PROFESSIONALISM IN MEDICAL

PRACTICE(FMC, 06.10.2016)

Ghaiath Hussein, MBBS, MHSc. (Bioethics)

Outline of the session■Professionalism:

– Approaches and Dimensions of professionalism– clinician’s Professional Relationships and

Duties■Saudi Code of Ethics for Medical Practitioners

■Reference:Citation: Hussein GM, Kasule OH, Al-Kaabba AF. Professionalism and Ethics Handbook for Residents. Ware J, Kattan T, editors. Riyadh, Saudi Arabia 2015

PROFESSIONALISMclinician’s Professional Duties & Relationships

Levels of Behavioural ‘Control’Morality

(Bio)Ethics

Laws & Regulations

Institutional Policies

Professional standardsPersonal beliefs &

preferences

• General unchallenged community value; voluntarily followed

• Inherited as is; not argued• Not written; changes slowly with time• Argued; logically established (moral philosophy)• Voluntarily; not universal• Inspires codes, policies, & laws

• Binding to everyone• Legal actions may follow, if not followed

• Binding to those in the institution• Should be followed; disciplinary action might

follow if not followed• Binding to those in profession• Mostly voluntary; disciplinary action might follow if

not followed• Written as Codes• Varies individually• Commits only you (and dependents)

Who is a/the ‘good’ doctor?

Thoughts?

Which doctor do you want to be?

Clinicians Beyond Hospitals!COUNTRY/REGION

Policy maker

Planner

Manager

COMMUNITYAdvocate

Researcher

Educator

CLINIC/HOSPITALProvider Manager Educator Research

er

So your expected roles are…CanMEDS (http://www.royalcollege.ca/) SaudiMEDS

Saudi Meds: A competence specification for Saudi medical graduatesRania G. Zaini , Khalid A. Bin Abdulrahman , Abdulaziz A. Al-Khotani , Abdol Monem A. Al-Hayani , Ibrahim A. Al-Alwan , Saddig D. Jastaniah Medical Teacher , Vol. 33, Iss. 7, 2011

SAUDI MEDSSaudiMED: Competence-Based Frameworks for the Saudi

Medical Colleges

SaudiMEDI: Scientific Approach to PracticeThe integration and application of basic, clinical, behavioral and social sciences in clinical practice.1. Integration of basic and clinical sciences in medical practice2. Delivery of evidence-based health care

II: Patient care■ The establishment and maintenance of essential clinical and interpersonal

skills to demonstrate proficient assessment and delivery of patient-centered management

3. Demonstration of the essential clinical skills4. Demonstration of clinical reasoning, decision making, and problem solving skills5. Management of life-threatening medical conditions6. Management of common medical problems7. Placing patients’ needs and safety at the center of the care process

SaudiMED competencies III: Community oriented practice■ The ability to practice based on an understanding of the Saudi health care

system and to apply health promotion and advocacy roles for the benefit and wellbeing of individual patients, communities, and populations.

8. Understand the healthcare system in Saudi Arabia9. Advocacy of health promotion and disease prevention9. Advocacy of health promotion and disease prevention

 IV: Communication and Collaboration The ability to communicate effectively with patients and their relatives and to practice collaborative care by working in partnership within a multi-professional team10. Effectively communicate with patients, colleagues, and other health professionals11. Teamwork and inter-professional collaboration12. Application of medical informatics in healthcare system

SaudiMED competencies V: Professionalism ■ The commitment to deliver the highest standards of ethical and

professional behavior in all aspects of health practice, and take a responsibility for own personal and professional development.

13. Adherence to professional attitudes and behaviors of physician14. Application of Islamic, legal and ethical principles of professional practice15. Commitment to personal and professional development

VI: Research and scholarship■ The contribution to the advancement of medical practice with the rigors

of scientific research.16. Demonstration of basic research skills17. Demonstration of Scholarly pursuits.

The round with Mr. Butcher (MD, MRCS)■ On his round, the well-known surgeon Mr. Butcher was always keen to

have all the residents and interns on his unit in attendance, in addition to other health care team members (dietician, physiotherapist, nurses, and others) to whom he always referred as the “paramedics.”

