Professionalism in Medical Practice

1. Professionalism in Medical Practice Dr Fadel Naim IUG _ Faculity of Medicine

2. We do an excellent job of preparing students to know and to do what patients need, but we must do more to develop our students’ character, and strengthen their moral fiber by role modeling. • In other words, we must do more to prepare them to be professionals. Cohen JJ. What New Doctors Must Learn. MedGenMed.2006;8(1):45.

3. No law, regulation, watchdog government agency, or fine print in an insurance contract can serve patients’ and the public’s interestsas well as physicians who are honor-bound to uphold the principles and responsibilities of professionalism Cohen JJ. What New Doctors Must Learn. MedGenMed.2006;8(1):45.

4. (Accreditation Council for Graduate Medical Education)ACGME Core Competencies • Medical knowledge • Patient Care • Interpersonal and communication skills • Practice-based learning and improvement • Systems-based practice • Professionalism

5. Your daughter is scheduled to graduate from high school this afternoon. As you are preparing to sign out to a colleague, one of your long time patients present in the ER with chest pain. • You enter the ER and a partner in your group practice is already there to evaluate the situation. As you know that he is competent and conscientious, you go to reassure your patient. He pleads with you to stay. Think about what aspects of professionalism are demonstrated by this situation

6. What does professionalism mean to you? • Take a few minutes and write down your thoughts … as a definition or description.

7. The professional physician is defined not only by what he or she must know and do, but most importantly by a profound sense of what a physician must be. • Character, integrity, honor, moral fiber these attributes are essential.

8. Definition Professionalism in medicine requires the physician to serve the interests of the patient (and community) above his or her self-interest.  “Medical professionalism signifies a set of values, behaviours, and relationships that underpins the trust the public has in doctors.”

9. ACGME Core CompetenciesProfessionalism • Respect, compassion شفقة, integrity • Responsiveness to needs • Altruism • Accountability • Commitment to excellence • Sound ethics • Sensitivity to culture, age, gender, disabilities

10. Elements of Professionalism Altruism is the essence of professionalism The best interest of the patients, not self-interest, is the rule. Accountability is required at many levels - to individual patients, society and the profession… Excellence entails a conscientious effort جهدا واعيا to exceed normal expectations and make a commitment to life-long learning…

11. ElementsofProfessionalism Duty is the free acceptance of a commitment to service. Honour and integrity are the consistent regard for the highest standards of behaviour and refusal to violate ones personal and professional codes. Respect for others:patients and their families, other physicians and professional colleagues such as nurses, medical students, residents, subspecialty fellows, and self is the essence of humanism…"

12. The Liverpool Professional

13. Professional Status is Not an Inherent RightIT IS GRANTED BY SOCIETY

14. It Must Be Constantly Earned by Meeting the Obligations Expected of a Professional

15. IF MEDICINE FAILS TO MEET ITS OBLIGATIONSSOCIETY WILL CHANGEITS STATUS

16. Society’s Expectations of Medicine to fulfill the role of the healer assured competence timely access to care respect for patient autonomy altruistic service morality, integrity, & honesty accountability and transparency team health care source of objective advice promotion of the public good Medicine’s Expectations of Society trust autonomy reasonable lifestyle health care system -value-laden -adequately funded & staffed - reasonable freedom role in public policy monopoly rewards - financial - non-financial • respect • status THE SOCIAL CONTRACT

17. These commitments form the basis of a social contract between a physician and society. • Society in return, grants physicians the privilege of profession-led regulation with the understanding that they are accountable to those served

18. Commitments as a professional Medical Student • Respect for • professors, preceptors, and peers • guest speakers and visiting patients • cadavers and anatomical specimens in the anatomy lab • the institution of which you are a part • patients and their families at clinical encounters • patient confidentiality • all members of the health care team • administrative and support staff • the core values of professionalism

19. Ethics Of Professionalism • More concerned with the characteristics and behaviours of physicians in the context of medicine as a profession. • Specifically, it examines desirable and undesirable attributes of physicians • Not only motivate patient-physician interaction, but also outline expected behaviour with other physicians, health care workers, medical students, and preceptors.

