INTRODUCTION TO MEDICAL INTRODUCTION TO MEDICAL PROFESSIONALPROFESSIONAL

Djamhoer MartaadisoebrataDjamhoer MartaadisoebrataDept. Obstetrics & GynecologyDept. Obstetrics & Gynecology

Fac of Medicine, Univ of Fac of Medicine, Univ of PadjadjaranPadjadjaran

What is PROFESSIONAL ?What is PROFESSIONAL ?A calling requiring specialized knowledge and A calling requiring specialized knowledge and

often long and intensive preparation often long and intensive preparation including instruction and skills and methods including instruction and skills and methods as well as in the scientific, historical or as well as in the scientific, historical or scholarly principles, underlying such skills scholarly principles, underlying such skills and methods, maintaining by force or and methods, maintaining by force or organization or concerned opinion, high organization or concerned opinion, high standard of achievement and conduct, and standard of achievement and conduct, and committing its members to continue study committing its members to continue study and to a kind of work which has for its prime and to a kind of work which has for its prime purpose the rendering of public service.purpose the rendering of public service.

Scientifically speaking it covers all Scientifically speaking it covers all dimensions : COGNITIVE, dimensions : COGNITIVE,

PSYCHOMOTOR and AFFECTIVE, PSYCHOMOTOR and AFFECTIVE, which depict the capacities of which depict the capacities of

INTELLIGENT QUOTIENT (IQ) and INTELLIGENT QUOTIENT (IQ) and EMOTIONAL QUOTIENT (EQ)EMOTIONAL QUOTIENT (EQ)

The International Commission The International Commission of Higher Education for 21of Higher Education for 21stst

CenturyCenturyUNESCO 1998 UNESCO 1998 Learning to know – Cognitive Dimension – Learning to know – Cognitive Dimension –

Rational attitude.Rational attitude. Learning to do – Operational/Psychomotor Learning to do – Operational/Psychomotor

Dimension – Practical attitudeDimension – Practical attitude Learning to be – Learning to be –

Emancipation/Emotional/Affective Emancipation/Emotional/Affective Dimension – Ethical attitudeDimension – Ethical attitude

Learning to live together – Ecological Learning to live together – Ecological Dimension – Cooperative attitudeDimension – Cooperative attitude

ARE DOCTORS ARE DOCTORS PROFESSIONAL ?PROFESSIONAL ?

INDEED WE ARE, because :INDEED WE ARE, because : Medical curriculum is professionally Medical curriculum is professionally

prepared.prepared. Doctors are clinically and ethically Doctors are clinically and ethically

competent.competent. We have professional organization, We have professional organization,

IDI, POGI, IKABI etc, with solid IDI, POGI, IKABI etc, with solid statues and rules of association.statues and rules of association.

ATTENTION !!!!ATTENTION !!!!NEW GRADUATED YOUNG DOCTORS NEW GRADUATED YOUNG DOCTORS ARE NOT YET PROFESSIONAL, ONLY ARE NOT YET PROFESSIONAL, ONLY

POTENTIALLY PROFESSIONALPOTENTIALLY PROFESSIONALWelch WH(1850-1934)Welch WH(1850-1934)

Medical education is not completed at Medical education is not completed at medical school, it is only begun.medical school, it is only begun.

To be professional :To be professional : They must have experience They must have experience

(Experience is a good teacher).(Experience is a good teacher). Long life educationLong life education Periodical self assessment, Periodical self assessment,

particularly in ethical conduct.particularly in ethical conduct.

HEALTH PARADIGMS IN HEALTH PARADIGMS IN MEDICAL PROFESSIONMEDICAL PROFESSION

1. PROFESSIONAL CHARACTERISTICS :1. PROFESSIONAL CHARACTERISTICS : SCIENTIFIC and BIOTECHNOLOGICALLY SCIENTIFIC and BIOTECHNOLOGICALLY

ACCOUNTABLEACCOUNTABLE SKILLFULSKILLFUL APPROPRIATE (BIO)ETHICAL CONDUCTAPPROPRIATE (BIO)ETHICAL CONDUCT GOOD MANAGERGOOD MANAGER

2. MORAL PHILOSOPHY of MEDICAL ETHICS2. MORAL PHILOSOPHY of MEDICAL ETHICS Beneficence : good deeds of doctorsBeneficence : good deeds of doctors Non Non Malficence : do not inlfict harmMalficence : do not inlfict harm Autonomy : right of patients to receive the Autonomy : right of patients to receive the

best information and service, involved in best information and service, involved in clinical decision making, treated as equal.clinical decision making, treated as equal.

