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
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2 components: content and methods of teaching.
Will focus on content
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Teaching doctors is too late; we need to start
at medical school
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Medical student professionalism should be
assessed too early and if necessary weed out bad ones
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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
·
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
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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
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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 .
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The prophetic teaching at Dar al Arqam: one to
one, observation
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Hadith literature: words, actions, and iqrar
Implications of reviving the holistic education
tradition
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Relative separation of service from teaching;
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Doing service while teaching vs. teaching while
doing service
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Teaching confined to only those who can / are
willing to be good role models
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Teachers should have enough time to teach with
reduced clinical loads
Assessing
professionalism: motivation
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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.
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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
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Nijmegen Professional Scale developed in the
Netherlands[xxxvii]
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Professional Mini Evaluation instrument
developed in Canada[xxxviii].
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Assessing knowledge, attitudes, and practice of
professionalism[xxxix];
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Peer assessment of professionalism[xl],
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Assessment of student behaviors such as
fulfilling duties[xli]
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