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2. I am grateful to Mark Wicclair for suggesting the distinction between “patient-based” and “patient-focused” standards for professional behavior.

3. Richard Cruess and Sylvia Cruess provide an historical survey of the uses and connotations of “professionalism” as understood by physicians themselves, and in the literature of medical ethics and the social sciences, in Cruess, RL, Cruess, SR. Teaching medicine as a profession in the service of healing. Academic Medicine 1997;72(11):941–52.CrossRefGoogle ScholarPubMed My interpretation of the predominantly profession-based character of this history draws primarily on the following sources: Edelstein, L. The professional ethics of the Greek physician. Bulletin of the History of Medicine 1956;30:392–418Google ScholarPubMed; Starr, P. The Social Transformation of American Medicine. New York: Basic Books; 1982Google Scholar; Berlant, JL. Profession and Monopoly: A Study of Medicine in the United States and Great Britain. Berkeley: University of California Press; 1975Google Scholar; Larson, MS. The Rise of Professionalism: A Sociological Analysis. Berkeley: University of California Press; 1977Google Scholar; Johnson, TJ. Professions and Power. New York: Macmillan; 1972Google Scholar; Gallagher, WT. Ideologies of professionalism and the politics of self-regulation in the California state bar. Pepperdine Law Review 1995;22(2):485–628Google Scholar; Goode, WJ. Community within a community: The professions. American Sociological Review 1957;22:194–200;CrossRefGoogle Scholar and Pellegrino, ED. Professionalism, profession and the virtues of the good physician. Mount Sinai Journal of Medicine 2002;69(6):378–84.Google ScholarPubMed For a discussion of Percival and his near contemporary, the Edinburgh physician John Gregory, disputing the characterization of medical ethics from this period as predominantly profession based, and arguing that Starr, Berlant, and others have misread Percival as having been simply concerned with “medical etiquette” rather than with “medical ethics” in a more modern sense, see McCullough, L. John Gregory and the Invention of Professional Medical Ethics and the Profession of Medicine. New York: Springer; 1998.Google Scholar For a similar argument concerning Percival, see Pellegrino ED. Percival’s Medical Ethics: The moral philosophy of an 18th-century English gentleman. Archives of Internal Medicine 1986;146(11):2265–9. Scholars have also pointed to strands of thought concerning physicians’ moral responsibilities to patients within the ancient and classical world that articulate something more closely approximating a patient-based approach; see, for example, the tradition exemplified by the first-century author Scribonius Largus, discussed by Edelstein and by Edmund Pellegrino in Pellegrino, ED. Toward a reconstruction of medical morality: The primacy of the act of profession and the fact of illness. Journal of Medicine and Philosophy 1979;4(1):32–56.CrossRefGoogle Scholar

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12. See note 9, Levinson et al. 2014, at 7.

13. See note 10, Lesser et al. 2010, at 2734.

14. See note 9, Levinson et al. 2014, at 7.

15. Additional lists such as these, which seem to have been derived in a similar manner, can be found in Van de Kamp K, Vernouij-Dessen MJFJ, Grol RPTM, Bottema JAM. How to conceptualize professionalism: A qualitative study. Medical Teacher 2004;26(8):696–702; Green, M, Zick, A, Makoul, G. Defining professionalism from the perspective of patients, physicians, and nurses. Academic Medicine 2009;84(5):566–73;CrossRefGoogle ScholarPubMed Accreditation Council for Graduate Medical Education. Advancing Education in Medical Professionalism: An Educational Resource from the ACGME Outcome Project; 2004; available at http://www.usahealthsystem.com/workfiles/com_docs/gme/2011%20Links/Professionalism%20-%20Faculty%20Dev..pdf (last accessed 29 Apr 2015); and Reynolds PP, Martindale J. Development of the Medical Professionalism Behavior Assessment Tool. Abstract presented at the Annual Conference of the Association for Medical Education in Europe, Milan, Italy, 2014 Aug 30–Sept 3.

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17. Examples of self-serving compromises that can be masked by appeals to “professionalism” might include lucrative participation in pharmaceutical company speakers bureaus (“colleague education”), refusals to speak publicly about substandard practice on the part of a colleague (“maintaining public confidence”), or resistance to a broadened scope of practice for, e.g., nurse practitioners or physician assistants (“patient safety”).

18. See note 3, Pellegrino 1979, at 44–5.

19. Sokolowski, R. The fiduciary relationship and the nature of professions. In: Pellegrino, ED, Veatch, RM, Langan, JP, eds. Ethics, Trust, and the Professions. Washington, DC: Georgetown University Press; 1991:23–43, at 27.Google Scholar

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41. The structural conditions affecting patients’ or communities’ trust are not the only factors largely outside the individual practitioner’s immediate control. The institutional environment within which the practitioner works—its policies, procedures, and general atmosphere, which can be more or less welcoming or intimidating, agency-enhancing or agency-sapping, for patients and families—is also likely to affect trust. Additional constraints on professional behavior with patients and families with likely influence on the practitioner’s ability to gain their trust come from institutional approaches to practice management, e.g., expectations regarding practitioner workload and patient volume, management surveillance, and pay-for-performance measures. Some of these issues have been discussed under the heading of “organizational professionalism”; see, e.g., Egener, B, McDonald, W, Rosof, B, Gullen, D. Organizational professionalism: Relevant competencies and behaviors. Academic Medicine 2012;87(5):668–74.CrossRefGoogle ScholarPubMed

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43. See note 22, Rogers et al. 2012, at 23; note 25, Miller 2012, at 94; note 24, Spiers 2000, at 719.

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