When the Boss Defines Professionalism: How Employment Structures Reshape Medical Ethics

Professionalism has long been treated as the moral spine of general internal medicine, a set of commitments that physicians carry into every clinic room and hospital ward regardless of who signs their paycheck. A new viewpoint published in the Journal of General Internal Medicine argues that this ideal is quietly being redefined, and not by physicians themselves. Gus W. Krucke of Northeast Georgia Health System contends that employers, payers, regulators, technology platforms, performance metrics, and shifting public expectations are increasingly shaping what counts as professional behavior, with employment structures serving as the most visible arena where these forces converge. The result, he warns, is a subtle transformation in which professionalism risks functioning less as a safeguard for fiduciary judgment and more as a language of organizational alignment.

The mechanism Krucke describes is deceptively simple. Institutional policies translate operational priorities into day-to-day expectations about productivity, access, documentation, communication, teamwork, and behavior. None of these expectations is inherently illegitimate. Hospitals must manage throughput, clinics must maintain access, and health systems must steward finite resources. But when those operational priorities are packaged as professionalism, the term begins to drift from its ethical foundations. A physician who raises concerns about unsafe staffing or unrealistic visit targets may find that the concern is redescribed as a problem of attitude, tone, or teamwork. The physician who adapts quietly becomes the model employee, and by extension, the model professional.

Crucially, Krucke’s argument is not a critique of employed physicians or of the compromises that real-world care demands. Doctors routinely choose among imperfect treatments, limited social supports, difficult discharge plans, and competing patient needs. Professionalism, as he frames it, is not an absolute demand for unconstrained or perfect care. It is a fiduciary obligation to exercise patient-centered judgment honestly and accountably under actual conditions. The Physician Charter, the landmark 2002 statement from the American Board of Internal Medicine Foundation, the American College of Physicians, and the European Federation of Internal Medicine, identifies the primacy of patient welfare, patient autonomy, and social justice as the fundamental principles of professionalism, embedded within medicine’s social contract with society. Those commitments require physicians to acknowledge scarcity, consider the needs of other patients, steward resources, communicate limitations, and participate responsibly in teams.

The ethical question, then, is where legitimate accommodation ends and moral compromise begins. Krucke offers a practical test. An accommodation remains professionally defensible when it protects safety to the extent reasonably possible, respects patient preferences, discloses meaningful limitations, considers justice, and permits escalation or review when serious concerns remain. A physician may appropriately accept a formulary restriction, a standardized workflow, or a less costly treatment when the decision is clinically defensible and honestly communicated. A poor discharge option may genuinely be the safest available option, and a physician may disagree with it while still helping the patient navigate it. Compromise, in other words, is not the enemy of professionalism. Concealment is.

The boundary is approached, he argues, when organizational priorities require concealment, misleading communication, disregard of patient preferences, or the transfer of unreasonable risk to patients and clinicians. It is also approached when an institution treats policy compliance as sufficient justification for overriding clinical judgment. The concern is not that physicians must resist every constraint placed upon them. It is that they may be expected to absorb unsafe contradictions without the authority or the opportunity to raise them. In that scenario, the ethical infrastructure of medicine is hollowed out from the inside: the vocabulary of professionalism survives, but its practical meaning shifts from fiduciary judgment to compliance.

These tensions are especially visible in general internal medicine, the specialty that anchors much of the American health care system. In ambulatory practice, panel size, inbox volume, prior authorizations, preventive care metrics, chronic disease management, and access expectations each serve legitimate purposes individually. Together, however, they can leave inadequate time for complex care. A physician who spends additional time coordinating care for a medically complicated patient may appear inefficient on a productivity dashboard even when acting squarely in the patient’s interest. In the hospital, expectations around throughput, length of stay, utilization review, coding, and discharge timing can conflict with clinical readiness, social circumstances, and safe follow-up. Krucke’s point is that neither speed nor delay is inherently professional. The ethical task is to judge what can responsibly be done for this patient, under these conditions.

The viewpoint names the phenomenon it describes as organizational capture. Capturing professionalism does not require institutions to reject its language; they may preserve the vocabulary while changing its practical meaning. The American College of Physicians has already recognized that physician employment and health care business practices can create conflicts involving professional integrity and patient interests. A broader framework of organizational professionalism, articulated in a 2017 charter published in Academic Medicine, likewise emphasizes that structural factors may impede physicians from fulfilling their professional commitments and that health care organizations bear responsibilities of their own to create cultures and operations consistent with professional values. Organizations, in this view, have professional obligations too: to support patient welfare, workforce well-being, honest communication, and meaningful accountability.

Krucke is careful to distinguish principled dissent from mere resistance to change, acknowledging that physicians can misuse autonomy to avoid teamwork or accountability. Dissent is professionally warranted, he writes, when it is grounded in identifiable duties to safety, autonomy, justice, honesty, or fiduciary responsibility; supported by relevant facts; communicated through appropriate channels; and open to review and correction. Institutions, for their part, should evaluate dissent by its ethical basis and evidence rather than simply by whether it creates friction. This distinction also clarifies the relationship between professionalism and physician distress. Not every difficult decision constitutes moral distress, and not every demanding expectation represents ethical conflict. Yet repeated pressure to recognize a problem without the time, authority, staffing, or institutional support to address it can produce genuine moral strain. Recent research has linked moral distress with occupational burnout, while scholarship on physician moral injury describes the corrosive conflict between professional obligations and systems that constrain action. Emotional support may help clinicians stay oriented, but it cannot substitute for examining the conditions that generate recurring ethical contradictions.

As an alternative to indefinite adaptation, Krucke proposes fortitude, a concept he developed in earlier work. Fortitude, in this framing, is the capacity to act responsibly before outcomes are known, amid uncertainty, and when principled action may carry personal cost. It is explicitly not endurance of institutional harm. It is moral agency directed toward honest judgment, accountable dissent, and repair. The question fortitude asks is not how much pressure a physician can absorb, but what the physician remains responsible for doing. This reframing shifts the burden of moral analysis away from individual resilience and toward the structural conditions under which judgment is exercised, placing responsibility on institutions to preserve credible avenues for physicians to identify and challenge unsafe or misleading practices.

The stakes extend well beyond physician morale. Professionalism matters, ultimately, because it supports public trust. Patients do not expect unlimited or perfect care, Krucke notes. They expect physicians to explain limitations honestly, exercise judgment responsibly, and remain accountable when institutional interests and patient interests diverge. If clinical recommendations begin to appear driven by productivity goals, payer requirements, patient-satisfaction incentives, or institutional convenience rather than clinical judgment, that trust erodes, and with it the social contract on which medicine’s authority rests. Employment structures will inevitably shape practice; the danger lies in allowing them to define professionalism so completely that ethical dissent itself begins to look unprofessional. If that happens, medicine may keep the language of professionalism while gradually surrendering the moral authority, and the public trust, that once made the term worth defending.

Subject of Research: The influence of physician employment structures on the definition and ethics of professionalism in general internal medicine

Article Title: When Employment Structures Define Professionalism in General Internal Medicine

Article References: When Employment Structures Define Professionalism in General Internal Medicine. (n.d.). https://doi.org/10.1007/s11606-026-10939-w

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10939-w

Keywords: professionalism, general internal medicine, medical ethics, physician employment, organizational capture, moral distress, moral injury, burnout, Physician Charter, organizational professionalism, fiduciary duty, public trust