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Presented at Alyamamah Hospital Riyadh on June 29, 2021 by Professor Dr. Omar Hasan Kasule Sr. MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Ex-Chairman, Human and Medical Ethics Committee, KFMC and Consultant Academic and Training Affairs, R2 Cluster.
OVERVIEW:
} Define
professionalism, its dimensions, and its teaching.
} Describe the
principles of medical ethics.
} Case scenarios of
professionalism and ethics.
ETHICS AND
PROFESSIONALISM: The Inner and Outer Dimensions
} Ethics and
professionalism are closely interlinked in good patient care but they come from
different conceptual backgrounds. Both are difficult to define exactly.
} In my view ethics
is the inner dimension while professionalism is the outer dimension. Ethics is
difficult to police but some consequences of lack of ethics can be detected.
} Professionalism
being an outer dimension would have been easy to police if it was easy to
define.
} The relation
between ethics (right vs wrong) and law (legal vs illegal) is complex and
differs between the Islamic and Western perspectives. Is right = legal? Is
wrong = illegal? How about exceptional circumstances (dharurat)?
CASE SCENARIO:
Professionalism or Ethics?
} Physician A called
in for consultation assessed the patient and told physician B (the attending
physician) that the patient needed ultrasound to rule out acute abdomen.
} Physician B
quoting official hospital policy disagreed insisting that if acute abdomen is
suspected general surgeons should be called in.
} Physician A
suddenly started to raise his voice with high tone and shouting in front of the
patient with all staff and patients and visitors watching.
} Physician A then
left while physician B was thinking ‘this attitude is affecting me as a health
care provider. Shouting and disrespecting me in my work place and I wonder, why
he would do such attitude to me.
DEFINITION OF
PROFESSIONALISM AS ATTRIBUTES AND BEHAVIORS:
} In general, professionalism is defined as attributes and behaviors expected of a healthcare
provider.[1]
} A fair level of
agreement can be reached by physicians, nurses, and the public on tangible
behaviors that constitute professionalism.[2],[3]
} 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).[4]
} 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)[5] 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).[6]
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.
6
DIMENSIONS OF PROFESSIONALISM - ABIM (AMERICAN BOARD OF INTERNAL MEDICINE)[7]
} Altruism
} Accountability
} Excellence
} Duty
} Honor and
integrity
} Respect for others
NEGATIVE
‘DIMENSIONS’ OF PROFESSIONALISM - ABIM[7]
} 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 ensures 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.[8]
TEACHING
PROFESSIONALISM - 1: 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.[9],[10]
} Schools struggled
to introduce a culture of professionalism using various strategies[11] including integration of
ethics and humanities.[12]
TEACHING
PROFESSIONALISM - 2: Approaches
} The teaching
should be as early as possible in the medical course before students pick up
bad habits.
} Teaching professionalism can be passive as apprenticeship.
} Apprenticeship
remains the best method because it is one to one and teaches practical wisdom[13] and students learn from
good role models.[14]
} The disadvantage
of apprenticeship is that students may feel deficient in professionalism if
they do not get teachers who are good role models.[15]
TEACHING
PROFESSIONALISM - 3: Methods
} Ireland:
professionalism in Ireland was taught as an interdisciplinary course assessed
by a student essay.[16]
} California:
professionalism was taught as part of an integrated longitudinal program
starting early in the medical course.[17]
} Among teaching
methods used were: use of simulated emails,[18] using movies,[19] medical television programs portraying hospital practice,[20] discourses on
professionalism,[21] online
programs,[22] and
learning from malpractice suits and malpractice experiences.[23]
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 is confined
to only those who can / are willing to be good role models.
} Teachers should
have enough time to teach with reduced clinical loads.
} The concept of a
good/bad sunnat.
UNDERLYING
ETHICAL PRINCIPLES:
} The principle of
intention, قاعدة القصد
} The principle of
certainty, قاعدة اليقين
} The principal of
injury, قاعدة الضرر
§ Autonomy of
patient and physician
§ Beneficence
§ Nonmalefacence
§ Justice
} Principle of
hardship فقاعدة المشقة
} Principle of
precedent قاعدة العرف
OTHER
PRINCIPLES:
} Privacy and
confidentiality
} Truthfulness and
disclosure
} Fidelity
ROLES
IN THE HOSPITALS:
} Healer
} Collaborator
} Manager
} Researcher
ROLES
IN THE MINISTRY OF HEALTH:
} Manager
} Planner
} Researcher
ROLES
IN THE COMMUNITY:
} Health educator
} Advocate
} Researcher
} Healer
DUTY
TO THE PATIENT - 1:
} Treat your patient
as a person, not just a body.
