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Presentation at a Grand Round, King Abdullah Medical City held at Makkah AlMukarramah, Saudi Arabia on 11 April 2017 by Professor Omar Hasan Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the Ethics Committee King Fahad Medical City.
PROFESSIONALISM:
• Concept of professionalism
• Development of professionalism
• Types of professional organizations
• 6 dimensions of professionalism – ABIM (American board of internal medicine) : altruism, accountability, excellence, duty, honor and integrity, respect for others
PROFESSIONALISM… Con’t.
• Negative ‘dimensions’ of professionalism – ABIM: abuse of power and sexual harassment, conflicts of interest, professional arrogance, physician impairment, fraud in research.
• Proposed 7 dimensions 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).
• Best teaching of professionalism is by apprenticeship.
CASE SCENARIO # 1:
• The Director of the residency program stopped 2 consultants from teaching because he thought that their work was not professional. They protested that they could not practice proper medicine because of the time pressure too many patients to see in a short time.
CASE SCENARIO # 2:
• A hospital director refused to employ a newly graduated resident with good recommendations and high grades because he remembered him as a very unprofessional and dishonest student.
CASE SCENARIO # 3:
• The hospital director was planning to terminate the contract of the best cardiovascular surgeon in the hospital because of immoral behaviors outside work. In 10 years of working at the hospital no ethical or professional infraction was reported on him.
PHYSICIAN PROFESSIONAL RELATIONSHIPS & DUTIES*:
• Physician roles
• Doctor’s duty to the profession 1
• Doctor’s duty towards colleagues
CASE SCENARIO # 1:
• The Ministry of Health issued a new policy that all doctors in its hospitals must be engaged in research and that research would be included in professional performance evaluation. There was a great protect by physicians who said they hardly had enough time for their patients where would they find the time to do research? How would you solve this problem?
CASE SCENARIO # 2:
• The hospital manager disciplined a physician who was 2 hours late for his cardiac follow up clinic because he was in a community program on prevention of cardiovascular disease. What do you think about this? What principles will you use?
CASE SCENARIO # 3:
• Hospital director wanted to discipline a doctor who refused to treat a patient with chronic bronchitis and had refused to give up smoking with the result that he had to come to the emergency room 2 or 3 times a week.
RELATIONS WITH THE PHARMACEUTICAL INDUSTRY AND CONFLICTS OF INTEREST
• Conflict of interest is Financial or non-financial benefit that affects professional judgment and practice
• Do small gifts affect the doctor’s judgment and prescription habits?
• Are physicians influenced to add medicine to the hospital formulary?
• Do gifts affect physician reporting of research results?
• What pharmaceutical companies offer physicians: Free drug samples, Expenses for attending conferences, Payments as consultants, Payments for giving lectures, Payments for research, Drug company representatives give drug information? Accurate? biased
CASE SCENARIO # 1:
• A physician involved in a multi-center clinical trial and receiving substantial financial compensation was told by the pharmaceutical company to terminate the study and he never asked for the reason. What do you think could be the underlying reason?
CASE SCENARIO # 2:
• A researcher was offered a fully paid conference package with his family when he published a paper favorable to the drug being introduced by the pharmaceutical company. The next year he published an unfavorable report about another drug of the company. No conference package was offered and his wife was asking him why they did not go overseas this year. Explain.
MEDICAL PRACTICE AND MEDICAL ERRORS - 1:
• Definition of Medical Error
• Definition of Malpractice
• Definition of Negligence
• Types of negligence: Contributory negligence, Comparative negligence
• Intentional negligence
• The 4 elements of negligence: (a) existence of a duty, (b) breach of the duty, (c) injury resulting from breach of duty, and (d) burden of proof of the causal connection between breach of duty and injury.
MEDICAL PRACTICE AND MEDICAL ERRORS - 2:
• Liabilities: (a) Physician liability: Battery for lack of informed consent, Errors, Neglect of duty: (b) Vicarious liability arises when a physician fails to supervise a junior or a trainee working under him or her. (c) hospital liability (d) manufacturer liability
• The basis of liability: Breach of contract, Tort of negligence, Breach of confidence
• Damages and compensation: Damages for personal injury, Damages for death, Damages for wrongful birth or wrongful life, Other forms of damage
• Disclosure of errors: The physician involved in treating a patient is required to inform the patient of any error. The disclosure must be immediate and complete.
EXAMPLE OF NEGLIGENCE IN GENERAL:
• Treatment without informed consent, false imprisonment or confinement, intentional infliction of emotional distress, defamation (slander if verbal and libel if written), abandonment of a patient, breach of confidentiality, negligent use of drugs and devices, negligent referrals when a physician fails to refer a patient to the right specialist, Failure to warn about risks, Failure to report a notifiable disease, professional errors that may be ordinary/extraordinary, harmful/ non-harmful.
EXAMPLES OF NEGLIGENCE IN OBSTETRICS AND GYNECOLOGY:
• Injuries at birth to both mother and fetus: congenital deformities, wrongful life, stillbirth, psychiatric injury, inappropriate care due to lack of current knowledge, errors of skill or judgment, wrongful termination of pregnancy due to failure to do a pregnancy test before gynecological surgery, failed abortion when an abortion is attempted but is not completed, negligence in fetal screening in which an anomaly is seen at amniocentesis, maternal blood sampling, or fetal blood sampling but it is not followed up, negligence in prescribing for a pregnant woman, false diagnosis of maternal disease that affects the fetus, mistakes in obstetric analgesia and anesthesia, negligence in labor and delivery by failure to detect fetal distress resulting in brain damage.
EXAMPLE OF NEGLIGENCE IN PSYCHIATRY:
• Sexual misconduct, failure to prevent suicide or attempted suicide, failure to prevent patient violence, wrong medication, negligent diagnosis, abandoning a patient, breach of confidentiality, early discharge, failure to hospitalize leading to suicide, failure to commit leading to murder, failure to control symptoms leading to suicide or injury to a 3rd party, negligent certification of mental status.
THE BOOLAM CASE: LEGAL TEST OF NEGLIGENCE:
• The judge ruled that doctors could not be found negligent if they acted according to a professional opinion accepted by a reasonable body of medical opinion even if there could exist a contrary opinion by another responsible body of medical opinion.
THE BOLITHO CASE: LEGAL TEST OF NEGLIGENCE:
• A patient suffered brain damage because the doctor failed to intubate in a home setting. The court ruled that doctors are expected to follow responsible medical opinion but would not be found negligent in cases in which that opinion did not stand up to logical analysis. The court thus set a principle that the court could over-rule medical opinion that was not logical in a specific case. The implication of this was that medical opinion was not the final arbiter of the standard of care to be used in defining negligence.
NOTE:
[*] The text was reproduced from Ghaiath MA Hussein Module 3 Doctor’s professional relationships and duties in Professionalism and ethical education for residents (PEER) handbook published by SCHS 2014. The case scenarios are from the author.