Reply from author: missing the forest for the trees.

We thank Dr Ong Siew Chey for his sincere comments. He opines that professional behaviour is a refl ection of an innate character trait, that behaviour is shaped early and is diffi cult to modify later, and that there are 3 ways of making doctors conform to professional norms. We would like to reframe the issue as this traditional view oversimplifi es and limits the appreciation of the complex problem of professionalism. Firstly, the pessimistic notion that ethical/moral behaviours are hard to change with increasing seniority is fortunately refuted by evidence. Advances in moral reasoning increase with age throughout a person’s lifespan, and this progression in adulthood is correlated with education.1 Secondly, even though character traits do infl uence professional behaviour, these traits are but one of several factors infl uencing professionalism when we take a systems perspective.2,3 Organisational culture is another component of the system infl uencing professional behaviours.3 In psychology, the phenomenon of “moral elevation” describes how others are motivated to behave ethically when they see others doing likewise.4 Regardless of a person’s traits, an institutional culture of ethical behaviour is another system component that can promote professional behaviour in both senior and junior doctors. Finally, there is evidence that professionalism can be shaped and improved. Dr Ong feels that reciting the Hippocratic Oath or the modern physicians’ pledge does not change professional behaviour. The pledge is an example of a moral reminder. Experimental psychology studies have shown that such moral reminders do alter ethical behaviour by reducing cheating during tests.5 Within the fi eld of medicine, a recent randomised trial at the Mayo clinic6 demonstrated that it was possible to promote professionalism using a targeted intervention. Notably, the participants were already qualifi ed specialists, showing that seniority was not an impediment to improving professionalism. These are just some examples of how elements within our system can be used to improve professionalism. By taking a systems viewpoint,3 instead of focusing on fi xed character traits, we see the forest, not just the trees. Extant evidence1,4-6 provides grounds for hope; we remain optimistic that professional behaviours can be shaped using a multifaceted systems approach. Nigel CK Tan, 1MBBS, FRCP, MHPEd , Caroline CP Ong, 2MBBS,