Transcript Preceptors & Ethics: Educating for Professionalism

Medical Ethics: Is It
Still Relevant to
Students and
Practicing Physicians?
Nancy W. Dickey, M.D.
President, Health Science Center and
Vice Chancellor for Health Affairs, A&M System
November 19, 2004
Professionalism, what is it?
 Principles of professionalism entail not only personal
commitment to the welfare of the patient but also collective
effort to improve the health care system for welfare of
society. Hafferty
 ABIM defines professionalism as requiring “the physician to
serve the interests of the patient above his or her selfinterest”
 Broadly speaking, ethics concerns itself with why and how
one ought to act. Candiles
 Despite all of this attention, a core understanding of what it
mean to be a professional remains elusive. Hafferty
Professionalism, what is it?
 For the individual physician professionalism is expressed
primarily in the clinical transaction.
 Professionalism is the basis of medicine’s contract with
society
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Establishes standards of competence & integrity
Essential is public trust in physicians
Professional responsibilities of honesty, confidentiality,
commitment to quality, caring, maintaining trust
 ACP-ASIM defines 3 principles
 The primacy of patient welfare
 The principle of patient autonomy
 The principle of social justice – promotion of a fair distribution of
health care resources
Professionalism & ethics,
are they different?
 According to the AMA, ethical principles are a
body of statements developed to guide
physician behavior primarily for the benefit of
the patient and for society
 They define the essentials of honorable
behavior for the physician
 They are standards or guides – not laws
 Having a body of ethical standards developed
by the profession is one of the things that
separates professionals from journeymen
AMA Medical Ethics
A physician shall…provide
…competent medical care, with compassion and respect,
…uphold the standards of professionalism, be honest…(and)
report physicians deficient in character or competence;
…respect the law ,
…respect the rights of patients, colleagues, and other health
professionals,
…continue to study, apply, and advance scientific knowledge,
maintain a commitment to medical education,
…recognize a responsibility to participate in activities
contributing to the improvement of the community,
…regard responsibility to the patient as paramount,
…support access to medical care for all people.
Professionalism
Why does it matter?
An Emerging Consensus:
 AAMC 1998 Initiative on Professionalism created
in response to growing concern among the public
and even the profession
 ABIM/ACP-ASIM 2002 Medical Professionalism
Project, “Changes in the delivery systems…
threaten the values of professionalism.”
www.annals.org/cgi/content/full/136/3/243
Professionalism
Why does it matter?
An Emerging Consensus:
 AMA initiated the STEP program (2003)
to fund selected medical schools in
designing innovative methods for
educating the next generation of
physicians in the competencies that
constitute professionalism
Why the change or the
perceived change?
 Changes in the health care delivery systems in countries
throughout the industrialized world threaten the values of
professionalism. Sox
 Deprofessionalization has been attributed in part to
specialization, with fragmentation of clinical care and loss
of an effective single voice for the profession…the image of
physician selflessness has been marred by perceived
increased emphasis on reward…and impact on perceived
priorities and trustworthiness of physicians …with regard to
the primacy of the patient in the clinical transaction.
Barondess
Why the change?
 A third pressure relates to health care costs and
their continuing escalation….which will ultimately
threaten the care of patients through a variety of
controls, re-entrenchments, erosion of clinical
quality…additional efforts might address especially
a focus on exuberant and not infrequently
inappropriate use of expensive technologies, which
are estimated to contribute 2/3 of annual increases
in rising health care costs. Barondess
Failure to respond…
 We are not alone…”A decade ago
Senator Daniel Patrick Moynihan
warned that the level of deviant
behavior in our society had
surpassed what the community could
‘afford to recognize’ and as a result
we have been redefining deviancy
down so that conduct previously
stigmatized is now acceptable….
Harvard Business Review 2004
We are not in this alone…
 Peers don’t report peers
 Faculty don’t fail learners
 Administrators cast a blind
eye
 Peer review misused
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For economic competition
Failure to act even in light of
problems
Culture is a contributor
 American culture
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Taboo on whistle blowing
Who am I to judge other
people’s values
(even today, I am not allowed to
judge other people values and I
have to keep mine neutral so I
don’t offend…)
Culture is a contributor
Professional issues
…medical personnel
facing moral dilemmas
have…turned to
attorney for guidance,
as if to say, “If we
cannot agree on what
is right, we shall at
least adhere to what
the courts
prescribe.”Trotter
There but for the grace
of God go I…
Professionalism matters
Professionalism, why does it
matter for our students?