■ During the round, he asked one of his unit’s female interns to examine a 65-year-old male patient who had had his prostate removed two days before. He asked her in a loud voice.

■ Both the intern and the patient felt embarrassed. The surgeon stopped her when she tried to pull the curtains, as there were few other patients next to this patient who would see him being examined if the curtains were not pulled. He said, “Nothing to be ashamed of. He is a patient in a teaching hospital so he expects that you will all examine him,” then, “isn’t that right Mr. X?” talking to the patient.

■ The intern asked the patient’s permission then examined him, and the operation site. The surgeon then asked her and the other “doctors” some questions. As usual in his round, the wrong answers were ridiculed, and the “paramedics” were never given a chance to answer.“Paramedics are to take the instructions doctors give them,” he would always say.

OVERVIEW ON PROFESSIONALIS

M

Professionalism (Definitions)

“constituting those attitudes and behaviors that serve to maintain patient interest above physician self-interest.”

American Board of Internal MedicineProfessional competence is the habitual and

judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served.

Epstein and Hundert

Professionalism (WMA)“Medical professionalism describes the skills,

attitudes, values and behaviours common to those undertaking the practice of medicine.

It includes concepts such as: the maintenance of competence for a unique

body of knowledge and skill set, personal integrity, altruism, adherence to ethical codes of conduct, accountability, a dedication to self-regulation, and the exercise of discretionary judgment.

Professionalism (WMA)Professionalism is also: the moral understanding among medical

practitioners that gives reality to what is commonly referred to as the social contract between medicine and society.

This contract in return grants the medical profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. ”

(Blackmer, Canadian Medical Association, July 2007)

What is professionalism about?Undesirable

conductDesirable Behaviors

Abuse of powerBias(Sexual) harassmentBreach of confidentialityArroganceGreedMisrepresentationImpairmentLack of conscientiousness and Conflicts of interest

AltruismAccountabilityExcellenceDutyHonorIntegrityRespect for others, and A commitment to lifelong learning

Source:http://www.med.uottawa.ca/students/md/professionalism/eng/what_is_professionalism.html

Source: https://www.cma.ca/En/Pages/medical-professionalism.aspx

Professionalism = clinical ethics or bioethics?■ The term "ethics" simply refers to a system of moral principles or

standards governing conduct (9).■ Bioethics is essentially an umbrella term for moral conduct in the broad

area of life sciences and medicine (12). It also encompasses the following subject areas: philosophy of science, biotechnology, politics, law, medicine, and theology.

■ Clinical ethics tackles patient-based ethical decision making. This area of ethics considers different judgments as they apply to the clinical practice of medicine. Thus, clinical ethics is a system of principles governing medical conduct with respect to patients and their families.

■ The ethics of professionalism in medicine is more concerned with the characteristics and behaviours of physicians in the context of medicine as a profession. Specifically, it examines desirable and undesirable attributes of physicians (4). The ethics pertaining to professionalism not only motivate patient-physician interaction, but also outline expected behaviour with other physicians, health care workers, medical students, and preceptors.

SOURCE: http://www.med.uottawa.ca/students/md/professionalism/eng/what_is_professionalism.html

SAUDI CODE OFETHICS FOR HEALTHCARE PRACTITIONERS

http://www.scfhs.org.sa/Reglations/CR/Documents/%D8%A3%D8%AE%D9%84%D8%A7%D9%82%D9%8A%D8%A7%D8%AA%20%D8%A7%D9%84%D9%85%D9%85%D8%A7%D8%B1%D8%B3%20%D8%A7%D9%84%D8%B5%D8%AD%D9%8A.pdf

Overview on the Saudi Code of Ethics (1)■  Introduction(A) Medical Profession Ethics and Regulations (B) Honour of the Healthcare Professions(C) Sources of Healthcare Professional Ethics (D) Healthcare Profession Honour (E) Role of Role-Models ■ Healthcare Practitioner Ethics (A) Devotion and Feeling the Worship of Allah (SWT)(B) Demonstration of the Best of Manners (C) Self-accountability(D) Avoidance of Trivialities and Pettiness

