PROFESSIONALISM & PROFESSIONALITY IN MEDICINE & PSYCHIATRY: Challenges and opportunities 1. Medicine and Challenges of Our Time 2. Professionalism & Professionality: Some Key terms 3. The Physician Charter – Defining Professionalism in Medicine 4. How to Overcome Seven Professional Sins or Non-virtues 5. Professional Culture and Identity
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PROFESSIONALISM & PROFESSIONALITY IN MEDICINE & PSYCHIATRY:Challenges and opportunities
1. Medicine and Challenges of Our Time
2. Professionalism & Professionality: Some Key terms
3. The Physician Charter – Defining Professionalism in Medicine
4. How to Overcome Seven Professional Sins or Non-virtues
5. Professional Culture and Identity
Što vidite na ovoj slici?
Koliko godina ima osoba koju vidite?
Što biste s tom osobom rado radili kad bi vam došla u posjetu?
U čemu biste joj rado pomogli ako bi vas zamolila?
Kako danas vidimo profesionalizam i profesionalnost u medicini i psihijatriji?
Part 1
Medicine and Challenges of Our Time
Medicine and challenges of our Liquid timeGlobal economic crisis & Increasing demands for health services with limited resources
Human rights: FREDA
The craft of care has transformed into the machinery of care.
The multiple professions of medicine
The multiple roles of medical doctors
Concerns over cost-effectivenes,
Commercialism, consumerism and market mentality
increasing emphasis on evidence as opposed to clinical experience
Evidence associated with the marketing based clinical trials
The conflict between responsibilities to the individual patient and responsibilities to the wider community
Old vs. New Professionalism
PATERNALISM - Old professionalism is concerned with: 1.exclusive membership, 2.conservative practices, 3.self-interest, 4.external regulation, 5.slow to change, and6.reactive
PARTNERSHIP - New (transformative) professionalism is characterized by 1.inclusive membership, 2. public ethicalcode of practice, 3.collaborativity and collegiality, 4.activist orientation, 5.flexibility and progressivity, 6.responsivity to change, 7.self-regulation, 8.being policy-active, 9.being enquiry-oriented, and 10.knowledge building
(Sachs 2003)
Part 2
Professionalism & Professionality: Some Key Terms
High standards expected from a person who is well trained in particular job
Contract between society and medicine
The way how we define and practice - Fundamental principles
- Professional responsibilities
Professionalism as a contract between medicine and society
Society's Expectations of Medicine: 1. services of the healer, 2. assured competence, 3. altruistic service, 4. morality and integrity, 5. accountability, 6. transparency, 7. source of objective advice, 8. promotion of the public good.
Medicine's Expectations of Society: 1. trust, 2. autonomy, 3. self-regulation, 4. health-care system value driven and adequately funded, 5. participation in public policy, 6. shared (patients and society) responsibility for health, 7. monopoly, 8. status and reward, financial and non-financial: respect and status
Some important terms
Profession - Vocation
Professionalism - Professionality
Professional culture - identity
Professional mission, virtues, ethics - morality
Professional roles - goals
Professional knowledge, skils & values
Professional boundaries - competences
Professional duties - responsibilities
Professional rules - standards
Profession
An occupation that requires extensive training and the study and mastery of specialized knowledge and skills.
Usually profession has been defined in the following terms: 1.possesion of a body of specialized knowledge, skills and compentences; 2.practice within some ethical framework; 3.fulfillment of some broad societal need; and 4.a social mandate that permits substantial latitude in setting standards of education and performance of its members (DeRosa 2006).
It usually requires accreditation, certification, or licencing. It has a specific code of ethics, and it holds members accountable.
Profession controls its own work, organized by a special set of institution sustained in part by a particular ideology of expertise and service (Freidson 1994).
Professionality & Professionalism
Professionality refers to belonging to a profession and behaving in a way that is consistent with professional standards.
It can be defined as an ideologically-, attitudinally-, intelectually-, and epistemologically-based stance on the part of an individual, in relation to the practice of the profession to which s/he belongs, and which influences her/his professional practice (Evans 2008).
Distinction between professionalims and professionaliry is, arguably, that the former is more attitudinal than behavioral in its focus and the latter more functional than attitudinal.
Professionality represent and individual professional behavioral response to professionalism, how professionals practice professionalism in real life, how they delivers the service and/or perform their designated function(s).