 Students who received comments about
unprofessional behavior were twice as likely to be
disciplined by the medical board when they
became practicing physicians.
 Medical students are routinely exposed to a range
of deleterious influences…and almost 2/3 of the
study respondents thought their ethical principles
had eroded because of their clinical experiences.
Educating for professionalism
 “To be good is noble; to teach others to be good is
nobler – and less trouble.”Mark Twain
 For medical educators, the reverse may be true
 The challenge of living up to the professional
standards set for ourselves is great
 The challenge of setting our students on the path
to professionalism is even greater.
A tough message
 Where ignorance is the problem, then education,
not punishment or discipline, is the answer. Where
poor ethics is simply misguided, not evil, then
(ethics) education may be in order. For deliberate
exploitation of patients for personal gain, then
responsibility and retribution are appropriate.
Morreim EH. Am I my brother’s warden? Hastings Center Report,. 1993; 23: 19-27.
What can medical education do?
 Institutions do not change on their own
 Individuals must act – and by so doing may
change institutions
 Recognize our obligation to
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Uphold professional values
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Accountability
Responsibility
Intervene in the system
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Accountability
Responsibility
What can we do?
You are in the vanguard
 Becoming a professional takes shape more
within medicine’s informal and hidden curriculum
than within its formally identified modules….
 Furthermore, and perhaps most disconcerting,
the norms and value orientations encountered by
students during their training are not always the
standards medicine realistically identifies as
defining medical practice.
What can medical education do?
 Maintain character –
 An issue of who we admit
 Mold character
 An issue of enhancing the qualities of the excellent
students we admit
 Transform technical education into
moral/professional education
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Either one alone is not enough – together they are
powerful
How do we do that?
 Provide a role model
 Albert Schweitzer is credited
with saying, “Example is not the
main thing in influencing others,
it is the only thing.”
 What teachers themselves do
with their knowledge and lives
is educationally and morally
significant.
What can medical education do?
 When concerning behaviors, attitudes,
or communications occur, do not ignore
them but directly address them.
 Consider asking either the leaders in
faculty development and
curriculum/evaluation for assistance or
ask the medical school to offer some
training/role playing to practice these
difficult interchanges
 Seek a balance between validation and
challenge
How do we do that?
 Discuss negative models
 Clinical faculty &
preceptors often offer an
early opportunity to ask
questions, have
discussions
 Listen carefully for the
question that may be
hidden within the
question – it is tough to
question a faculty
member’s behavior
What can we do?
 When you next encounter the
unprofessional behavior of a learner or
colleague, outline what steps will you
take in responding to him/her?
 Create a culture that is supportive and
challenging…help students and faculty
to perform better every year
 Discuss challenges & opportunities
with academic administration and help
develop consistent processes across
the clinical campus
When all else fails….
 “When a student does not
attain these skills, then the
student should not finish
medical school.”
D. Papadakes
Professionalism matters
Professionalism matters for
clinicians
 Because
you…we…are the
examples from which
our students will
learn…either as
great examples of
what to do or
examples of what not
to do.
Professionalism under seige
 Albert Jonsen illustrates how some feel
about the current situation, “…Outrage
greets stories of the uninsured, injured
who are turned away from the ED.
 Stories of the doctor whose golf game or
cocktail party delays attendance at the
patient’s bed arouse anger…”Trotter
 Nov, 04 Dallas Morning News article on
the effect of medical school teaching
expectations on quality of patient care.
Professionalism,
why does it matter for clinicians?
 Trust is widely recognized as being central to the doctor-
patient relationship…resonating with both doctors and
patients and distinct from satisfaction.
 In the healthcare marketplace, the absence or presence of
trust in patient-provider relations can have life-changing
consequences.
 A person who trusts his provider is more likely to seek care,
to comply with treatment recommendations, and to return
for follow-up care than a person who has little trust in a
specific provider or a health care system. Thom
 In the words of Galen, one of the founders of modern
medicine, “He cures most in whom most are confident.”
Professionalism is…
 Jonsen writes, “The ethics of
competence, fully understood as
mastery of the science and skills of
diagnosis, therapy, and
prevention…are the standard to
which all physicians must be held.
They stand as the modern
extension of Hippocratic ethics into
the age of scientific medicine.”Trotter
How does that fit ?
