title: Paradoxes of professionalism and error in complex systems.
abstract: Professionalism is at the heart of risk management in complex, dangerous work such as medicine, aviation, and military operations. Professionalism is closely connected to expertise and is therefore closely connected to the ability to prevent and mitigate errors. But there are two paradoxes in this connection. First, professionalism can increase, rather than reduce, the risk of errors and accidents by promoting practitioners' tendency to break procedural rules. This is because professional expertise tends to favor adaptation to local circumstances over standardized approaches to problem-solving. Second, professionalism can create blind spots within organizations, blocking the flow of critical information about unsafe conditions. This is because professional groups develop unique subcultures, specialized language, and communication habits that tend to separate them from other professional groups, even when those groups work within the same organization. I illustrate these paradoxes using case studies from several different professional domains. I then outline some methodological challenges for research on safety and professionalism. Finally, I argue that the kind of professionalism that can prevent errors is rooted in organizational practices that reduce the social separation between professional groups and promote the maintenance of adequate margins of safety. This requires the acceptance of safety as a central value that is at least as important as productivity.
authors: National Board of Medical Examiners, Assessment Programs, 3750 Market, Philadelphia, PA 19104, USA. mholtman@nbme.org
authors: Matthew C
authors: MC
authors: Holtman
mesh_terms: D003142:Communication; D019300:Medical Errors / Q000517:prevention & control; D011361:Professional Competence; D012308:Risk Management / Q000379:methods*