Justice : full access to medical service, for Justice : full access to medical service, for all.all.

3. HEALTH SERVICE, in accordance to 3. HEALTH SERVICE, in accordance to definition of MEDICINE :definition of MEDICINE :

Medicine in the ART and SCIENCE of Medicine in the ART and SCIENCE of the DIAGNOSIS and TREATMENT of the DIAGNOSIS and TREATMENT of

THE DISEASE and the MAINTANANCE THE DISEASE and the MAINTANANCE of HEALTHof HEALTH

SCIENCE – clinical competence SCIENCE – clinical competence (expertise) – to make D/ and (expertise) – to make D/ and Th/ = Th/ = CURECURE

ART – ethical competence – CAREART – ethical competence – CAREProper health care = combination of Proper health care = combination of CURE and CARE, given proportionally.CURE and CARE, given proportionally.

BIOETHICSBIOETHICS MC MC CulloughCullough & Laurence & Laurence Is the disciplined study of the morality Is the disciplined study of the morality

of health care, including the morality of health care, including the morality of the physicians, patients, the of the physicians, patients, the institution of health care that institution of health care that

organize, deliver or pay of health organize, deliver or pay of health care, and heath care policycare, and heath care policy

Abel Abel Bioethics is the interdisciplinary study Bioethics is the interdisciplinary study

of problems, caused by the of problems, caused by the development of biology and development of biology and

medicine, in micro as well as in medicine, in micro as well as in macro scale, and its impact on the macro scale, and its impact on the

community values systems, at community values systems, at present, as well as in the future.present, as well as in the future.

BIOETHICSBIOETHICS MEDICAL ETHICSMEDICAL ETHICS HOSPITAL ETHICSHOSPITAL ETHICS ETHICS IN BIOMEDICAL RESEARCHETHICS IN BIOMEDICAL RESEARCH

Medical EthicsMedical EthicsRegulation of behavior or conduct of Regulation of behavior or conduct of

physicians to patientsphysicians to patientsREMEMBER REMEMBER HIPPOCRATES’s OATH !!!!HIPPOCRATES’s OATH !!!!

HOW DO WE BEHAVE AND HOW DO WE BEHAVE AND CONDUCT ETHICALLY ?CONDUCT ETHICALLY ?

Be honest, humble and full of Be honest, humble and full of compassioncompassion

Promise to give the best information and Promise to give the best information and carecare

Do not act paternalistically, but treat the Do not act paternalistically, but treat the patients as equalpatients as equal

Acknowledge patient’s right for integrity, Acknowledge patient’s right for integrity, confidentiality and decision makingconfidentiality and decision making

CURRENT ISSUES IN MEDICAL CURRENT ISSUES IN MEDICAL PROFESSIONPROFESSION

Shift of paradigm: Paternalistic – EqualityShift of paradigm: Paternalistic – Equality Ambivalent feeling :Ambivalent feeling :1.1. Admiration for biomedical technology Admiration for biomedical technology

(CURE)(CURE)2.2. Dissatisfaction for malpractice and Dissatisfaction for malpractice and

ethical misconduct (CARE)ethical misconduct (CARE) Negative ethical issues is increasing, Negative ethical issues is increasing,

quantitative, qualitative and more quantitative, qualitative and more openlyopenly

EXTREME EXAMPLE OF EXTREME EXAMPLE OF NEGATIVE ISSUESNEGATIVE ISSUES

I will sue the doctors until they have I will sue the doctors until they have only their underwearonly their underwear

There are 29 lawyers, ready to defend There are 29 lawyers, ready to defend the helpless patients, free of charge, the helpless patients, free of charge,

from malpractice of the doctorsfrom malpractice of the doctors I will open their eyes, to make realize, I will open their eyes, to make realize,

not to act arrogantlynot to act arrogantly

Are our behavior really as bad as that ?Are our behavior really as bad as that ? Has our medical profession gone down Has our medical profession gone down

as low as that ?as low as that ? FOR A CORRECT ANSWER, WE MUST FOR A CORRECT ANSWER, WE MUST HAVE THE COURAGE TO CONTEMPLETE HAVE THE COURAGE TO CONTEMPLETE HONESTLY, INDIVIDUALLY AS WELL AS HONESTLY, INDIVIDUALLY AS WELL AS