The elements of professionalism1. Education/scholarship through substantial intellectual training and development of legal skills, competence and expertise;
2. Integrity recognized through ethical and professionally responsible conduct and practice,
3. Honour including integrity, dignity, courage, and upstanding character,
4. Leadership,
5. Indepenendence from politics,
6. Pride, with an appreciation for the history and traditionof the profession and its modern contribution,
7. Spirit and enhusiasm,
8. Collegiality and civility,
9. Service to the public good, through client relationship and responsibilities for health and social justice,
10. Balanced commercialism, a livelihood motivated by service.
Professionalismthe identification and expression of what is required and expected of a members of a profession (Evans 2008).
a consensus of the norms which may apply to being and behaving as a professional within personal, organizational and broader political conditions (Day 1999).
as „professionality-influenced practice that is consistent with commonly-held consensual delineations of a specific profession and that both contributes to and reflects perceptions of the profession's purpose and status and the specific nature, range and levels of service provided by, and expertise prevalent, within, the profession, as well as the general ethical code underpinning this practice (Evans 2008).
having an internal set of ideals, values and goals as well as standards of performance and behavior.
Professionals aspire to high ideals like altruism, honor and integrity, respect, caring compassion, and communication, responsibility and accountability, and leadership.
Professional ethics
As the learned professions are professed to the welfare of those who seek their help, a profession in the best sense of the term is an ethical enterprise and moral undertaking.
Professional ethics focuses on what people should do or how people shoud act, while professional identity indicates what kind of persons people belonging to a profession should be.
The major pillars of medicine as a profession
1. a specialized body of knowledge,
2. the altruistic service to patients and society
3. the right to establish practice standards for medical doctors (MDs) who maintain them through self regulation
4. the responsibility to guard the integrity of the profession's knowledge and its use
Spandorfer et al. 2010
Part 3
The Physician Charter – Defining Professionalism in Medicine
Fundamental principlesProfessional responsibilities
Contribution of psychiatry to professionalism in medicine
Fundamental principles
Primacy of client/patient welfare
Patient autonomy: FREDA concept
Social justice
Set of Professional responsibilities
Commitment to professional competence
Commitment to honesty with patients
Commitment to patient confidentiality
Commitment to maintaining appropriate relations
Commitment of improving quality of care
Commitment to improving access to care
Commitment to a just distribution of finite resources
Commitment to scientific knowledge
Maintaining trust by managing conflicts of interest
Commitment to professional responsibilities
Contribution of psychiatry to professionalism in medicine (Jakovljevic 2012)
1. Transdiciplinary principles of the learning organization (Senge 2006, Jakovljević 2012)
2. Commitment to person-centered medicine with holistic approach to physical, psychological, social and spiritual needs
3. Commitment to medicine as a calling, vocation, mission not only as a job/duty (A mission is a sense of purpose that lures us into our future)
4. Commitment to moral development related to the development of professionalism
Part 4
HOW TO OVERCOME SEVEN PROFESSIONAL SINS OR NON- VIRTUOS
Seven professional sins or non-virtues
„All professions are conspiracy agains the laity“ George Bernard Shaw: The Doctor's Dilemma
1. Greed: Money. Power. Fame.
2. Abuse of power: Patients and their families. Collegues. Position
3. Arrogance: Patients. Colleagues.
4. Misrepresentation: Lying. Fraud
5. Lack of conscientiousness: Lack of commitment. Doing only the minimum. Iresponsibility. Iatrogenesis and „doctor-made“ sickness and injury
6. Impairment: Drugs. Alcohol. Severe smoking. Illness
7. Conflict of interest: Financial. Industry
The struggle to stay centered on values in the profession of medicine (Inui 2003)
Ideal Foundational value RealityEvidence-based Truth/Science Uncertainty
COI (confluence) Therapeutic Aliance COI conflict
Caring, healing Curing Risk-harming
Open heart/mind Accepting, Emphatic Arrogant/unmoved
Error-free Right action Mistake-prone
Analytic Reflective Hassled, knee-jerk
Self-sacrificing Altruistic Avaricous
Teaching and learning methods (Passi et al. 2010)
Experiential; Reflective practice
Clinical contact including tutor feedback
Undergraduate ethichs teaching
Problem based learning
Role play exercises Bedside teaching
Educational portfolios
Videotaped consultation analysis
Significant event analysis
Workshops, Interactive lectures
Humanities writing: reading poetry/prose related to patients and doctors
Monitoring programmes
The Fifth DisciplineArt and Practice of Learning Organization
Systems thinking practiceThe unhealthiness of our world
today is in direct proportion to our inability to see it as a whole
“Discipline for seeing wholes”
Increasing personal masteryOutstanding ability/expert knowledge
Control over somebody/somethingPersonal growth & learning
Changing mental modelWhat we carry in our heads are
images, assumptions and stories
Part 5
PROFESSIONAL CULTURE & IDENTITY
Profesionalna kultura: Svi mi ulažemo svoju sudbinu
i duševno zdravlje u neko vjerovanje i svjetonazor.
