Physician organizations, academic institutions and accrediting bodies agree that professionalism is important to medicine. A number of them have created codes of conduct and competencies related to professionalism. Yet studies have shown that physicians face challenges as they seek to put the principles of professionalism into practice. This article examines four realities of medicine today-the potential for conflicts of interest, the advent of social media, the lack of professionalism education beyond medical school and residency, and the lack of support from organizations for which physicians work-that challenge medical professionalism.