Professionalism in medicine (Dr. Mohamed Al-Rukban)

ProfessionalismProfessionalism

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MedicineMedicine

ProfessionalismProfessionalism

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MedicineMedicineByBy

Dr. Mohammed O. Al-Dr. Mohammed O. Al-RukbanRukban

Associate Professor Associate Professor Family Medicine Family Medicine

ConsultantConsultant

Do You Still Remember A Role Model Do You Still Remember A Role Model Who Influenced Your Training?Who Influenced Your Training?

If Yes? Mention Some of Their If Yes? Mention Some of Their Qualities and Attributes.Qualities and Attributes.

• What is professionalism?

• How can we Implement it in the Curriculum?

• How can we Teach it?

• How can we Assess it?

Professionalism

What does professionalism means to you?

• Take a few minutes and write down your thoughts … as a definition or description.

What is Professionalism?• It is not easy to define a It is not easy to define a professionprofession, but it , but it

is likely to have all or Some of the is likely to have all or Some of the following characteristics:following characteristics:– It is a vocation or calling that implies service to It is a vocation or calling that implies service to

othersothers

– It has a distinctive knowledge base which is kept It has a distinctive knowledge base which is kept up to dateup to date

– It determines its own standards and sets its own It determines its own standards and sets its own examinationsexaminations

– It has a special relationship with those whom it It has a special relationship with those whom it serves e.g. patients, students….serves e.g. patients, students….

– It has particular ethical principlesIt has particular ethical principles

• ProfessionalismProfessionalism is a term which is a term which embodies numerous qualities of embodies numerous qualities of physicians as public servants.physicians as public servants.

• It has been described by The American It has been described by The American Board of Internal Medicine (ABIM) as:Board of Internal Medicine (ABIM) as:

““Constituting those attitudes and Constituting those attitudes and behaviors that serve to maintain others behaviors that serve to maintain others interest above physician Self-interestinterest above physician Self-interest””

بطبعه مهنٌي� المسلم بطبعه الطبيب مهنٌي� المسلم الطبيب

“ويؤثرون على أنفسهم ولو كان بهم خصاصة“”ويؤثرون على أنفسهم ولو كان بهم خصاصة”“إن الله يحب من العامل إذا عمل أن يتقن“”إن الله يحب من العامل إذا عمل أن يتقن”“.........إذا ذبحتم فأحسنوا الذبحة.........“”إذا ذبحتم فأحسنوا الذبحة” ال يؤمن أحدكم حتى يحب ألخيه ما يحب ” ال يؤمن أحدكم حتى يحب ألخيه ما يحب ”

لنفسه..“لنفسه..“

'Project Professionalism' (ABIM, 'Project Professionalism' (ABIM, 2001)2001)

Developed the Physician Charter and Developed the Physician Charter and identified identified six key elements six key elements of of professionalism: professionalism:

1- Altruism1- Altruism (giving priority to patient (giving priority to patient interests rather than self-interests); interests rather than self-interests);

2- Accountability2- Accountability (being answerable to (being answerable to patients, society and profession); patients, society and profession);

3- Excellence3- Excellence (conscientious effort to (conscientious effort to perform beyond ordinary expectation, perform beyond ordinary expectation, and commitment to life-long learning); and commitment to life-long learning);

'Project Professionalism''Project Professionalism' (ABIM, (ABIM, 2001)2001)

4- Duty4- Duty (free acceptance of (free acceptance of commitment to service – i.e. commitment to service – i.e. undergoing inconvenience to achieve undergoing inconvenience to achieve a high standard of patient care); a high standard of patient care);

5- Honor and integrity5- Honor and integrity (being fair, (being fair, truthful, straightforward, and keeping truthful, straightforward, and keeping to one's work); to one's work);

6- Respect for other6- Respect for other (respect for (respect for patients and families, colleagues, patients and families, colleagues, other healthcare professionals and other healthcare professionals and students and trainees).students and trainees).

The concept of professionalism includes the following values:

HonestyHonestyTrustTrustServiceServiceCommitmentCommitment

CommunicationCommunicationAccountabilityAccountabilityLife-long learningLife-long learning

Defining ProfessionalismDefining Professionalism

What specific behaviors are What specific behaviors are unprofessional in unprofessional in

classroom and clinical classroom and clinical settings?settings?