 More than 50% of patients with diabetes, hypertension, tobacco
addiction, hyperlipidemia, congestive heart failure, asthma, depression
and chronic atrial fibrillation are currently managed inadequately
(Institute of Medicine, 2003c)
 Americans die each year from heart attacks because they did not
receive preventive medications, although they were eligible for them
(Chassin, 1997; Institute of Medicine, 2003a)
 Only 55% of patients in a recent random sample of adults received
recommended care, with little difference found between care
recommended for prevention, to address acute episodes or to treat
chronic conditions (McGlynn et al., 2003)
How does that fit?
 Over 1 million American annually suffer medical
errors
 44,000 – 98,000 die annually as a result of error
 $29 billion annually spent as a result of error
 One third to one half are considered
preventable
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Harvard Medical Practice Study
IOM, To Err Is Human, 1998
The physician-patient relationship:
cornerstone of patient trust,
satisfaction, and loyalty.
As baby boomers reach middle age, they will have a
dramatic effect on mainstream health care services in
the United States. They will demand to play a greater
role in their own care, as well as the care of their children
and parents. What was once thought to be satisfactory
care and service will be deemed insufficient for
themselves and their families. Physicians and other
caregivers who understand and accommodate these
changing preferences will do well in a world where
informed patients become the rule and not the exception.
Montaglione CJ. Manag Care Q. 1999 Summer;7(3):5-21.
However,let us not lose track
 June 3, 2004
FOR IMMEDIATE RELEASE
Scott & White Among Nation's 100 Best Hospitals
College of Medicine Presents Teaching Award in Temple
A member of the A&M Health Science Center College of Medicine
faculty in Temple was recognized with an award for outstanding
teaching…
At a White Coat Ceremony 84 entering medical students received
a white coat signifying the beginning of their medical training
as the Class of 2008 at the College of Medicine. This is the
largest medical school class in the College’s 27-year history.
Out of more than 2,300 applicants, these students represent 40
colleges and universities throughout the state and nation.
Bibliography
Adams D. Professionalism starts in medical school. AMNews. Mar 15 2004.
http://www.ama-assn.org/amednes/2004/03/15/prsa0315.htm
Barondess JA. Medicine and professionalism. Archives of Internal Medicine. 2003; 163:145149.
Candiles PJ. Distinguishing law and ethics: a challenge for the modern practitioner. Pychiatric
Times XIX no 12 (Dec 2002):1-6.
http://www.psychiatrictimes.com/ethics/html
Hafferty FW. In search of lost cord. Educating for Professionalism. Ed. Wear ED & Bickel J.
University of Iowa Press. 2000.
Montaglione CJ. Manag Care Q. 1999 Summer;7(3):5-21.
O’Brien L. How to restore the fiduciary relationship. Harvard Business Review. May 2004: 7178.
Reiser, SJ. The moral order of the medical school. Educating for Professionalism. Ed. Wear
ED & Bickel J. University of Iowa Press. 2000.
Bibliography
Sox, HC. Medical Professionalism in the new millenium: a
physician charter. Annals of Internal Medicine. 136no3: Feb
2002:243-246.
Thom DH, Hall MA, Pawlson LG. Measuring patient trust in
physicians when assessing quality of care. Health Affairs.
2004; 23 no3:124-132.
Trotter G, The Loyal Physician: Roycean Ethics and the Practice of
Medicine. 1997. Vanderbilt University Press.
The End
 Please proceed to post test
 Download post test
 Complete post test
 Return post test to Dr. Sandra Oliver
407i TAMUII
Post test question one
ABIM defines professionalism as:
1. Interact with consultants respectfully
2. Recognize obstacles to patient care
3. Place the patient’s interest first
4. Recognize own limitations in learning
Post test question two
Which of the following is not identified by
ACP-ASIM as a principle of professionalism?
1.
2.
3.
4.
The primacy of patient welfare
The principle of patient autonomy
The principle of social justice
The principle of societal beneficence
Post test question three
Medical students who received comments
about unprofessional behavior were:
1. Twice as likely to be disciplined by the
medical board when they became
practicing physicians
2. Shown to have no correlation with
professional behavior as physicians
3. One third as likely to drop out of
medical school.
Post test question four
According to Dickey, when you next encounter the
unprofessional behavior of a learner or colleague,
what steps will you avoid in responding to
him/her?
1. Report minor incidents that may be in violation
of the Texas Medical Practice Act
2. Refer students and faculty for help
3. Discuss challenges & opportunities with
academic administration
4. Help develop consistent processes across the
clinical campus