■ Healthcare Practitioner’s Duties Towards Patients

(A) Good Treatment of Patient (B) Achieving Patient’s Interest and Guarding His/Her Right (C) Patient’s Consent (D) Reassurance of Patient (E) Maintaining Patient’s Secrets - Confidentiality(F) Photographing Patients and Recording Their Voices (G) Dealing with Patients Who Refuse a Medical Procedure (H) Conscientious Objection to Refrain from Treating a Patient■ Healthcare Practitioner’s Duties

Towards Community■ Healthcare Practitioner’s Duties

Towards Professional Colleagues ■ Healthcare Practitioner’s Duties

Towards Him/Herself

Overview on the Saudi Code of Ethics (2)■ Healthcare Practitioners’

Duties Towards His/Her Profession

■ Observance of Religious Rulings

(A) Ruling on Exposing Private Parts of the Body (Awra) (B) Rulings in Abortion (C) Relation Between the Opposite Sexes (D) Healthcare Practitioner’s Relations Outside the Limits of the Profession(E) Religiously Forbidden Procedures and Treatment Methods■ Ethics of Teaching and

Learning on Patients

■ Ethics of Documentation and Authentication

(A) Medical Record (B) Certificates and Reports (C) Medical Prescriptions ■ Ethics of Financial Affairs in the

Healthcare Field(A) Healthcare Practitioner’s Fee (B) Practicing in Private Sector (C) Advertisements and Publicity .(D) Participation in the Media (E) Gifts and Benefits (F) Relationships with Pharmaceutical and Medical Equipment Companies(G) Insurance

Overview on the Saudi Code of Ethics (3)■ Ethics of Conducting

Biomedical Research(A) Conducting Biomedical Research on Humans(B) Conducting Research and Experiments on Animals(C) Regulations for Accepting Scientific Research Grants (D) Regulations for Innovative Interventional Procedures■ Ethics of Dealing with

Communicable Diseases ■ Ethics of Dealing with the

Developments in Healthcare Practices

■ Ethics of Dealing with Emergency Situations

■ Ethics of Dealing with Life-threatening and Incurable Diseases

(A) Does the Patient Have the Right to Refuse Treatment in Incurable Conditions? (B) Should Medical Treatment Be Stopped?(C) Cardiopulmonary Resuscitation(D) Conditions of Prolonged or Terminal Coma due to Cerebral Cortical Damage

Muslim Doctors’ Duties Towards PatientsRespect for Patient المريض احترامRespect for Privacy المريض خصوصية ضمانComprehensive care للمريض الشاملة الرعايةRespect for patient’s autonomy المريض استقاللية احترام Inform the patient about his/her condition تبصير

مرضه بطبيعة المريضProtect patient's interests المريض مصلحة حمايةKeep the patients’ secrets (confidentiality) سر كتمان

المريضSource: Islamic Code of Medical & Health Ethics

Physician's Duties Towards Colleagues To deal with, and act towards his colleagues in a good manner and in the same way he would prefer to be treated

To avoid direct criticism to his colleague in front of patients

Not to indulge in defaming the honor of his colleagues

To exert every possible effort to educate the colleagues

Respect the differences with colleagues (sex, culture, belief…).

The physician should respect other non-physician medical profession colleagues, and appreciate their roles in healthcare of the patient

She/he must report the incidence in which a colleague could be dangerous to the authority concerned

clinician’s Duties Towards his/her Profession

Respect the honour of the profession;Develop him/herself to develop the profession

through CME, research, and publications;Adhere to the standards of practice (GCP, EBM,

guidelines, etc.)Abstain from any behaviour/action that would

question his/her credibility, or establish dishonest affairs with patients or their families;

Avoid the request of fame on the account of the professional ethics and standards

To provide role model for his colleagues and patients

Source: Islamic Code of Medical & Health Ethics

clinician’s Duties Towards his/her ProfessionReflect sincere devotion and dedication to

the medical profession.To avoid any action that could lead to

contempt of the medical profession and to maintain the standards of medical profession

To contribute in the development of the profession through research and continuous learning.