Examples of Unprofessional Behaviors

Classroom Setting-Students/Trainee

• Arriving for class late and/or leaving early• Being unprepared for group sessions• Not completing assigned tasks• Disrupting class sessions• Failing to attend scheduled class sessions• Cheating on an exam

Examples of Unprofessional Behaviors

Classroom Setting-Students/TraineesClassroom Setting-Students/Trainees

• Using Mobile Phone during classUsing Mobile Phone during class• Chatting during classChatting during class• Focusing on the test vs. learningFocusing on the test vs. learning• Prejudging content in advancePrejudging content in advance• Intolerance of the opinions of othersIntolerance of the opinions of others

Examples of Unprofessional Behaviors

Classroom Setting-Faculty

• Plagiarism• Judgmental attitude or favoritism• Coming late• Sloppy handouts and syllabi• Abusive behavior• Using Mobile Phone during class

Examples of Unprofessional Behaviors:

Clinical Setting-Students

• Dressing inappropriately• Avoiding work and/or responsibilities• Exhibiting little empathy for patients• Demonstrating lack of sensitivity to patients’

cultural backgrounds• Not protecting patient confidentiality

Examples of Unprofessional Behaviors:

Clinical Setting: Faculty Clinical Setting: Faculty

• Showing favoritism Showing favoritism • Failing to attend scheduled sessionsFailing to attend scheduled sessions• Using inappropriate language or behaviorUsing inappropriate language or behavior• Asking learners to perform personal tasks, for Asking learners to perform personal tasks, for

example, picking up laundryexample, picking up laundry

Common Examples

• Marketing for a new drug?Marketing for a new drug?

• Conflicts between government vs private Conflicts between government vs private commitments.commitments.

Signs and SymptomsSigns and Symptoms The work of Project Professionalism The work of Project Professionalism

(ABIM, 2001) describes unprofessional (ABIM, 2001) describes unprofessional behaviour in terms of behaviour in terms of sevenseven broad broad categories of 'categories of 'signs and symptomssigns and symptoms'. '.

1- Abuse of power 1- Abuse of power (abuse while (abuse while interacting with patients and interacting with patients and colleagues; bias and sexual colleagues; bias and sexual harassment; and breach of harassment; and breach of confidentiality); confidentiality);

2- Arrogance2- Arrogance (offensive display of (offensive display of superiority and self-importance); superiority and self-importance);

3- Greed3- Greed (when money becomes the (when money becomes the driving force); driving force);

Signs and SymptomsSigns and Symptoms4- Misrepresentation4- Misrepresentation ( (lyinglying, which is , which is

consciously failing to tell the truth; and consciously failing to tell the truth; and fraudfraud, which is conscious misrepresentation , which is conscious misrepresentation of material fact with the intent to mislead); of material fact with the intent to mislead);

5- Impairment5- Impairment (any disability that may prevent (any disability that may prevent the physician from discharging his/her the physician from discharging his/her duties); duties);

6- Lack of conscientiousness 6- Lack of conscientiousness (failure to fulfill (failure to fulfill responsibilities); responsibilities);

7- Conflicts in interests 7- Conflicts in interests (self-promotion/ (self-promotion/ advertising or unethical collaboration with advertising or unethical collaboration with industry; acceptance of gifts; and misuse of industry; acceptance of gifts; and misuse of services – overcharging, inappropriate services – overcharging, inappropriate treatment or prolonging contact with treatment or prolonging contact with patients).patients).

How professionalism How professionalism can be implemented?can be implemented?

Professionalism and Curriculum Design

PerformanceOf Task

Patient managementPatient management

KnowledgeKnowledge

Practical proceduresPractical procedures

Patient investigationPatient investigation

Clinical skillsClinical skills

Health promotion and Health promotion and Disease preventionDisease prevention

Decision making skills and clinicalreasoning and judgment

Basic, Social and clinical sciences

Personal DevelopmentPersonal Development& Lifelong Learning & Lifelong Learning

Role of the doctor within the health service and communityRole of the doctor within the health service and community

PerformanceOf task

Professionalism

• Role of the doctor within the health service– Understanding of the

health care system– Understanding of clinical

responsibilities– Appreciation of doctor as

researcher– Appreciation of doctor as

mentor or teacher– Appreciation of doctor as

manager including quality control

– Team working

• Personal Development– Lifelong Learner– Self awareness– Self confidence– Self regulation

• Self care• Self control• Personal time

management

– Motivation• Achievement drive• Commitment• initiative

– Career choice

How professionalism can be How professionalism can be taught?taught?

Professionalism in the Professionalism in the CurriculumCurriculum There is strong support for professionalism to be There is strong support for professionalism to be

considered as: considered as: A learning outcomeA learning outcome (ACGME, 2007; Harden (ACGME, 2007; Harden etet al., 1999; CanMeds 2000), al., 1999; CanMeds 2000), A skill setA skill set (Emanuel, 2004)(Emanuel, 2004) or or A competenceA competence (Leach, 2004; Hester and Kovach, 2004; Fryer-Edwards & (Leach, 2004; Hester and Kovach, 2004; Fryer-Edwards &

Baernstein, 2004).Baernstein, 2004). Many medical schools have their integrated Many medical schools have their integrated

curriculum content about professionalism within curriculum content about professionalism within their curriculum, added courses on their curriculum, added courses on professionalism in the first two years, or have professionalism in the first two years, or have introduced behaviour into the clinical clerkshipsintroduced behaviour into the clinical clerkships

(Whitcomb, 2002).(Whitcomb, 2002).

