Professionalism

Plato teaches us in The Republic that the ideal leader is someone who commits himself and is trained for a life of service and devotion to fellow citizens^[1] . The power and authority should be directed to the good of others. When directed primarily to self-interest, Plato also teaches, such power and authority corrupt and are dangerous to the good of all. In other words leadership requires competence and the direction of that competence toward human good.

Professionalism is receiving increasing attention both within and beyond academic medicine. Undergraduate medical educators are in a position to provide students a moral compass early in their careers. A recent article by William Branch, MD, contained an appropriate idea: “Good clinical practice cannot be separated from professional ethical behavior. Current clinical training, by focusing summarily on the biomedical aspects of medicine, may inhibit many medical students as moral agents.” Clinical competence and professionalism are intertwined.

Professionalism - Hard to define, but you know it when you see it. It is our desire to try and help you define professional behavior on student RHEP rotations and report behavior indiscretions back to the students’ home school. The students need to be reminded that they are being observed and evaluated on these criteria.

The book “Everything I Needed to Know in Life I Learned in Kindergarten” may become the Primer of professionalism for health professional students. Like common sense and knowing when you’re hungry, this is not rocket science. Honesty, integrity, reliability, dependability, non-judgmental behavior-these are characteristics that we would like to see in everyone. Probably the hardest part of being health care professionals is that we have no “off and on” times when this behavior is expected or not. It has to be part of our lives, day in and day out. This made the most sense to me when I went over some professional scenarios with the students.

As individuals, health care professionals' personal values may vary, but as members of their professions, they are expected to share and uphold those values that characterize the practice of healing and medicine. Three major features of medical professionalism—the ethic of service, clinical autonomy and self-regulation—benefit society. They should be willing to take reasonable risks to themselves when required to do so to meet the needs of patients. This does not mean doing the most for patients but doing what will benefit them clinically. Those in the medical professions are characterized by a strong commitment to the well-being of patients, high standards of ethical conduct, mastery of an ever-expanding body of knowledge and skills, and a high level of autonomy.

Characteristics:

Self-sacrifice requires the physician-leader to be “other-directed”, not “self-directed”

Self-effacement means that clinical judgment should not be affected by differences between doctors and patients, such as class, gender and race, which can introduce irrelevant and destructive bias into clinical judgment and practice

Compassion means that the physician should always be aware of the patient's pain, suffering, and distress and promptly seek to ameliorate them.

Integrity requires the physician to practice medicine according to standards of intellectual and moral excellence. Essential to integrity is open and honest communication with subordinates and accountability.

Self-regulation: Health professionals have traditionally been granted this privilege by society. It includes the control of entrance into the profession by establishing educational standards and setting certifying examinations, the licensing of its members, and the establishment and ongoing review of standards of medical practice. In return for this privilege, health care professionals are expected to hold each other accountable for their behavior and for the outcomes they achieve on behalf of their patients. It has evolved into a partnership with the public. The profession's commitment to the maintenance of those standards is demonstrated by its willingness to participate in outcomes review at many levels, from institutional quality assurance activities to formal prospective peer review, and to actively support their statutory and legislated licensing authorities.

The competent health care professional should possess the adequate knowledge, judgment, professionalism, and clinical and communication skills to provide high-quality patient care. Patient care encompasses the promotion of health; prevention of disease; and diagnosis, treatment, and management of medical conditions with compassion and respect for patients and their families. Maintenance of competence should be demonstrated throughout the health professional’s career of lifelong learning and ongoing improvement of practices.

The four required elements for maintenance of certification are: Evidence of professional standing, evidence of a commitment to lifelong learning and involvement in a periodic self-assessment, evidence of cognitive expertise, and evidence of evaluation of performance in practice.

Professionalism in health care professionals comprises those attributes and behaviors that serve to maintain the interest of the patient above one's own self-interest.

A commitment to the highest standards of excellence in the practice of medicine and in the generation and dissemination of knowledge.

A commitment to the attitudes and behaviors that sustain the interests and welfare of patients.

A commitment to be responsive to the health needs of society. Professionalism aspires to altruism, accountability, excellence, duty, service, honor, integrity, and respect for others.

The interest of the patient lies above self-interest--an indispensable attribute of all health professional transcending our technical abilities, our scientific knowledge, and even our attitudes of compassion and caring. What it means is that we offer to others a special sensitivity. To remain professionals, dignity and understanding must permeate all our interactions--all our thinking, teaching, learning, and listening.

At its most fundamental level, the practice of medicine should not be regarded as a science, an art, or a business, even though each of these elements is essential. The practice of medicine is rooted, instead, in a relationship between the patient as person and the physician as professional.

The principle of confidentiality is one of the most widely accepted and historically influential principles governing the patient-physician relationship in Western cultures. The Hippocratic oath mandates that the physician not divulge “whatsoever I shall see or hear in the course of my profession as well as outside my profession in my intercourse with men, if it be what should not be published abroad.” The 1980 Principles of Medical Ethics of the American Medical Association mandate that the physician “shall safeguard patient confidences within the constraints of the law.”

Confidentiality is important as a way of encouraging patients to be frank in their communications and preserving confidentiality strengthens the relationship between an autonomous patient and a professional physician.

As the delivery of health care has changed from the model of a single physician caring for individual patients to the model of a team of health care workers in an institutional setting caring for a wide variety of patients, the mandate of confidentiality has changed. The emphasis has switched from physicians keeping secrets to physicians divulging patient information only to those health care team members and other institutional employees who need the information, either to provide appropriate care or to meet appropriate institutional needs (e.g., monitoring quality of care or organizing reimbursement). The underlying theme remains that information should not be provided to anyone else without the patient’s consent.

PERFORMANCE-BASED ASSESSMENT OF PROFESSIONALISM

There are many who say we need to judge and rate professionalism, but a Medline search did not find one tool that is being used consistently by any group. It all seems so hard to quantify. I found one form available on-line from UCSF, and they called it “physicianship” – this is under separate cover – and we will discuss it separately.

Also, other ideas are:

1. The students keep a log of learning issues, which points at self-reflection

2. Have them work on ethical vignettes as a group or singly to examine value systems

3. Do meaningful community service – with reflective service learning, to show community engagement and interaction

4. Discuss in small groups the economics of medicine – where values are placed by society and the individual

5. Examine personal commitment to the altruistic nature of being a healer