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

“Respect Heaven & Love People

Building shared visionPicture of patient’s future

that foster genuine alliance

Dialogue: Thinking togetherNot discussion, percussion¸, arguing

concussion

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

Attachment – Altruism – Cooperation

Respect – Dialogue/Trust – Cooperation/Mutuality – Partnership -Friendship – Collective Security

Hector u potrazi za srećom (Francois Lelord)

“Mnogi su željeli ugovoriti termin kod Hectora,

i to ne samo zato što je izgledao kao pravi psihijatar, nego i zato što je

imao tajnu koju znaju dobri liječnici,

a koja se ne uči na fakultetu:

ljudi su ga zaista zanimali”

Evaluation of professionalism in residents (American Academy of Pediatrics, Klein et al. 2003)

Meets expectations Needs improvement Cannot assess

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?

55

What do we see?

We see not onlywhat we see, but also what welearned to see