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Dr Omar Hasan Kasule DrPH Faculty of Medicine, King Fahad Medical City, Riyadh,
Saudi Arabia Telephone +966 548867916. Email omarkasule@yahoo.com
ABSTRACT
Professionalism
is defined as behaviors and attitudes. The American Board of Internal Medicine
(ABIM) It listed 6 dimensions of good professionalism as: altruism,
accountability, excellence, duty, honor and integrity, and respect for others;
and listed elements that erode professionalism: abuse of power and sexual
harassment, conflicts of interest, professional arrogance, physician
impairment, and fraud in research. The formulation of professionalism from an
Islamic perspective consists of 7 dimensions: (faith (iman),
consciousness (taqwat), best character (ahsan al akhlaq),
excellent performance (itqaan al ‘amal), strife toward perfection (ihsan),
responsibility (amanat), and self-accountability (muhasabat al nafs).
From the earliest human history medical practice was by non-professionals, members
of the family and religious leaders. Development of scientific medicine and its
technology required training of dedicated professionals who had specialized
skills and had to follow codes of professionalism. Professional organizations
were set up to defend the rights of members, regulate and discipline
practitioners, regulate training, and promote scientific research and exchange.
Professionalism is taught actively as structured curriculum courses or
passively as apprenticeship under good role models. Various approaches are used
in assessment of professionalism such as using special instruments like the
Nijmegen Professional Scale developed in the Netherlands and the Professional
Mini Evaluation instrument developed in Canada. Professionalism can also be
assessed by (a) assessing knowledge, attitudes, and practice of
professionalism; peer assessment of professionalism, (b) assessment of student
behaviors such as fulfilling duties, and (c) analysis of student narratives on critical incidents.
Key
words: professionalism, professional organization
Definition
of professionalism
Medical
professionalism is poorly conceptualized and understood; it is therefore not
easy to define.[1]
As a concept and practice it has its own
history and has been evolving. The evolution is not at the same stage in all
institutions and all countries; one place may operate with an earlier
formulation of professionalism while another place may operate with a later
formulation. Medical students get confused with apparently contradictory
concepts of professionalism if they do not realize that they are dealing with
different models of professionalism.[2] In
general professionalism is defined as attributes and behaviors expected of a
physician.[3] A
professional who is engaged in the same activities on a daily basis develops
special skills. In earlier times with limited knowledge and technology it was
possible to list skills that a professional was supposed to have; this is not
possible today but the skill dimension is still assumed in attributes of
professionalism such as such as ‘excellence’ because you cannot achieve
excellence without being skilled.
A
fair level of agreement can be reached by physicians, nurses, and the public on
tangible behaviors that constitute professionalism.[4],
[5]
Behaviors are easier to observe and measure than are attitudes and other intangibles
that are acquired by apprenticeship or experience but which cannot be described
in concrete terms. It is these intangibles that can explain similar reactions
of professionals to a situation without having to discuss or refer to a rule or
code. The intangibles could almost be called ‘trade secrets’ or practical
wisdom (phronosis).[6]
They can be considered under the Islamic legal principle of custom, ‘urf,
with various formulations such as: what is known as customary has the force of
law, al ‘aadat muhakkamat (Majallat Article No 36)[7]
and what is known customarily is considered an agreed condition among the
practitioners of a profession like trade, al ma’aruf ‘urfan ka al mashroot
shartan (Majallat Article No. 43 and 44).[8] It
is easier to define professionalism negatively because the consequences of
deficient professionalism are serious and are therefore very prominent as
professional malpractice and negligence.
