Integrated Medical Education Resources: 141109P

Presentation at a training program for family medicine resident s at the National Guard Madina 9-10 November 2014 by Professor Omar Hasan Kasule Sr. MB ChB (MUK). M{H (Harvard), DrPH (Harvard) Chairman of the Ethics Committee King Fahad Medical City.

Introduction

} 2 components: content and methods of teaching. Will focus on content

} Teaching doctors is too late; we need to start at medical school

} Medical student professionalism should be assessed too early and if necessary weed out bad ones

} Apprenticeship is the best vehicle of teaching professionalism

Concept of professionalism

· Medical professionalism is poorly conceptualized and understood; therefore not easy to define[i].

· As a concept and practice it has its own history and has been evolving.

· The concept has different formulations depending on space-time variations

· Medical students get confused with apparently contradictory concepts of professionalism if they do not realize that they are dealing with different models of professionalism[ii].

Definition of professionalism as attributes and behaviors

· In general professionalism is defined as attributes and behaviors expected of a physician[iii].

· A fair level of agreement can be reached by physicians, nurses, and the public on tangible behaviors that constitute professionalism[iv]^,
[v].

· 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.

Definition of professionalism as intangibles

· Intangible aspects of professionalism 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)[vi].

· Intangibles 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)[vii] 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)[viii].

Definition of professionalism as skills

· Professionalism can also be defined as skills: 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

· It is not possible to list comprehensively skills of a professional 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.

Variation of professionalism perceptions by place and time

· The definition of professionalism varies by place, time, and culture[ix]^,[x].

· 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[xi].

· 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[xii].

· A Taiwan formulation found differences from the western perception with special emphasis on the centrality of self-integrity and harmonization between personal and professional roles[xiii].

Development of professionalism

— Medicine in the family and by religious leaders

— Trained professionals

— Professional organizations

— Professional codes

Types of professional organizations

— Defend the interests of physicians: British Medical Association, American Medical Association, Canadian Medical Association

— Regulate and discipline physicians: General Medical Council of the UK, US State Licensing Boards, Saudi Commission for Health Specialties

— Promote research and academic exchange: Saudi Internal Medicine Association

— Others: Islamic Medical Association of North America, Islamic Medical Association of KSA

6 Dimensions of professionalism – ABIM (American Board of Internal Medicine) [xiv]

· Altruism

· Accountability

· Excellence

· Duty

· honor and integrity

· Respect for others

Negative ‘dimensions’ of professionalism – ABIM¹⁴

· 5 attitudes, behaviors, and actions erode professionalism

· Abuse of power and sexual harassment

· Conflicts of interest

· Professional arrogance

· Physician impairment

· Fraud in research).

Discussion of the ABIM dimensions of professionalism

· The ABIM formulation is very practical and pragmatic by having both positive and negative definitions that leave little room for ambiguity.

· The ABIM formulation is not exhaustive enough

· The ABIM formulation 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.

· Hence the attempt at a formulation from the Muslim perspective attempts to overcome these defects.

Proposed 7 dimensions of professionalism 1

· 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).

Proposed 7 dimensions of professionalism 2

· Iman improves professionalism in two ways: holism and humility

· Iman motivates the practice of holistic medicine emanating from the integrative doctrine of monotheism

· Iman makes 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.

Proposed 7 dimensions of professionalism 3

· 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),

Proposed 7 dimensions of professionalism 4

· 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 (masuliyyat ijtima’iyyat).

· Professionalism is part of the social contract involving responsibility of the professional to society[xv].

Teaching professionalism: motivation

· 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[xvi]^,[xvii].

· Schools struggled to introduce a culture of professionalism using various strategies[xviii] including integration of ethics and humanities[xix].

Teaching professionalism: 2 approaches

· The teaching should be as early as possible in the medical course before students pick up bad habits.

· Teaching of professionalism can be passive as apprenticeship.

· Apprenticeship remains the best method because it is one to one and teaches practical wisdom[xx] and students learn from good role models[xxi].

· The disadvantage of apprenticeship is that students may feel deficient in professionalism if they do not get teachers who are good role models[xxii].

Teaching professionalism: methods

· Ireland: professionalism in Ireland was taught as an interdisciplinary course assessed by a student essay[xxiii]

· California: professionalism was taught as part of an integrated longitudinal program starting early in the medical course[xxiv].

· Among teaching methods used were: use of simulated emails[xxv], using movies[xxvi], medical television programs portraying hospital practice[xxvii], discourses on professionalism[xxviii], online programs[xxix], and learning from malpractice suits and malpractice experiences[xxx].

Teaching professionalism: revival of a holistic educational tradition 1

} Traditional Muslim education based on a student being with the teacher all through the waking hours and being awarded permission to teach others, ijazah, at the end of a long apprenticeship

} The system was not only about transferring knowledge but also transferred ethics, behavior, and attitudes by actual observation and interaction with a mentor.