Professional culture/subculture
makes up a large proportion of what is considered professionalism.
It may be defined as shared ideologies, values and general ways of attitudes to working – a configuration of beliefs, practices, relationships, language and symbols distinctive to a particular social unit (Hoyle & Wallace 2005).
Professional subculture is „the collective programming of mind“ applied within occupational groups. It involves the set of shared attitudes, values, goals, and practices that characterizes a profession, company or corporation.
BEHAVIORAL CHANGE STAIRWAY MODEL OF STABILITY, SECURITY AND PROGRESS
RESPECT
DIALOGUE & TRUST
COLLABORATION
PARTNERSHIP
FRIENDSHIP
OH 2, Pg 7
LOVE – POWER – FREEDOM – HAPPINESS – PURPOSE
RESPECT
DIALOGUE & TRUST
COLLABORATION
PARTNERSHIP
FRIENDSHIP
OH 2, Pg 7
Balkanizam i balkanizacija
„Zašto balkanske zemlje ne mogu da uđu u krug prosvećenog sveta, čak ni preko svojih najboljih i najdarovitijih predstavnika. Odgovor je jednostavan. Ali čini mi se da je jedan od razloga odsustvo poštovanja čoveka, njegovog punog dostojanstva i pune unutarnje slobode i to bezuslovnog i doslednog poštovanja. To je naša velika slabost i u tom pogledu svi mi često i nesvesno grešimo. Tu školu još nismo prošli ni taj nauk naučili. Taj nedostatak mi svuda nosimo sa sobom kao neki istočni greh našeg porekla i pečat manje vrednosti koji se ne da sakriti.
O tome bi trebalo govoriti i na tome raditi.”
Ivo Andrić
Profesional identity32
Professional identity
A profession is much more than a job, it is an identity
one's professional self-concept based on attributes, beliefs, values, motives, and experiences. It is a way of being and relating in professional contexts associated with sets of beliefs, attitudes, and understanding about professional roles, within the context of work.
the set of attributes, beliefs, values, motives and experiences by which we people define themselves in their professional lives.
an aspect of personal and social identity that develops in professional personnel as a result of their work activities.
The process of professional identity development refers to the successful integration of personal attributes and professional training in the context of a professional community.
Being a member of a professional community involves a sense of identity and personal commitment,
Medical professionalism can be divided in the four contexts:
1. professionalism with patients
2. professionalism in clinical/health-care teams
3. professionalism across care pathways
4. professionalism in healthcare organisation
Christmas & Millward 2011
The major pillars of medicine as a profession
1. a specialized body of knowledge,
2. Humanism: the altruistic service to patients and society
3. the right to establish practice standards for medical doctors (MDs) who maintain them through self regulation
4. the responsibility to guard the integrity of the profession's knowledge and its use
Spandorfer et al. 2010
Humanism and psychopolitical cultures
Narcissistic political psychoculture
Paranoic political psychoculture
Humanistic political psychoculture
Narcissistic - expansive cultureWe are OK, you are not OK
Egoistic and egocentric perspective: The stronger survives This world is competitive
Our group (nation, etc.) is superior, the chosen, the elite
Outsiders are competitors, potential enemies
Our rights and claims are supersede others’ rights
Their lives are expendeble
If I help ingroupers, it makes me a better person
Concept of competitors
Logical level model – Narcisoid cultureIdentity: We are historical, chosen nation, the elite, great nation
Beliefs/Values: Force, fairness, honesty, integrity and conscientiousness define us, Everybody must respect us
Capability: Drivers: be perfect, be strong. Good, but egoistic political, negotiation and warrior skills; High capacity to manage stress/conflict and juggle priorites
Behaviours: Hyperassertive and agressive, egocentric and egoistic, selfish, competitive, expansive, demanding, ungrateful
Environment: Competitive. Dominant or leading position in the region, mastering and managing over others
Paranoid cultureWe are OK, others are dangerous
Paranoid perspective: Homo homini lupus est; This world is a dangereous place
Our group (nation, etc.) is better
Outsiders are potential or actual enemies
Our rights are endangered
Concept of enemies
Prisoners of hate
Logical level model – Paranoid cultureIdentity: Unsecure; False identity of great, heroic nation; Winners in the wars, losers in the peace
Beliefs/Values: Everybody must love us, Who is not with us is against us. The attack is the best defence. Force is the most important
Capability: Imagined superiority based on an inferiority complex,
Behaviours: Endangered Persecutors, Agressive
Environment: Possible enemies are everywhere around us
Humanism and medical professionalism
Professionalism is what we do when other people are looking,
Humanism is who we are when no one is looking
Humanističko-altruistička psihopolitička kultura: Ima li nade ?
