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Presentation at a Workshop on Professionalism In Clinical Practice held at Princess Noura University, Riyadh on 12 February 2020. By Professor Omar Hasan Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the Institutional Review Board and 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.
} 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.
DEFINITION
OF PROFESSIONALISM AS ATTRIBUTES AND BEHAVIORS:
} In general
professionalism is defined as attributes and behaviors expected of a physician.
} A fair level of
agreement can be reached by physicians, nurses, and the public on tangible
behaviors that constitute professionalism.
} 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).
} 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) 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).
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.
} 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.
} 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.
} 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.
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):
} Altruism,
} Accountability,
} Excellence,
} Duty,
} Honor and integrity,
} Respect for
others.
NEGATIVE
‘dimensions’ of PROFESSIONALISM - ABIM:
} 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.
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.
} Schools struggled
to introduce a culture of professionalism using various strategies including
integration of ethics and humanities.
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
and students learn from good role models.
} The disadvantage
of apprenticeship is that students may feel deficient in professionalism if
they do not get teachers who are good role models.
TEACHING
PROFESSIONALISM: Methods
} Ireland: professionalism in Ireland was taught as
an interdisciplinary course assessed by a student essay.
} California: professionalism was taught as part of an
integrated longitudinal program starting early in the medical course.
} Among teaching methods used were: use of simulated
emails, using movies, medical television programs portraying hospital practice,
discourses on professionalism, online programs, and learning from malpractice
suits and malpractice experiences.
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.
} Student assessment
can be at the start, during, and at the end of the medical course.
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 the least in the first year and highest in the fifth
year.
} Unprofessional
behavior in student days is likely to resurface during internship and
professional practice.
} Students with low
professionalism are more prone to errors.
ASSESSING
PROFESSIONALISM: During Training - 2:
} Nijmegen
Professional Scale developed in the Netherlands.
} Professional Mini
Evaluation instrument developed in Canada.
} Assessing knowledge,
attitudes, and practice of professionalism.
} Peer assessment of
professionalism.
} Assessment of
student behaviors such as fulfilling duties.
} Analysis of
student narratives on critical incidents.
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[1]
} Physician roles.
} Doctor’s duty to
the profession 1.
} Doctor’s duty
towards colleagues.
[1] 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.
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 PHARMA-CEUTICAL 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
& wrongful birth,
} Stillbirth,
} Psychiatric
injury,
} 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.