The
definition of professionalism varies by place, time, and culture.[9]
While a panel of Arab medical professionals and academics found the 6
dimensions of the formulation of professionalism by ABIM appropriate to the
Arab context, they added autonomy to make 7 dimensions.[10] A
US study found little difference between native and immigrant medical students
in perceptions of professionalism but differences were found between graduates
of Indian and North American schools.[11] A
Taiwan formulation found differences from the western one with special emphasis
on the centrality of self-integrity and harmonization between personal and
professional roles.[12]
Most
existing definitions of professionalism were formulated from a European
perspective that is based on secular, Greco-Roman, and Judeo-Christian world
views. This perspective is found in all parts of the world where Europeans
settled (Americas, Australia, New Zealand, and South Africa) or where they
dominate the intellectual and professional scene. Because of its different
world view, the Muslim world is also challenged to formulate a definition of
professionalism that could differ from the European one. In this paper I shall
use the formulation of professionalism by ABIM as a prototype of the European
formulation and then present what I think should be the Muslim formulation.
The
ABIM formulation of professionalism is a fair representation of the thinking in
Europe and America. It listed 6 dimensions of good professionalism (altruism,
accountability, excellence, duty, honor and integrity, and respect for others) and
also listed 5 attitudes, behaviors, and actions that erode professionalism (abuse
of power and sexual harassment, conflicts of interest, professional arrogance,
physician impairment, and fraud in research).[13] The
ABIM formulation is very practical and pragmatic by having both positive and
negative definitions that leave little room for ambiguity. It has some defects:
it is not exhaustive enough and has no statement of an underlying moral theory
that could be the basis for the intangibles of professionalism which as
mentioned above exist but are not obvious. The formulation below from a Muslim
perspective attempts to overcome these defects.
Professionalism from an Islamic
perspective should be based on basic values that consist of faith (iman),
consciousness (taqwat), best character (ahsan al akhlaq),
excellent performance (itqaan al ‘amal), strife toward perfection (ihsan),
responsibility (amanat), and self-accountability (muhasabat al nafs).
Iman improves professionalism in two
ways: (a) motivating the practice of holistic medicine emanating from the integrative
doctrine of tauihd (b) making the physician more humble and less
arrogant through the realization that he is an agent and the not the cause of
cure; cure is in Allah’s pre-determination, qadar. Taqwat makes
the physician conscious of his duties and meticulous in performance in the full
knowledge that Allah is watching and knows all what is being done unlike human
observers who cannot see hidden mistakes and bad intentions. Akhlaq
ensure the best human interaction between the physician on one hand and the
patients and professional colleagues on the other hand manifesting as balance (tawazun),
humility (tawadh’u), brotherhood (ukhuwwat), social
respectability (muru’at), Itqan and ihsan motivate
the physician to improve his skills and knowledge to have the best outcome in
his medical procedures. The physician should take his work as a trust (amanat),
involving: sincerity of intentions (ikhlas al niyyat); quality
work (itqan & ihsan), and social responsibility. As one
author observed professionalism is part of the social contract involving responsibility of the professional to society.[14]
The physician will accept accountability (muhasabat) for any defects in
the work and will be ready to make corrections and amends.
Table #1:
Proposed Islamic formulation of the basic values of professionalism
Faith (iman)
Consciousness (taqwat)
Best character (ahsan
al akhlaq),
Excellent
performance (itqaan al ‘amal),
Strife toward
perfection (ihsan),
Responsibility (amanat),
Self-accountability
(muhasabat al nafs).
Brief
history of professionalism
Professionalism
has grown pari passu with the development of medical knowledge and
medical technology. The earliest medical professionals doubled as religious
leaders because religion and medicine were inseparable. In Pre-historic times
magic and superstition were mixed with medical care and were closely related to
the prevailing belief systems. Mesopotamian medicine was magico-religious with
priests serving also as physicians. Early Egyptian medicine was mystical and
priestly. Chinese, Indian, Roman, and Greek medicine were related to religions
and beliefs and religious leaders played leading roles. European medicine of
the Middle Ages was closely related to religious beliefs and the Christian
priests had leading roles. In my understanding Muslim medicine was the first to
have physicians who did not have a religious vocation and in reality many of
the leading physicians in the Abassid era, the golden era of Muslim medicine,
were not Muslims. Professionalism was taken seriously in the Abassid era with
physicians having to pass a rigorous examination before being allowed to
practice.
