Are codes of ethics enough learning professionalism on the playing fields of ethics
This presentation is the property of its rightful owner.
Sponsored Links
1 / 63

Are Codes of Ethics Enough? Learning Professionalism on the Playing Fields of Ethics PowerPoint PPT Presentation


  • 75 Views
  • Uploaded on
  • Presentation posted in: General

Are Codes of Ethics Enough? Learning Professionalism on the Playing Fields of Ethics. Healthcare Ethics & Law Institute Samford University April 9, 2010. DeWitt C. Baldwin Jr. M.D. Scholar-in-Residence ACGME. Appreciations. The HEAL Institute and Samford University Lori Bateman

Download Presentation

Are Codes of Ethics Enough? Learning Professionalism on the Playing Fields of Ethics

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Are codes of ethics enough learning professionalism on the playing fields of ethics

Are Codes of Ethics Enough?Learning Professionalism on the Playing Fields of Ethics

Healthcare Ethics & Law Institute

Samford University

April 9, 2010

DeWitt C. Baldwin Jr. M.D.

Scholar-in-Residence

ACGME


Appreciations

Appreciations

  • The HEAL Institute and Samford University

  • Lori Bateman

  • Professor Wilton Bunch

  • Dr. Edmund Pellegrino

  • My colleagues:

  • Steven Daugherty PhD

  • Patrick Ryan MD


Learning professionalism on the playing fields of ethics

Learning Professionalism on the Playing Fields of Ethics

  • The biographies of many famous British leaders often contain some variation of the sentence “ Everything I needed to know about (life, leadership,, success, getting along, etc.), I learned on the playing fields of Eton” ( a well-known, upper-class “public school” in England).

  • I have chosen this metaphor to portray a picture of ethics and professionalism as “contact sports”, conceived of as a struggle to “do the right thing”, between frequently conflicting values, played out daily on the “playing fields” of life and work, whose limits, dimensions, and rules are set by codes of desired conduct and behavior.


Professionalism definition

Professionalism:Definition

  • Professionalism…a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

ACGME, Minimum Program Requirements Language

Approved Sept. 28, 1999


Levels of professional behavior

Levels of Professional Behavior

  • Ideal (e.g., consistently goes beyond the call of duty)

  • Expected (e.g., complete care and disposition of patients before signing them out)

  • Unacceptable (e.g., make passes at students or patients)

  • Egregious (e.g., falsify medical records)

    (Larkin, 2003)


Judging professional behavior between the ideal and the deviant

Zone of

Enforcement

Actual Behaviors

Judging Professional Behavior: Between the Ideal and the Deviant

Ideal Standard

Deviant Boundary

Zone of

Possibility

Sanction

Exclusion

Positive

Negative


Residents reactions to their residency experience two factor cluster analysis

Residents’ Reactions to their Residency Experience (two factor cluster analysis)

Unpublished data


Learning professionalism on the playing fields of ethics1

Learning Professionalism on the Playing Fields of Ethics

  • Professionalism must be defined before it can be evaluated or taught.

  • Usually presented in terms of multiple distinct ideals.

  • Such ideals are difficult to express in operational terms.

  • Often portrayed in oppositional and dichotomous terms: “professional” vs. “unprofessional”; “ethical vs. unethical”.

  • Frequently grasped in metaphorical or global intuitive terms.

    • Justice Potter Stewart: “I know it when I see it”.

  • Situation and Context-dependent- clinical, cultural

  • Professional Standards (Codes) are necessary, but insufficient.


How do students learn ethical and professional values

How do Students LearnEthical and Professional Values?

  • Bring some to medical school with them.

  • Learn some through the formal teaching curriculum.

  • Learn more from faculty role models.

  • Learn a lot through the “hidden” curriculum.

  • Learn most in clinical situations, because these are the complex “playing fields” of moral, ethical, and professional action, where ideals, values, and behavior are tested, contested, and adopted or rejected.


Are codes of ethics enough learning professionalism on the playing fields of ethics

Conflict between Values

  • Professionalism is rarely taught through simple expression of values, (e.g., “always be honest.”)

  • More commonly, professionalism is taught when two or more worthy values come into conflict, (e.g., honesty conflicts with confidentiality.)


