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Presented at the Grand round held at King Salman Heart Center on October 25, 2016 by Professor Dr. Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard), Chairman, Institutional Review Board, KFMC – Head, International Collaboration & Academic Exchange, FOM-KFMC – Chairman, Ethics Committee, KFMC
[*] Lecture to medical students at Majmah University
later published in the Taibah University Journal of Medical Science
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.[1]
·
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.[2]
Definition of professionalism
as attributes and behaviors:
·
In general professionalism is defined as attributes and behaviors
expected of a physician.[3]
·
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.
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).[6]
·
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)[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]
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 & time:
·
The definition of professionalism varies by place, time, and culture.[9],[10]
·
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.[11]
·
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.[12]
·
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.[13]
6 Dimensions of
professionalism – ABIM (American Board of Internal Medicine)[14]
·
Altruism
·
Accountability
·
Excellence
·
Duty
·
honor and integrity
·
Respect for others
Negative ‘dimensions’
of professionalism - ABIM[14]
·
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.[15]
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.[16],[17]
·
Schools struggled to introduce a culture of professionalism using
various strategies[18] including integration of ethics and
humanities.[19]
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[20] and students learn from good
role models.[21]
·
The disadvantage of apprenticeship is that students may feel deficient
in professionalism if they do not get teachers who are good role models.[22]
Teaching
professionalism: Methods
·
Ireland: professionalism in Ireland was taught as an interdisciplinary
course assessed by a student essay.[23]
·
California: professionalism was taught as part of an integrated
longitudinal program starting early in the medical course.[24]
·
Among teaching methods used were: use of simulated emails,[25] using
movies,[26] medical
television programs portraying hospital practice,[27] discourses
on professionalism,[28] online programs,[29] and learning from malpractice suits and
malpractice experiences.[30]
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.[31]
·
Student assessment can be at the start, during, and at the end of the
medical course.[32]
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 - 1
·
Exposure to unprofessional behavior was least in the first year and
highest in the fifth year.[33]
·
Unprofessional behavior in student days is likely to resurface during
internship[34] and professional practice.[35]
·
Students with low professionalism are more prone to errors.[36]
Assessing
professionalism: During training - 2
·
Nijmegen Professional Scale developed in the Netherlands.[37]
·
Professional Mini Evaluation instrument developed in Canada.[38]
·
Assessing knowledge, attitudes, and practice of professionalism.[39]
·
Peer assessment of professionalism.[40]
·
Assessment of student behaviors such as fulfilling duties.[41]
·
Analysis of student narratives on critical incidents.[42],[43]
References:
[1] Clin
Med. 2012 Feb; 12(1):9-11.
[2] J
Gen Intern Med. 2010 Dec;25(12):1330-6.
[3] N Z Med J. 2010 May
14;123(1314):123-32.
[4] Acad Med. 2009
May;84(5):566-73.
[5] Clin Med. 2010
Aug;10(4):364-9.
[6] J Med Philos. 2011
Apr;36(2):114-32.
[7] Majallat al Ahkaam al
Adliiyyat Dar Ibn Hazm Beirut 2004 G / 1424H page 90
[8] Majallat al Ahkaam al
Adliiyyat Dar Ibn Hazm Beirut 2004 G / 1424H page 91
[9] N Z Med J. 2012 Jul
29;125(1358):64-73.
[10] Med Educ. 2012
Mar;46(3):257-66.
[11] Med Teach. 2012;34 Suppl
1:S90-5.
[12] Conn Med. 2009
May;73(5):289-94.
[13] Acad Med. 2011
Nov;86(11):1407-14.
[14] American Board of
Internal Medicine. Project Professionalism was sponsored by the ABIM Committee
on Evaluation of Clinical Competence in conjunction with the ABIM Clinical
Competence 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.
[15] Perspect Biol Med. 2011
Autumn;54(4):455-69.
[16] Keio J Med. 2009
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[17] Eur J Intern Med. 2009
Dec;20(8):e148-52.
[18] P R Health Sci J. 2009
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[19] Acad Med. 2012
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[20] J Med Philos. 2011
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[21] Acad Med. 2009
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[22] Med Teach.
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[23] Med Teach.
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[24] Med Teach. 2009
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[25] Acad Med. 2010 Oct;85(10
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[26] Med Teach. 2009
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[27] BMC Med Educ. 2011 Jul
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[28] Med Educ. 2011 Jun;45(6):585-602.
[29] Acad Med. 2010 Oct;85(10
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[30] Acad Med. 2011
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[31] Yonsei Med J. 2009 Dec
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[32] Med Teach. 2009
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[33] Educ Prim Care. 2011
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[34] J Gen Intern Med. 2007
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[35] Acad Med. 2010 Jul;85(7):1105-7.
[36] Med Teach.
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[37] Med Teach.
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[38] Med Educ. 2009
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[39] Med Teach. 2009 Oct;31(10):928-32.
[40] J Gen Intern Med. 2009
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[41] Clin Teach. 2010
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[42] Acad Med. 2010
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[43] Med Educ. 2009
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