In Reply to Barnhoorn and Youngson and to Jones and Thaxton.

We appreciate the thoughtful and provocative comments by Drs. Barnhoorn and Youngson and by Drs. Jones and Thaxton about our article on reconceptualizing medical professionalism. We applaud their respective calls to place patients at the center of professional activities. At the same time, there are important differences between their respective visions that our definition can help explicate. Barnhoorn and Youngson approach professionalism at the level of the individual. More specifically, they target the individual practitioner and his or her obligations regarding patient-centered practice. By contrast, our definition approaches professionalism as a collective rather than an individual enterprise. Thus, we stress the notion of professionalism not only as a belief system but as a belief system about how best to organize and deliver health care as a collective enterprise. Moreover, instead of leaving things at the level of individual good intentions (which we view as necessary, but not sufficient for collective action), we frame professionalism as a challenge to group members (i.e., members of the medical community) to “jointly declare” what the public and patients can expect of medicine regarding “shared competency standards and ethical values.” Finally, our definition includes a call for medicine, as an organizational entity and collective endeavor, to include details about the structures and process constructed by the group to “ensure that all medical professionals live up to these promises.” In short, we wrote our definition for the profession rather than for professionals. We also wrote a definition that places collectively developed standards of care and competencies, collectively declared ethical values (including patient-centeredness), and collectively supported enforcement mechanisms at the hub of what, after all, is a social contract between medicine and the public. Jones and Thaxton deliver a very different patient-centered message, with quite provocative and far-reaching implications. Their letter is an important reminder that all too often, whether it be around issues of professionalism or related aspects of quality and safety in medical practice, allopathic medicine has appeared reluctant to engage other health professionals or the public in creating understandings of what medical professionalism means and what it requires. Their call for “the role of communit[ies] outside medicine in forming the people who will identify professionalism as something worth believing” points us in new and exciting directions. It also resonates with recent work through the Institute of Medicine calling for broader engagement in defining professional ethics.1 Although we do not wish to imply a stepwise or sequential model of change, we see two related, yet distinct, challenges at hand. The first is to help medicine function more as a cohesive community that operates with shared values and understandings of its work—in short, as an entity capable of forming a meaningful social contract. This step necessarily involves medicine moving beyond notions of professionalism at the level of individuals to a more collective representation. The second challenge is that the fullest expression of such a collective approach to professionalism must include the “engagement with moral communities beyond medicine” advocated by Jones and Thaxton. We thank them for their vision. Frederic W. Hafferty, PhD Professor of medical education and associate director, Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota. Matthew K. Wynia, MD, MPH Director of patient and physician engagement, Improving Health Outcomes Team, American Medical Association, and clinical assistant professor, Department of Medicine, University of Chicago, Chicago, Illinois; [email protected] Maxine A. Papadakis, MD Professor of medicine, Department of Medicine, University of California, San Francisco, and staff physician, San Francisco Veterans Association Medical Center, San Francisco, California. William M. Sullivan, PhD Founding director, Educating Tomorrow’s Lawyers, University of Denver, Denver, Colorado.