The informal hidden curriculum

The Informal (Hidden) Curriculum

“[The] hidden curriculum can . . . be represented by the three R’s, but not . . . reading, ‘riting, and ‘rithmetic”.

“It is . . . the curriculum of rules, regulations, and routines, of things teachers and students must learn if they are to make their way with minimum pain in the social institution called the school.”

Jackson P. Life in classrooms. Holt. 1968: 353


When are values taught

When Are Values Taught?

Shift

Type Call

Stern D. Acad Med. 1998; 73: 28S-30S


Changing attitudes values and behavior during medical education

Changing Attitudes, Values, and Behavior during Medical Education

  • Ethical and Professional attitudes, values, and behaviors change during the course of medical education--not necessarily in ways we like.

  • Moral Reasoning (Kohlberg) progress shuts down with entry to medical school and remains low during residency without specific remediation. (Self et al., Baldwin & Self.)

  • Cynicism “Ethical erosion” and unprofessional behaviors are observed and manifested by medical students and residents. (Baldwin et al.; Feudtner et al.)


Are codes of ethics enough learning professionalism on the playing fields of ethics

The problem is that medicine has had a culture, in which:

  • Medical students have been humiliated for not knowing and so have learnt to hide their ignorance,

  • Junior doctors are reluctant to call their seniors and so take

  • on more than they should,

  • It is seen as weakness to admit to anxieties or shortcomings,

  • Errors are seen as unacceptable and so are hidden, and

  • Doctors find it hard to confront colleagues who are

  • performing poorly.

Source unknown


Are codes of ethics enough learning professionalism on the playing fields of ethics

The Ethical Environment of Undergraduate Medical Education

Medical Student Studies


Reports of perceived mistreatment

Reports of Perceived Mistreatment

First-year Residents (n=571)

Medical Students (n=580)

Baldwin et al. Western J. Med. 1991; Acad Med. 1998


Reports of perceived mistreatment1

Reports of Perceived Mistreatment

First-year Residents (n=571)

Medical Students (n=580)

Baldwin et al. Western J. Med. 1991; Acad Med. 1998


Are codes of ethics enough learning professionalism on the playing fields of ethics

Percent of Third Year Medical Students Reporting at Least One Episode of Observing What They Believed to Be Ethical or Professional Misconduct

Sheehan et al. JAMA 1990;263:533-7


Are codes of ethics enough learning professionalism on the playing fields of ethics

“Ethical Erosion” in Third Year Medical Students (N=665)

58% believed they had done something unethical

52% believed they had misled a patient

98% had heard physicians refer to patients

derogatorily

62% had observed unethical behavior by a clinical

team member. (54% felt like accomplices)

67% had felt bad or guilty about something they did

as clerks

62% felt that some of their ethical principles had

eroded

Feudtner et al. ACAD. MED 69(1994):670-9


The ethical environment of graduate medical education

The Ethical Environment of Graduate Medical Education


Are codes of ethics enough learning professionalism on the playing fields of ethics

Development of Graduate Medical Education in the US


Are codes of ethics enough learning professionalism on the playing fields of ethics

Development of Graduate Medical Education in the US (Cont.)


Are codes of ethics enough learning professionalism on the playing fields of ethics

Development of Graduate Medical Education in the US (Cont.)


Are codes of ethics enough learning professionalism on the playing fields of ethics

Lifestyle

Work

Shifting Dimensions of Subjective Well-being in

Graduate medical Education

Year

High

2010

$50,000

Sleep

$40,000

2000

MonetaryCompensation

$30,000

1990

$10,000

1975

Well-being

$1,000

1950

$0

1900

Low

Less

Freedom of Choice

Satisfaction

More


Are codes of ethics enough learning professionalism on the playing fields of ethics

Changing Issues for

Residency Training

Lifestyle

Sleep

  • Required Knowledge

  • Complexity of Medical care

Work

Time

Time

A

B


Are codes of ethics enough learning professionalism on the playing fields of ethics

Quick Review of Our Previous Resident Survey Data

(1988-89 and 1998-99)


Distribution of reported resident work hours 1999

Distribution of Reported Resident Work Hours (1999)

80 hrs/week

PGY 1 & PGY 2 Residents (1998-99)


Work hour distributions for selected specialties 1999

Work Hour Distributions for Selected Specialties (1999)


Are codes of ethics enough learning professionalism on the playing fields of ethics