The physician should not take advantage of his profession position for obtaining any material or moral gains, which are not in conformity with or violate the laws and tradition.

clinician’s Duties Towards his/her ProfessionTo take the appropriate procedure when he

comes to know that one of the members of the health team is sick, ignorant or negligent of his duties; in furtherance of protecting the patient in the first place and the medical profession next.

The physician should refrain, when dealing with the patient, from any act or conduct that would infringe his honesty and integrity.

To avoid seeking fame at the expense of the profession ethics and principles.

clinician’s Role Towards CommunityPositive interaction with the community’s affairsProtect the community by reporting

reportable/epidemic diseases Improve health in the community through advocacy

and health education, and involvement in community health activities

Rational use of the healthcare institutions’ resources

Effective contribution to the development of policies and health systems that respond to the community needs and facilitates easier access to health care.

Source: Islamic Code of Medical & Health Ethics

clinician’s Role Towards Community

To be as a role model in his/her attitude and religion

Promotion of health equity among the society members

Maintenance of health resources and the ideal utilization of such resources.

Use his skills, knowledge and expertise to improve the standards and quality of health services rendered to the society.

Lack of ProfessionalismSigns of lack of professionalism (ABIM, 2001)1. Abuse of power:

– Abuse while interacting with patients and colleagues; – Bias and sexual harassment; and – Breach of confidentiality

2. Arrogance (offensive display of superiority and self-importance); 3. Greed (when money becomes the driving force); 4. Misrepresentation (lying, which is consciously failing to tell the

truth; and fraud, which is conscious misrepresentation of material fact with the intent to mislead);

5. Impairment (any disability that may prevent the physician from discharging his/her duties); 6. Lack of conscientiousness (failure to fulfill responsibilities); 7. Conflicts in interests (self-promotion/ advertising or unethical

collaboration with industry; acceptance of gifts; and misuse of services – overcharging, inappropriate treatment or prolonging contact with patients).

Discussion of Mr. Butcher’s Case■ On his round, the well-known surgeon Mr. Butcher was always keen to

have all the residents and interns on his unit in attendance, in addition to other health care team members (dietician, physiotherapist, nurses, and others) to whom he always referred as the “paramedics.”

■ During the round, he asked one of his unit’s female interns to examine a 65-year-old male patient who had had his prostate removed two days before. He asked her in a loud voice.

■ Both the intern and the patient felt embarrassed. The surgeon stopped her when she tried to pull the curtains, as there were few other patients next to this patient who would see him being examined if the curtains were not pulled. He said, “Nothing to be ashamed of. He is a patient in a teaching hospital so he expects that you will all examine him,” then, “isn’t that right Mr. X?” talking to the patient.

■ The intern asked the patient’s permission then examined him, and the operation site. The surgeon then asked her and the other “doctors” some questions. As usual in his round, the wrong answers were ridiculed, and the “paramedics” were never given a chance to answer.“Paramedics are to take the instructions doctors give them,” he would always say.

Discussion of Mr. Butcher’s Case: Summary Points

■ Referring to non-doctor health care providers as paramedics is not acceptable, at least in the way he uses the term. It is more respectful to your colleagues to call them by their job titles.

■ An old male patient feels quite depressed-if not abused-to be put in a situation where a female of his daughter’s age examines his private areas.

■ By not pulling the curtains, the doctor deprives his/her patient of his/her least level of privacy.

■ Not asking for the permission of the patient to be examined is never acceptable, unless it is an emergency or the patient is unable to give permission. This is applicable even in teaching university hospitals.

■ Humiliating your colleagues, especially the junior ones, is completely unethical. It is abusive, and totally inappropriate as a role model for junior practitioners.

■ All health care team members are of equal value and should be given the chance to share the knowledge they have. You can learn a lot from them, as much from your physician colleagues.

Summary points ■ Being a clinician is about being part of a team. You have

rights and duties as part of this team.■ Central to your care is your patient (not your ego and not

your bank account).■ Many of the positive attitudes and skills can be developed

through training, and self-development.■ Developing and adhering to these standards develops you,

improves health care, and enhances public trust in the health system.

■ By respecting your patients, colleagues, and the community in general, you build better relations and a better reputation for being a faithful model clinician