful way. As you grow in your capacity for emotional regulation, you learn to not take things personally. Everyone has a point of view, and creates their worlds in unique ways that may not be consistent with your world view. People have their own stressors and emotional triggers. You can choose not to feel offended or diminished by disapproving or angry comments of others.

Those who love us the most are especially good at pushing our buttons.  I've been married for 48 years and sometimes emotional regulation is still a challenge.  If both my wife and I have had difficult work days, our patience might be thin by evening. If she says something that triggers me, my first reaction would be to say something like, "You think I'm ____, well how about when you ___!"  I stop myself, though, knowing that my comment could be the beginning of a sharp exchange that would end in anger and resentment.  I think to myself, "Let's see, how do I want to spend the next few hours, before I eventually apologize?" I also think about what I may have said verbally or non-verbally that might have elicited her angry comment. I take a breath and then might then say something like, "I'm sorry – I've had a difficult day, what about going out to dinner tonight?" Or, "how was your day?"  Or, "yes, I guess sometimes I am ____."

You will experience many negative emotions related to how you are treated by your peers, supervisors, other members of healthcare teams and by your patients/clients. Your emotional reactions in these situations can often be helpful, and sometimes serve as a barometer to the underlying affect of others with whom you interact. For example, if you are beginning to feel sad while interviewing a patient/client, it could be that the individual is depressed. Your emotions can inform your responses to others, but must be tempered by your thinking about the consequences of your intended response and by your understanding of how best to achieve your goals. A person who insults or belittles you might be feeling depressed or helpless or desperate. You can react to insults by feeling disrespected and angry. However, if you stop and think about what might be going on for that person, and inquire and approach him or her with curiosity and empathy, you can do much to enhance your therapeutic relationship.

Perhaps most people who enter the healing professions are high achievers with perfectionist tendencies. It has taken a lot of energy and motivation to enter your professional school. However, the rigors of health profession education can be daunting. Many students are dismayed by the intensity and volume of the workload. Many students, who are used to being among the top students in their classes, find that they are struggling. Many who are used to being successful and expect nothing less of themselves will be overly self-critical, feeling that they are not measuring up. Many trainees have the "Imposter Syndrome," feeling that they are not as smart as people think they are, and that someday people will figure that out. While it is critical to reflect on how you can do better and seek help if you need it, too much self-criticism may lead to discouragement and even impairment. It is equally important to recognize what you do well and to give yourself credit for it. There is often much to appreciate that can get overlooked. There is much for which to be grateful. Giving yourself credit for your successes can bolster your self-esteem and confidence, and guide your future work.

Negativity bias is a universal human phenomenon, and may be more pronounced in healthcare profession trainees. This is a well-known psychological process: even when of equal intensity, things of a more negative nature (e.g. unpleasant thoughts, emotions, or social interactions; harmful/traumatic events) have a greater effect on one's psychological state and processes than do neutral or positive things. Negativity bias affects many cognitive processes, including Impression formation, attention, learning, memory, decision-making and evaluation of risk. To counter the effects of negativity bias, positive psychologists recommend savoring the good moments in life: a compliment, feelings of accomplishment, a good meal. (Hanson 2013) A simple exercise, "Three Good Things," involves writing down at the end of the day three good things that happened, and the cause of them. Martin Seligman has shown that one week of doing this exercise leads to greater happiness on a validated scale six months later. (Seligman 2005) (http://www.actionforhappiness.org/take-action/find-three-good-things-each-day)