Average Weekly Hours By Specialty

(1999)

PGY 1 & PGY 2 Residents (1998-99)


Reported errors by average weekly work hours

Reported Errors by Average Weekly Work Hours

PGY 1 & PGY 2 Residents (1998-99)


Reported errors by average daily hours of sleep

Reported Errors by Average Daily Hours of Sleep

X2=56.5, DF=5, p<.0001

PGY 1 & PGY 2 Residents (1998-99)


Interprofessional conflict and medical errors

Interprofessional Conflict and Medical Errors

Baldwin and Daugherty. J. Interprofessional Care. 2008: 22(6); 1-14


Choices in residency

Choices in Residency

Choice Difficulty

50 hrs

120 hrs

Easy Choices

No Real Choices

(40%)

(20%)

N=1,274

N=695

70 hrs

90 hrs

Difficult Choices

(40%)

N=1,320

80 hrs

Work Hours


Are codes of ethics enough learning professionalism on the playing fields of ethics

Expanding Our Search

Past

Work

Present

Work

Sleep

Future

Work

Sleep

Personal

(Defined areas are estimates for illustrative purposes)


Ethical and professional environment of residency training

Ethical and Professional Environment of Residency Training

* Not Directly Comparable


Ethical and professional environment of residency training1

Ethical and Professional Environment of Residency Training

* Not Directly Comparable


Ethical and professional environment of residency training2

Ethical and Professional Environment of Residency Training

* Not Directly Comparable Preliminary Data


Ethical and professional environment of residency training3

Ethical and Professional Environment of Residency Training

*Preliminary Data

Not Directly Comparable


Ethical and professional environment of residency training4

Ethical and Professional Environment of Residency Training

*Not Directly Comparable Preliminary Data


Ethical and professional environment of residency training changes 1989 1999

Ethical and Professional Environment of Residency TrainingChanges 1989-1999


Ethical and professional environment of residency training changes in satisfaction by specialty

Ethical and Professional Environment of Residency Training Changes in Satisfaction by Specialty


Ethical and professional environment of residency training changes in satisfaction by specialty1

Ethical and Professional Environment of Residency Training Changes in Satisfaction by Specialty


Ethical and professional environment of residency training changes in satisfaction by specialty2

Ethical and Professional Environment of Residency Training Changes in Satisfaction by Specialty


Changing demographics

Changing Demographics


Negative experiences in residency training

Negative Experiences in Residency Training

  • Overwork

  • Sleep Deprivation

  • Inadequate Supervision

  • Falsification of Records (observing others)

  • Mistreatment of Patients (observing others)

  • Sexual Harassment

  • Psychological Abuse

  • Physical Abuse

  • Racial Discrimination

  • Medical Errors

  • Impaired Performance (self)

  • Impaired Performance (observing others)

  • Interprofessional Conflict

  • Malpractice Suits

  • Stress

  • Alcohol Use and Abuse

  • Drug Use and Abuse

  • Weight Change

  • Accidents and Injuries


Are codes of ethics enough learning professionalism on the playing fields of ethics

Science strives for certainty (generalizations)

Medicine deals with uncertainty (individual variation).

Not everything can be empirically known, predicted, or measured.

Institutions dislike variation; promote standardization.

Individuals dislike standardization; seek variation.

Zero tolerance for errors

Learning involves mistakes

Some Unavoidable Tensions


What have we learned

What have we learned?

  • Satisfaction is related to attending faculty contact and teaching, not to work or sleep hours.

  • Medical errors are linked to sleep deprivation and fatigue, but also to other variables.

  • The specific residency program matters more than specialty or hospital in predicting residency experience. Is each program a unique “culture”?

  • Large variations exist within programs

    • There is no “average resident”, nor an average residency experience.


Are codes of ethics enough learning professionalism on the playing fields of ethics

  • From 1989 Survey…

  • Satisfaction is a consequence of Reward + Punishment

  • What residents want is 1) contact and teaching from the attending while

  • 2) mistreatment is minimized

Daugherty et al. JAMA 1998; 279:1194-1199


What have we learned1

What Have We Learned?

  • “Medicine has become too complex for the way we deliver health care.”

    Chaos and Organization in Health Care

    Thomas Lee MD and James Mongan MD

  • Medicine has become too complex for the way we train physicians.