} Respect your
patient’s autonomy.
} Treat all patients
equally, without discrimination.
} Fear God when
dealing with your patients; show respect for their beliefs, religions and
traditions.
} Ask only for the
tests needed for the patient without adding any tests not justified by the
patient’s case. A doctor should base his whole diagnosis and treatment on the
best available evidence and data.
DUTY
TO THE PATIENT - 2:
} Explain honestly
to the patient or anyone representing him/her the type, causes, and
complications of the illness, and of the usefulness of diagnostic and
therapeutic procedures.
} Relieve the
patient’s pain and give him the feeling that the physician is eager to give him
proper care and attention.
} Respect Privacy.
} Respect the
patient’s autonomy.
} Inform the patient
about his/her condition.
} Keep the patients’
secrets (confidentiality).
DUTY
TO THE PATIENT - 3:
} DO NOT hesitate to
refer the patient to a more experienced doctor or to a doctor who has more
effective equipment whenever the patient’s case calls for such a referral, nor
to refer him to a doctor whom the patient wishes to consult.
} Continue to give
an emergency patient the proper treatment until it is no longer needed or until
care for the patient is taken over by another doctor.
DUTY
TOWARDS COLLEAGUES:
} Deal with, and act
towards his/her colleagues in a good manner and in the same way he/she would
prefer to be treated.
} Avoid direct
criticism to his/her colleague in front of patients.
} Do not indulge in
defaming the honor of his/her colleagues.
} Exert every
possible effort to educate the colleagues.
} Respect the
differences with colleagues (gender, culture, belief…).
} Respect other
non-physician medical professional colleagues, and appreciate their roles in
the healthcare of the patient.
} Report the
incidence in which a colleague could be dangerous to the authority concerned.
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 repeated
myocardial infarction and had refused to give up smoking, compliance with
dietary and drug treatment with the result that he had to come to the emergency
room 2 or 3 times a week.
CASE
SCENARIO - 4:
} An 80-year old
woman with severe coronary artery disease was in the ICU for the past 6 months
with repeated episodes of MI and cardiac arrest always relieved by CPR. The
physician wrote a DNR order to relieve her from further suffering.
CASE
SCENARIO - 5:
} A 70-year old man
was admitted with severe MI. After initial treatment and stabilization the
doctors decided to offer him a coronary graft operation. His sons told the
doctors to go ahead with the operation without telling the patient the
diagnosis because knowing he had a heart problem would depress him and he might
refuse the operation.
CASE
SCENARIO - 6:
} Physician A called
in for consultation assessed the patient and told physician B (the attending
physician) that the patient needed ultrasound to rule out acute abdomen.
Physician B quoting official hospital policy disagreed insisting that if acute
abdomen is suspected general surgeons should be called in. Physician A suddenly
started to raise his voice with high tone and shouting in front of the patient
with all staff and patients and visitors watching. Physician A then left while
physician B was thinking ‘this attitude is affecting me as a health care
provider. Shouting and disrespecting me in my work place and I wonder, why he
would do such attitude to me.
REFERENCES:
[1] N Z Med J.
2010 May 14;123(1314):123-32.
[2] Acad Med.
2009 May;84(5):566-73.
[3] Clin Med.
2010 Aug;10(4):364-9.
[4] J Med
Philos. 2011 Apr;36(2):114-32.
[5] Majallat al
Ahkaam al Adliiyyat Dar Ibn Hazm Beirut 2004 G / 1424H page 90
[6] Majallat al
Ahkaam al Adliiyyat Dar Ibn Hazm Beirut 2004 G / 1424H page 91
[7] 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.
[8] Perspect
Biol Med. 2011 Autumn;54(4):455-69.
[9] Keio J Med.
2009 Sep;58(3):133-43.
[10] Eur J Intern Med. 2009 Dec;20(8):e148-52.
[11] P R Health Sci J. 2009 Jun;28(2):135-9.
[12] Acad Med. 2012 Mar;87(3):334-41.
[13] J Med Philos. 2011 Apr;36(2):114-32.
[14] Acad Med. 2009 May;84(5):574-81.
[15] Med Teach. 2011;33(10):840-5.
[16] Med Teach. 2011;33(9):710-2.
[17] Med Teach. 2009 Jul;31(7):e295-302.
[18] Acad Med. 2010 Oct;85(10 Suppl):S1-4.
[19] Med Teach. 2009 Jul;31(7):e327-32.
[20] BMC Med Educ. 2011 Jul 29;11:50.
[21] Med Educ. 2011 Jun;45(6):585-602.
[22] Acad Med. 2010 Oct;85(10 Suppl):S68-71.
[23] Acad Med. 2011 Mar;86(3):365-8.