There is a growing literature on the need for healthcare professionals to have moral courage. This means being able to speak up in an effective way for what is right despite a variety of considerations or barriers. If you are putting a patient's or client's best interest first, speaking up is the right course of action. Many of us grow up respecting authority and the wisdom of our elders, and many cultures emphasize this value. However, sometimes authority figures act in ways that are inconsistent with our values, or are hurtful. Also, we all have a need to be accepted and appreciated by our peers and leaders. These emotional needs are often challenged in clinical settings. Your team members may disparage a patient or other health professionals. You feel this is wrong, but want to be accepted by the other members of the team. You think your supervisor may have made an error of judgment in diagnosis or care plan, but question your own knowledge, and don't want to risk a poor evaluation. You may be afraid to confront a colleague who you suspect is impaired. You may have made or have witnessed a medical error, but are afraid to disclose it. You may become aware that one of your colleagues has cheated or taken unacceptable shortcuts in care, but feel reluctant to confront that person or to tell a faculty member. There are many other instances in clinical care that require moral courage. As you grow in your commitment to putting the interests of those in your care first, and speak up when necessary, you will find your ability to express moral courage will increase. There are examples of how you might express moral courage in PFO Modules 3, 4 and 9. Also, it is critical to understand that although you will be affected by the hidden curriculum, you have a role in shaping the hidden curriculum. If a supervisor makes an unprofessional comment and you do not speak up, you contribute to a culture that accepts unprofessionalism. Your moral courage can enable you to say something that can change the culture of your team for the better. PFO Module 11 provides a fuller discussion of how you contribute to the culture of your learning and care environments.

If a patient or client is telling you about a difficult emotional situation, it is unlikely that you will be helpful if you are thinking, "you think you've got problems!" Many healthcare professionals will lose themselves in overwork, declining to delegate, taking more responsibility than they need to while neglecting their own physical and emotional well-being. Over-involvement in work to the exclusion of personal needs and relationships can lead to deteriorating relationships with loved ones and friends, isolation and burnout. Many will engage in a "psychology of postponement," rationalizing that they will begin to prioritize their well-being and relationships when they have finished training, when they have gotten a coveted fellowship, etc. This psychology of postponement, though, can be self-perpetuating and open-ended. If you realize you are doing this, you can make other, healthier choices. You can make time for healthy eating, for exercise, for get-togethers with friends.  We will explore this topic further in PFO Module 10, and in Exercise 10 below.

Maintaining your well-being also includes getting help when you need it.  Many healthcare trainees will experience symptoms of depression or anxiety that undermine their effectiveness. Over 400 physicians commit suicide every year, with younger physicians being more vulnerable.  Chiropractors and pharmacists are at higher risk than the general population as well. The PHQ-9 is a commonly used depression screening.  Consider taking it yourself and follow up with a mental health professional if indicated.  (The PHQ website is not connected in any way to PFO.) Your own personal well-being as a foundation for your ability to deliver optimal clinical care and cannot be ignored. Consider it a duty to yourself, your patients/clients and colleagues to seek appropriate help.

I suffered with an episode of depression as a third-year medical student, and didn't know it. I thought that my performance as a student was fine. I was persistently sad and anxious, but I thought that was how I was supposed to feel in medical school.  When I was on my psychiatry clerkship, one of my supervisors pulled me aside and said, "I'm concerned about you – you are clearly depressed."  He told me that he wouldn't let me continue in the clerkship unless I sought help.  I saw a psychiatrist the next day, which began a helpful journey of personal growth, and treatment of what I came to understand was a medical condition.

We have presented a number of objectives that, if achieved, will contribute greatly to your personal and professional growth. There will be many challenges along the way. Those in your care will suffer and die; you will be in difficult situations and not know what to do or say; you will make mistakes; you will doubt yourself; and you will be criticized. But you will have many triumphs and satisfactions as well. And you can thrive if you are intentional about your personal and professional growth and well-being. Be open, seek advice, and allow your mentors, colleagues, friends and families to help you along the way. We hope that PFO will contribute to your journey.

Exercise 1: Listening
Exercise 2: Being/Doing
Exercise 3: Your Family
Exercise 4: Gender Issues
Exercise 5: Sociocultural
Exercise 6: Love/Caring
Exercise 7: Anger/Conflict
Exercise 8: Death/Dying
Exercise 9: Mistakes
Exercise 10: Self-Care

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Appendix 1

This is a 35-minute video of medicine interns (post-graduate year 1) at the end of their internship at Hahnemann Hospital, reflecting on how they have grown during the past year.

In addition to myself, Neal Shah, Matthew Meleka, Paul Pourhassani, Doris Rivas, Shefali Shah, Neehar Raj, Michael Yee, and Mario Montalvo are around the table.