  • Resident training is too complex for rigid rules or simple cause and effect explanations– (and may be hazardous to your health and ethical and professional development!).


Dealing with complexity

Dealing with Complexity

Health Care Organizations, Hospitals, and Social, Educational, and Professional Development Programs and Institutions are uniquely COMPLEX SYSTEMS-- non-linear, dynamic, interactional, unpredictable, and emergent - characterized by technological and professional heterogeneity.

Where individual agents have the “freedom to act in ways that are not always predictable, and whose actions are interconnected, so that one agent’s actions change the context for others”.

Complexity Science and Health Care Management , 2001 (McDaniel and Driebe)


Complexity theory

Complexity Theory

  • SIMPLE- (Cooking a dish) Time tested, reliable, reproducible , predictable outcome, expertise not required.

  • COMPLICATED- (Landing on the moon) Difficult, rules and formulae essential, expertise required, high degree of certainty, solution is external to system, success increases assurance of continuing success.

  • COMPLEX- (Raising a child or training a physician) Unique experience, no clear formulae, expertise no guarantee, uncertain and unpredictable outcome, nonlinear, solution is part of system, interaction with dynamic environment.


Are codes of ethics enough learning professionalism on the playing fields of ethics

NEED FOR NEW CONCEPTUAL FRAMEWORKS

  • Conceptual Frameworks- Ways of thinking about a problem or a study, or ways of representing how complex things work. Illuminate some aspects, but may exclude others.

  • Complexity- The world and it’s problems are becoming increasingly complex: non-linear, un-predictable, emergent outcomes, solution part of system, changing processes, interaction with dynamic, changing environment.


Are codes of ethics enough learning professionalism on the playing fields of ethics

Need for New Conceptual Frameworks

  • Graduate medical education, like medicine, is bedeviled by a unitary concept of the physician.

  • “A resident is a resident is a resident”.

  • The aim and purpose of residency training has been profoundly affected by many internal and external forces, in what has become a complexsystem, involving accountability (regulation), money (profit), service load (health care system), workload (increase in procedures, lab tests, medications, severity of illness), education (competencies, teamwork, patient safety), as well as changing demographic and social conditions.


Competing conceptualizations about residency training

Competing Conceptualizations about Residency Training

  • GME is caught up in serving an industrialized, assembly-line, “product” development model of professional education.

  • Such an educational model fails to see residents as colleagues, so they are not accorded the respect of equal participation in the process and all sorts of dehumanization can take place.


Are codes of ethics enough learning professionalism on the playing fields of ethics

Competing Conceptualizations about Residency Training

  • This conceptual framework results in a focus on a

  • production model of education aimed at a standardized result, rather than on the

  • complex developmental process of “identity formation,” and on the educational methods required to

  • transform students into physicians, who will be competent, ethical, humanistic and compassionate, and capable of balancing the art and science of medicine in the service of their patients.


Can we change a person

Can We Change a Person?

*With a targeted, defined intervention (educational or psycho-social)…

…can change attitudes/beliefs(e.g., Tang et al. 2002, )

…can change moral sensitivity, knowledge and reasoning(e.g., Self & Baldwin., 1994)

…can change behaviors(e.g., Sheehan et al. 1987)


Can we change the environment

Can We Change the Environment?

*We don’t know yet, but we do know that immersion is enough to impact…

…opinions/attitudes(Crandall et al.,1993)

…reasoning(Self & Baldwin 1998; Lind et al., 2000),

…behavior(e.g., Baldwin et al., 1991).

…institutional culture (e.g., Cottingham et al., 2008)

*Can we reason that a positive professionalism environment is likely to exert a positive influence on professionalism? (see Nelson et al.,-p14)


Are codes of ethics enough learning professionalism on the playing fields of ethics

“Our students will be humanized, if at all, by witnessing compassion, gentleness, and empathy manifested in patient interviews, in rounds on the wards, in their preceptor’s office- and not by studying a body of knowledge.”

K. Danner Clouser

Arden House. 1971


Are codes of ethics enough learning professionalism on the playing fields of ethics1

Are Codes of Ethics Enough?Learning Professionalism on the Playing Fields of Ethics

Healthcare Ethics & Law Institute

Samford University

April 9, 2010

DeWitt C. Baldwin Jr. M.D.

Scholar-in-Residence

ACGME


  • Login