} The mentor also had ample time to observe the student and correct any deviations

Teaching professionalism: revival of a holistic educational tradition 2

} The Qur’an describes this system in the education of Musa (PBUH) who travelled with the righteous man Khidhr and learned deep ethical lessons from him .

} The prophetic teaching at Dar al Arqam: one to one, observation

} Hadith literature: words, actions, and iqrar

Implications of reviving the holistic education tradition

} Relative separation of service from teaching;

} Doing service while teaching vs. teaching while doing service

} Teaching confined to only those who can / are willing to be good role models

} Teachers should have enough time to teach with reduced clinical loads

Assessing professionalism: motivation

} Due to its central role in medical practice, professionalism has been assessed among students and among physicians in practice.

} Assessment enables us assess whether what students know is what the teachers taught[xxxi].

} Student assessment can be at the start, during, and at the end of the medical course[xxxii].

Assessing professionalism: at the start

} Assessment at the start is useful to detect and start correcting unprofessional behaviors and attitudes.

} 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.

Assessing professionalism: during training

} Exposure to unprofessional behavior was least in the first year and highest in the fifth year[xxxiii].

} Unprofessional behavior in student days is likely to resurface during internship[xxxiv] and professional practice[xxxv].

} Students with low professionalism are more prone to errors[xxxvi].

Assessing professionalism: during training

} Nijmegen Professional Scale developed in the Netherlands[xxxvii]

} Professional Mini Evaluation instrument developed in Canada[xxxviii].

} Assessing knowledge, attitudes, and practice of professionalism[xxxix];

} Peer assessment of professionalism[xl],

} Assessment of student behaviors such as fulfilling duties[xli]

} Analysis of student narratives on critical incidents[xlii]^,[xliii].

[i] Riley S, Kumar N. Teaching medical professionalism. Clin Med. 2012 Feb; 12(1):9-11.

[ii] Borgstrom E, Cohn S, Barclay S. Medical professionalism: conflicting values for tomorrow's doctors. J Gen Intern Med. 2010 Dec;25(12):1330-6.

[iii] Wearn A, Wilson H, Hawken SJ, Child S, Mitchell CJ. In search of professionalism: implications for medical education. N Z Med J. 2010 May 14;123(1314):123-32.

[iv] Green M, Zick A, Makoul G. Defining professionalism from the perspective of patients, physicians, and nurses. Acad Med. 2009 May;84(5):566-73.

[v] Chandratilake M, McAleer S, Gibson J, Roff S. Medical professionalism: what does the public think? Clin Med. 2010 Aug;10(4):364-9.

[vi] Hall DE The guild of surgeons as a tradition of moral enquiry. J Med Philos. 2011 Apr;36(2):114-32.

[vii] Majallat al Ahkaam al Adliiyyat Dar Ibn Hazm Beirut 2004 G / 1424H page 90

[viii] Majallat al Ahkaam al Adliiyyat Dar Ibn Hazm Beirut 2004 G / 1424H page 91

[ix] Wilkinson TJ, Moore M, Flynn EM. Professionalism in its time and place: some implications for medical education. N Z Med J. 2012 Jul 29;125(1358):64-73.

[x] Chandratilake M, McAleer S, Gibson J. Cultural similarities and differences in medical professionalism: a multi-region study. Med Educ. 2012 Mar;46(3):257-66..

[xi] Al-Eraky MM, Chandratilake M. How medical professionalism is conceptualised in Arabian context: a validation study. Med Teach. 2012;34 Suppl 1:S90-5..

[xii] Shah MM, Summerhill EM, Manthous CA. Medical professionalism in the new millennium: are there intercultural differences? Brief report and commentary. Conn Med. 2009 May;73(5):289-94..

[xiii] Ho MJ, Yu KH, Hirsh D, Huang TS, Yang PC. Does one size fit all? Building a framework for medical professionalism. Acad Med. 2011 Nov;86(11):1407-14..

[xiv] American Board of Internal Medicine. Project Professionalism was sponsored by the ABIM Committee on Evaluation of Clinical Competence in conjunction with the ABIM ClinicalCompetence and Communications Programs. For additional copies please call 215-446-3630 or fax 215-446-3470. First printing 1995, second printing 1996, third printing 1997, fourth printing 1998, fifth printing 1999, sixth printing 2000, seventh printing Philadelphia 2001.

[xv] Reid L. Medical professionalism and the social contract. Perspect Biol Med. 2011 Autumn;54(4):455-69..

[xvi] Mueller PS. Incorporating professionalism into medical education: the Mayo Clinic experience. Keio J Med. 2009 Sep;58(3):133-43.