Modern
European medicine was stimulated by the transfer through translations of Muslim
medicine from the Near East and North Africa through Spain and Italy to the
rest of Europe. The empirical approaches of Muslim medicine stimulated the
growth of medical science and technology starting in the renaissance and
culminating in the great discoveries of the late 19th and early 20th
centuries of the Gregorian calendar. Before the era of scientific medicine the
medical profession was in general practiced by untrained people in the home and
outside the home. Professionalism
started when scientific medicine required specific professional training with
medical schools being set up in Baghdad and Cairo and later in various European
cities. The professional standards required increased with growth of medical
knowledge and technology with the emphasis being practical skills and
knowledge.
Medical
professional organizations starting in the 19th century were
essentially ‘trade unions’ with the objective of protecting and promoting the
interests of the members. The first task they addressed was to improve the
knowledge and skills of professionals to gain public respect for example a
medical and surgical journal founded in Philadelphia in 1826 had the objective
of changing the poor public opinion of the medical profession.[15] After
gaining respect for the profession by improving standards of training and
practice, the professional bodies turned to their main mission of protecting
the interests of their members that sometimes involved forays into
controversial political advocacy[16]
and they can run into conflicts of interest especially if they accept money
from commercial organizations.[17]
By
the end of the 20th century professionalism changed to fit the
changing medical scene.[18]
Professionalism became formal codes of professionalism[19] that
physicians were required to follow although full compliance was not always guaranteed.[20]
The human dimension of professionalism that was known before the technology era
found renewed emphasis with patient-physician relation came to the fore. The
pressures of managed medicine resulted in a situations in which physicians were
no longer independent professionals with the last word on how to treat their
patients but have to consider managerial wishes regarding resources.[21] The increasing democratization of society and
the assertion of patient rights forced a change from a paternalistic model of
practice under which the physician was assumed to know what was in the
patient’s best interests to the autonomy model that envisages a role for the
patient in medical decision making and control of treatment. Medical
e-professionalism and tele-medicine were another challenge than changed medical
professionalism by eliminating the direct physician-patient interaction[22].
Brief
history of professional organizations
Several
types of professional organizations can be described according to objectives:
defense and promotion of professional interests of physicians, defining and
enforcing professional standards in medical training and practice, promoting
academic research and exchange, and outreach to the community. I shall describe
representative examples of each type of organization.
Modern
medical professional organizations arose in the 19th century of the
Gregorian calendar in Europe and America with the primary objective of
advocating for the interests of their members. They had the additional role of
establishing and enforcing professional codes[23] but
this role has been shared with governmental or semi- governmental
organizations. Among the earliest professional organizations set up to defend and
promote doctors’ rights were the British Medical Association (BMA) in the UK,
the American Medical Association (AMA) in the US, and the Canadian Medical
Association (CMA) in Canada. The forerunner of BMA was formed in 1832 as a
trade union for doctors in Britain and got its present name in 1856. It publishes the British Medical Journal and
runs various educational programs for its members.[24]
AMA was established in 1847, represents the majority of US doctors, and publishes
the Journal of the American Medical Association (JAMA). Its main work it advocacy
for its members: lobbying for favorable legislation at federal and state
levels, defending private medical care, limiting damages for malpractice.[25]
CMA is the largest physician organization in Canada set up in 1867. It fights
for physician interests and runs a pension fund for them.[26]
Professional organizations that
regulate the registration and disciplining of physicians exist in all countries
and are governmental or semi-governmental. Among the earliest was the General
Medical Council in the UK set up by Parliament in 1856. It sets standards for
registering doctors. It maintains professional standards, disciplines
physicians, and regulates standards of under graduate and post graduate
education.[27]
The role of GMC in the US is undertaken by statutory bodies at the state level.