„Ako svijet valja dovesti u red, moja se nacija mora prva promijeniti.
Ako se moja nacija mora promijeniti, moj se rodni grad mora prvi obnoviti.
Ako se moj rodni grad mora obnoviti, moja se obitelj prva mora dovesti u red.
Ako se moja obitelj mora dovesti u red, ja se moram ponajprije dovesti u red“
Nepoznati kineski vojskovođa
Altruistic – humanistic cooperative cultureWe are OK, you are OK, they are OK
All people are equal and worthwhile
Outsiders are potential friends
No group has a prior claim
All lives are sacred
If I help outgroupers, it makes me a better person
1. Honesty/integrity: is truthful with patients, peers, and in professional work (e.g., documentation, communication, research).
2. Reliability/responsibility: Is accountable to patients and colleagues. Can be counted on the complete assigned duties and tasks. Accepts responsibility for errors.
3. Respectful of others: Talks about and treats all persons with respect and regard for their individual worth and dignity; is fair and non-discriminatory. Routinely inquires about or expresses awareness of the emotional, personal, family, and cultural influences on patient well-being and their rights and choices of medical care; is respectful of other members of the health care team. Maintains confidentiality. 4. Compassion/empathy: Listens attentively and responds humanely to patient's and family members' concerns; provides appropriate relief of pain, discomfort, anxiety.
Evaluation of professionalism in residents(American Academy of Pediatrics, Klein et al. 2003)
5. Self-improvement: Regularly contributes to patient care or educational conferences with information from current professional literature; seeks to learn from errors; aspires to excellence through self-evaluation and acceptance of the critiques of others
6. Self-awareness/knowledge of limits: Recognizes need for guidance and supervision when faced with new or complex responsibility; is insightful oft he impact of one's behavior on others and cognizant of appropriate professional boundaries
7. Communication/collaboration: Works cooperatively and communicates effectively to achieve common patient care and educational goals of all involved health care providers.
8. Altruism/advocacy: Adheres to best interest of the patient; puts best interest of the patient above self-interest and the interest of other parties.
Organize your mental model for successful results
Identity: who MISSION
Beliefs: why needs/values
Capability: how ROLES
Behavior: what
Environment: where and when GOALS
Logical level modelIdentity: I’m supportive and kind person, I’m a father and husband, I’m psychiatrist
Beliefs/Values: Family & Medicine first: I must have balance in my life; It’s vital for me to do the best I can at all times; Fairness, honesty, integrity and conscientiousness define me
Capability: I have good interpersonal skills and I am emotionally intelligent; I am an excellent lecturer; I have the capacity to manage stress/conflict and juggle priorites
Behaviours: I listen, support and help; I actively manage my work/life balance; I’m always there for my family, patients, friends…
Environment: I must have people around; My home is my haven/castle; Openness, enjoyment, fun & sociability are key
KEY MESSAGES
Take-home messages
„With malice toward none, with charity for all; with firmness in theright, as God gives to see the right, let us strive on to finish thework we are in; to bind up the nation’s wounds; to care for him whoshall borne the battle, and for his widow and his orphan, to do all which may achieve and cherish a just and lasting peace amongourselves, and with all nations” – Abraham Lincoln
„We must build a new world, a far better world; one in which theeternal dignity of man is respected” – Harry S. Truman
Medicine should be a calling, not a bussines
William Osler
Key messages
Learning medical professionalism is a challenging, evolving, lifelong endeavor
The role of MDs has always changed in response to changes in society, public expectations, the structure of health care services and the developing state of medicine itself.
The model of the heroic doctor single-handedly treating patients has little relevance compared with the collaborative nature of modern health care
Professionalism is not only about fullfiling a pre-defined role, it is also about recognising which role any given situation calls for
He cures most successfully in whom the people have the most confidence“
Galen
„The practice of medicine is an art based on science“ Sir William Osler
Doctor, I have a Bipolar Disorder, but, before I tell you more, let me present to you my lawyer, my ethicist, and my information
technologist.
Who should have the last word?
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What do we see?
We see not onlywhat we see, but also what welearned to see