Curriculum content relating to Curriculum content relating to professionalismprofessionalism

The key attributes of a professional:The key attributes of a professional: ethics, decision making/moral reasoning, ethics, decision making/moral reasoning,

humanism, multiculturalism, empathy values, humanism, multiculturalism, empathy values, truth telling, care for the vulnerable, trust, truth telling, care for the vulnerable, trust, attitudes and communication, confidentiality of attitudes and communication, confidentiality of patient data, contact with patients, emotional patient data, contact with patients, emotional intelligence, mental health, and self-assessment intelligence, mental health, and self-assessment (using reflective practice).(using reflective practice).

systematic review, Veloski systematic review, Veloski etet al. (2005) al. (2005)

These should be integrated into the component These should be integrated into the component courses of the curriculum rather than taught as a courses of the curriculum rather than taught as a stand alone course.stand alone course.

How Students LearnProfessional Values

Bring some to medical school with them.

Learn some through the formal curriculum.

Learn some from role models.

When Are Values Taught?

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Long Post Short Off

Shift Type Call

How can We Teach Professionalism?

• Role Modeling

• Bed Side Teaching

• Simulated Patients

• Small Group Discussions

Do that.. & Don’t do

that

Follow Me

How can professionalism be How can professionalism be Assessed?Assessed?

Miller’s Triangle

Knows

Shows how

Knows how

Does

Pro

fess

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Pro

fess

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Written, Oral orComputer based assessment

Performance or hands on assessmentPortfolios

Use Suitable Assessment Tools

• Multiple choice questions-Knows??• Faculty evaluations-Knows, knows

how, shows how??• Clinical vignettes & OSCE & OSPE-

Knows, knows how??• Standardized patients-Knows how,

shows how??

Assessment of Assessment of ProfessionalismProfessionalism

Structured, standardized rating scales are the Structured, standardized rating scales are the most effective measure. most effective measure.

The Outcome Project (ACGME, 2007) and Project Professionalism (ABIM, 2001)The Outcome Project (ACGME, 2007) and Project Professionalism (ABIM, 2001) Rating scales have been used in two contexts: to Rating scales have been used in two contexts: to

assess performance in the workplace, through assess performance in the workplace, through direct observation direct observation (Cohen, 2001); (Cohen, 2001); and to assess how and to assess how the students respond to case vignettes the students respond to case vignettes (ACGME, 2007). (ACGME, 2007).

The PMEX (Professionalism Mini Evaluation The PMEX (Professionalism Mini Evaluation Exercise) of the ABIM Exercise) of the ABIM (Norchi (Norchi et et al., 2003) al., 2003) and EPRO-GP and EPRO-GP (van de Camp (van de Camp et et al., 2005) al., 2005) are examples of rating scales are examples of rating scales for assessing professionalism in the workplace. for assessing professionalism in the workplace.

For assessing professionalism using case For assessing professionalism using case vignettes, both ACGME vignettes, both ACGME (ACGME, 2007) (ACGME, 2007) and ABIM and ABIM (ABIM, (ABIM,

2001) 2001) have compiled compendia of case vignettes.have compiled compendia of case vignettes.

Assessment of Assessment of ProfessionalismProfessionalism

Rating scales have been used to assess Rating scales have been used to assess professionalism in a variety of settings. professionalism in a variety of settings.

ACGME, for example, uses rating scales in: ACGME, for example, uses rating scales in: self-assessment; direct observation by self-assessment; direct observation by faculty; ethics OSCE stations; peer-faculty; ethics OSCE stations; peer-assessment assessment (Hafferty, 2002); (Hafferty, 2002); and 360 degree and 360 degree assessment assessment (Kirk, 2007). (Kirk, 2007).

All the above rating scales have All the above rating scales have demonstrated validity and feasibility. demonstrated validity and feasibility.

(Holmboe (Holmboe et et al., 2003; van de Camp al., 2003; van de Camp et et al., 2005) al., 2005)

Reliability, however, in many of these Reliability, however, in many of these examples is not yet available.examples is not yet available.

How can We Assess Professionalism?

• Peer Evaluation-Peer Evaluation-DoesDoes• Patient Surveys-Patient Surveys-DoesDoes• Staff evaluations-Staff evaluations-DoesDoes• Professionalism Portfolio (self evaluation)-Professionalism Portfolio (self evaluation)-

DoesDoes• 360 degree evaluation-360 degree evaluation-DoesDoes

Take Home MessagesTake Home Messages

• Professionalism should be part of the Professionalism should be part of the formal curriculumformal curriculum

• Professionalism must be taught and Professionalism must be taught and assessedassessed

• Professionalism must be relevant to the Professionalism must be relevant to the society it servessociety it serves

Final WordFinal Word

“ “There is a tendency to There is a tendency to underemphasize the personal underemphasize the personal

characteristics… , because they characteristics… , because they are harder to measure, and to are harder to measure, and to overemphasize the more easily overemphasize the more easily measured indices of academic measured indices of academic

achievement” achievement” Cohen (2002) Cohen (2002)