In Saudi Arabia this role is undertaken by the Saudi Commission for Health
Specialties established by Royal Decree No. M/2 on 6/2/1413 AH to undertake
several roles: registration and training of health professionals.[28]
Postgraduate medical education in
the UK, US, Canada, Australia, and New Zealand is controlled by private
non-governmental colleges, one for each specialty. Some of the colleges were
set up a long time ago for example the Royal College of Physicians of London
was set up in 1518 and The Royal College of
Surgeons of Edinburgh was set up in 1505. Doctors who
complete postgraduate training are admitted to membership of a royal college
(in the UK, Canada, Australia, and New Zealand) and to the American Board in
each specialty.
Each
academic medical discipline set up a professional academic association that
publishes a journal and holds seminars and conferences. The number of associations
is increasing daily as growth of knowledge leads to more sub-specialty specialization
requiring an association for each sub subspecialty or sub-sub specialty. These
organizations focus on research and academic exchange among members. They also
play a role in fostering networking among members. Academic associations can
join regional and international federations.
Some
professional organizations are set up on the basis of faith such as the
Christian Medical Associations[29]
and the Jewish Medical Association.[30] The Islamic medical associations (IMAs) have
played many roles in disaster relief, medical assistance, famine relief, and
other humanitarian programs. The first IMA was set up in the US and Canada in
1975.[31]
It was followed by IMAs in Jordan, Malaysia, Egypt, Pakistan, South Africa,
Uganda, and others. They united to form the Federation of Islamic Medical
Associations (FIMA) in 1981.[32]
IMAs are also interested in the Islamic perspective of medicine.
Teaching
professionalism
Growing
awareness of the importance of professionalism and the horrors of the
consequences of its failures have forced including professionalism in medical
curricula at undergraduate and postgraduate levels.[33]
Schools struggled to introduce a culture of professionalism using various
strategies[34]
including integration of ethics and humanities.[35] The teaching should be as early as possible in the medical
course before students pick up bad habits. Professionalism in Ireland was taught as
an interdisciplinary course assessed by a student essay[36]
and in California as part of an integrated longitudinal program starting early
in the medical course.[37]
Among teaching methods used were: use of simulated emails,[38]
using movies,[39] medical
television programs portraying hospital practice,[40] discourses
on professionalism,[41]
online programs,[42] and learning from malpractice suits and malpractice
experiences.[43]
Teaching of professionalism can be
passive as apprenticeship. Apprenticeship remains the best method because it is
one to one and teaches practical wisdom[44]
and students learn from good role models.[45] The
disadvantage of apprenticeship is that students may feel deficient in
professionalism if they do not get teachers who are good role models.[46]
Assessing
professionalism
Due to its central role in medical
practice, professionalism has been assessed among students and among physicians
in practice. Student assessment can be at the start, during, and at the end of
the medical course.[47] Assessment at the start is useful to detect
and start correcting unprofessional behaviors and attitudes. Assessment enables
us assess whether what students know is what the teachers taught.[48] Professional attitudes
are set quite early in the student’s career by the ‘hidden curriculum’. Early
assessment enables discoveries of unprofessional attitudes and behaviors quite
early. Exposure to unprofessional behavior was least in the first year and
highest in the fifth year.[49]
Unprofessional behavior in student days is likely to resurface during
internship[50]
and professional practice.[51]
Students with low professionalism are more prone to errors.[52]
Various approaches are used in
assessment. Special instruments have been developed such as the Nijmegen
Professional Scale developed in the Netherlands[53]
and the Professional Mini Evaluation instrument developed in Canada.[54] Other
approaches used are: assessing knowledge, attitudes, and practice of
professionalism;[55]
peer assessment of professionalism,[56] assessment of
student behaviors such as fulfilling duties,[57]
and analysis of student narratives on critical
incidents.[58]
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