I went to a large public high school in New Orleans where I played on the varsity volleyball team. My high school coach treated every season as if we were preparing for the Olympics. We had two, sometimes three, a-day practices in the summer. We had multiple matching jerseys, shoes, bags, and warm-ups and paid for these items by working concession stands on the weekends. My father wrote letters to our principal suggesting that all of this was interfering with our academics, but despite his best efforts, by my sophomore season, the program had won four state championships in a row. We were good.

During my junior season I remember us goofing around a bit during warm ups before a match we knew we’d win. Afterwards, our coach was furious. Wouldn’t talk to us. Piled us all back in our fancy team van and drove us back to our school gym where she made us run. And run. And run. After we were exhausted she finally spoke, telling us that the reason we had run was because two of us had our jerseys untucked during the match. We’d been arrogant, and hadn’t cared and we were going to pay for it.

This is one example of many. If you were one minute late to practice, we all ran. One minute. I once argued with my coach in front of the entire team while we were watching tape. I was kicked out and sent to practice with the JV. Time and time again, these principles were drilled into our heads; respect, discipline, teamwork, accountability. It’s not about you. It’s about everyone else. It’s about accomplishing something together.

A few years ago, I had the privilege of working with a behavioral economist at Duke University named Dan Ariely on a project focused on Medical Professionalism. Dan had recently completed a documentary based on his book, The Honest Truth About Dishonesty, and wanted to parlay the idea into medicine. The project initiated with the hope of interviewing healthcare professionals across Duke who were involved in especially sticky stories, like the Erin Potts-Kant case. The goal was to deconstruct the behaviors leading up to these transgressions to illustrate how small, seemingly inconsequential decisions can become a slippery slope to serious problems.

If you can believe it, no one wanted to talk to us about their involvement in such events. But as I continued talking to healthcare providers across the University, learning more about the nature and definition of medical professionalism, a much more universal story began to emerge. Medical professionalism as a concept is broad and amorphous. It suggests one should behave in the best interest of one’s colleagues and patients. The problem with this definition is that it’s not particularly useful. No one is either “good” or “bad”, professional or unprofessional, but rather, we are all floating around somewhere in the middle. The “gray zone” of decision making, where complexities often create hidden opportunities to behave in one’s own interest at the expense of those around us.

Small things like copying and pasting EHR notes from one patient to the next is time-saving, but is it the right thing to do? What if there is an inconsistency in doing this that negatively impacts the treatment decision and outcomes for that next patient? An EKG feels like a normal, routine test to order but is it necessary or is your subconscious profit motive driving your decision making? It’s hard to say, but these are the everyday, gray zone examples of professionalism that impact the delivery of care to patients and represent opportunities to improve. It is therefore the act of managing “the middle” that is essential to maintaining professionalism – both at an individual and an institutional level.

I wrote my last piece on small things men can do to become more active participants in the movement to support women in medicine. Contracting the large idea of support down to actionable steps that put that support into motion. If, for example, you see a male co-worker treating a female co-worker inappropriately, say something. Don’t let it slide. In a similar, but much more impressive way, Dr. Julie Silver from Harvard Medical School recently positioned equity for women in the workforce as an ethical imperative, providing detailed ideas for how institutions can champion this effort from the top down. Is supporting women in medicine an ethical or professional responsibility? I happen to think so, but it doesn’t matter what I think. It matters how you manage the middle. Whether you tuck your shirt in and require others to do the same. It’s about accomplishing something together.

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