Reframing Professionalism Through Executive Function: A Multi-Institutional Analysis of Professionalism Lapses in Medical Education

Abstract Background Professionalism is a core competency in medical education, yet challenges persist in translating professionalism expectations into observable, assessable, and teachable behaviors. Executive function (EF), a set of cognitive processes that support planning, self-regulation, emotional control, and adaptive behavior, may offer a complementary framework for understanding how professional behaviors may be enacted in practice. Methods We conducted a multi-institutional mixed-methods exploratory study examining professionalism concerns through an EF lens. Medical educators were surveyed regarding professionalism lapses observed among learners in undergraduate and graduate medical education. Responses from 80 participants representing 64 institutions were coded into predefined EF domains using a structured coding framework. Descriptive analyses examined EF frequencies, regional distributions, and co-occurring EF domains. Open-ended responses underwent reflexive thematic analysis to explore broader perspectives regarding professionalism. Results Participants reported 425 professionalism concerns, yielding 646 EF coding occurrences. The most frequently identified EF domains were metacognition (18.0%), planning/prioritizing (17.0%), response inhibition (14.4%), and emotional control (13.5%). Common EF pairings included emotional control with response inhibition and metacognition with planning/prioritizing. Reflexive thematic analysis of 30 open-ended responses identified five themes: Professionalism as a Socio-Cultural Construct, Longstanding Professionalism Challenges Within Medical Education, Professionalism Behaviors Consistent with Executive Function Processes, Modern Professionalism Challenges, and the COVID-19 Pandemic as an Inflection Point. Conclusions Professionalism concerns clustered around identifiable EF domains. An EF-informed framework may help operationalize professionalism by linking expectations to observable behaviors and may support more specific feedback, coaching, and assessment while preserving professionalism as a complex socio-cultural construct.