21. Physicians’ Charter on Medical Professionalism • An example of one international effort to articulate fundamental principles and practical manifestations of professionalism Medical Professionalism, Physician Charter ndation.org/Professionalism/Physician-Charter.aspx Authored by: American Board of Internal Medicine (ABIM) Foundation www.abim.org/ American College of Physicians Foundation www.acpfoundation.org/ European Federation of Internal Medicine www.efim.org/ accessed June 22, 2011

22. Physician Charter Fundamental Principles • Primacy of patient welfare • altruism in the service of the interest of the patient • Patient autonomy - honesty and empowerment • as key in the patient-doctor relationship to aid patients in making their own decisions • Social justice - • Equity in the distribution of health care resources and the elimination of all forms of discrimination

23. PhysicianCharterTenCommitments • Professional competence – • lifelong learning and self-regulation to ensure competence of all members of profession • Honesty with patients – • informed consent and disclosure in medical error • Patient confidentiality

24. PhysicianCharterTenCommitments • Maintaining appropriate relationships with patients - zero tolerance to any form of exploitation • Improving quality of care • Improving access to care • reduce all barriers to health care • Just distribution of finite resources

25. PhysicianCharterTenCommitments • Scientific knowledge – • integrity of knowledge • Maintaining trust • by managing conflicts of interest

26. Sometimes things are just so complex only a word cloud will do!

27. Challenges to Professionalism • Abuse of Power • Arrogance • Greed • Misrepresentation • Impairment • Lack of conscientiousness • Conflict of interest

28. Abuseofpower • Interactions with patients and colleagues - Bias and sexual harassment - Breech of confidentiality

29. Arrogance • Offensive display of superiority • fostered by residency training • destroys professionalism by: • losing empathy for the patient • Removing the beneficial role of self-doubt

30. Greed • Money or power become the driving force • lose understanding, compassion and personal integrity • must always ask “is this in the best interest of the patient or my own financial interest.”

31. Misrepresentation • Consists of lying and fraud • both are conscious efforts • Fraud is the misrepresentation of material fact with the intent to mislead • Insurance company fraud

32. Impairment • Drug addicted, alcoholic or mentally impaired physician • protected or unnoticed by colleagues and allowed to care for unsuspecting patients.

33. LackofConscientiousness • failure to fulfill responsibilities • this is the physician who is committed to doing the bare minimum • takes the least amount of history • waits for an x-ray report rather then review it himself

34. LackofConscientiousness • failure to fulfill responsibilities • does not return patients phone calls • reviews charts rather than the patient • too busy to fulfill his teaching responsibilities to residents or students • comes late for rounds or conferences • shifts the care of patients to trainees not yet prepared for unsupervised responsibility

35. ConflictofInterest • Avoid situations in which the interest of the physician is placed above of the patient 1. Self referral 2. Acceptance of gifts 3. Utilization of services

36. Self referral • Ordering of laboratory test or diagnostic procedures for a patient from businesses in which the physician has a financial interest

37. Acceptance of gifts • Gifts or subsidies from drug companies for travel, lodging, meals or personal expenses to attend educational conferences should be discouraged or restricted.

38. Utilization of services • Inappropriate procedures • Multiple unnecessary office visits • Keeping dying patients alive

39. Getting to Professional • Graduation from medical school does not confer a guarantee of professionalism. • How then, is one to become "professional"?

40. Having a clear definition of what is expected by the profession and society helps • Some of what we learn during medical school and residency training is formally stated • Some through watching and purposeful imitation • Some is learned as if by osmosis.

41. The Hidden Curriculum • Includes what is implicitly learned, not explicitly taught and can be positive or negative in nature. • Reflects the values and culture of the institution one is part of, the unofficial rules for survival and advancement.

42. What residents and students learn by watching their preceptor when explicit teaching is not taking place. • Students’ perception of the profession’s values are very much influenced by the informal and hidden curriculum

43. Role Models • "A person considered as a standard of excellence to be imitated“ • A role model teaches by example. • Learners pattern themselves on physicians they respect and trust. • The learning can be conscious, with observation and reflection, or subconscious also.

44. Role Models • Role models have a significant influence on the career choices of medical students. • This is often made with roles models in mind. • What role models say about different specialties is incorporated into learners’ views of medical careers.

45. Role Models • Things that can be learned from role models including • communication skills • clinical reasoning • resource management • dealing with conflict • reporting medical error.

46. Identify the behaviours that are considered professional and aid with the promotion of relationships with patients and colleagues.

47. greet patients by their name and tell them your name and role in their care. • being late • Smile • standing when talking to patients • learn who your patients are • allow interruptions, even if personal or non-urgent

48. discuss patient issues in public places • the physician is usually in charge • be compassionate and caring • glancing at your phone during a patient interaction • drinking coffee while doing rounds • criticizing another medical specialty

49. using labels to describe your patients. "the borderline patient in room 202 is having abdominal pain" • mimicking a patient's accent or disability for comic effect • making an effort to learn and use the names of the people you work with.

50. Some of the behaviours above may be inevitable but should be avoided and recognized if they occur. • For example: • looking at your phone may be necessary if waiting for an urgent call. • However, the patient should be informed that this is an urgent medical issue.