INSTITUTIONALLYINSTITUTIONALLY

JONSEN et al : development of JONSEN et al : development of Clinical Ethics to prevent Clinical Ethics to prevent

Ethical ConflictEthical Conflict Clinical Ethics is a practical discipline Clinical Ethics is a practical discipline

which provide a structured approach which provide a structured approach in decision making, by identifying, in decision making, by identifying,

analyzing and solving ethical issues analyzing and solving ethical issues in clinical medicine.in clinical medicine.

FOUR TOPICS related to FOUR TOPICS related to CLINICAL ETHICSCLINICAL ETHICS

Medical Indication, a capacity of a Medical Indication, a capacity of a doctor in clinical decision making, doctor in clinical decision making, including diagnosis and intervention, as including diagnosis and intervention, as a result of his education, experience a result of his education, experience and professional attitude.and professional attitude.

Patient’s preference, patient’s behavior Patient’s preference, patient’s behavior as a reaction to doctor’s suggestion as a reaction to doctor’s suggestion which could be an approval or refusal.which could be an approval or refusal.

Quality of Life (QOL). It is necessary Quality of Life (QOL). It is necessary to predict before hand whether the to predict before hand whether the QOL after treatment will be better, QOL after treatment will be better, stationary or worse.stationary or worse.

Contextual factors, external factors Contextual factors, external factors closely related to treatment and care closely related to treatment and care of the patients, such as family, of the patients, such as family, social, economical, cultural and law.social, economical, cultural and law.

ETHICAL CONFLICT WILL OCCUR IF ETHICAL CONFLICT WILL OCCUR IF THERE IS A PROBLEM IN ONE OR THERE IS A PROBLEM IN ONE OR

MORE OF THOSE TOPICS.MORE OF THOSE TOPICS.

IF Jonsen’sIF Jonsen’s PARADIGM, IMPLEMENTED PARADIGM, IMPLEMENTED CONSISTENTLY = definition of CONSISTENTLY = definition of

MEDICINE (CURE & CARE)MEDICINE (CURE & CARE)

DOES THE CURRENT NEGATIVE DOES THE CURRENT NEGATIVE ISSUES IN MEDICAL PROFESSION ISSUES IN MEDICAL PROFESSION

OCCUR BECAUSE OF INCONSISTENCY OCCUR BECAUSE OF INCONSISTENCY IN IMPLEMENTING IN IMPLEMENTING Jonsen’s Jonsen’s

PARADIGM ?PARADIGM ?

FACTORS CAUSING ETHICAL FACTORS CAUSING ETHICAL CONFLICT OR MALPRACTICECONFLICT OR MALPRACTICE

Basically, they are bad doctorsBasically, they are bad doctors Basically, they are good doctors, due Basically, they are good doctors, due

to personal needs, environmental to personal needs, environmental influence, tight competition, influence, tight competition, unintentionally, involved in unintentionally, involved in malpractice of ethical misconductmalpractice of ethical misconduct

Provision of Code of Ethics, not Provision of Code of Ethics, not sufficientsufficient

Community’s demand for health care Community’s demand for health care is increasingis increasing

Globalization, especially introduction Globalization, especially introduction to high biomedical technology and to high biomedical technology and human right, without reservationhuman right, without reservation

Inconsistency in implementation of Inconsistency in implementation of Jonsen’s paradigmJonsen’s paradigm

IT IS POSSIBLE TO NEUTRALIZE ALL THOSE IT IS POSSIBLE TO NEUTRALIZE ALL THOSE NEGATIVE ISSUES ?NEGATIVE ISSUES ?

I M P O S S I B L E !!!I M P O S S I B L E !!!Because the causes are Because the causes are

multifactorial,multifactorial, and will always exist and will always exist BUT AT LEAST WE COULD & SHOULD BUT AT LEAST WE COULD & SHOULD

MINIMIZE IT.MINIMIZE IT.

HOW SHOULD WE REACT TO HOW SHOULD WE REACT TO THOSE NEGATIVE ISSUES ?THOSE NEGATIVE ISSUES ?

WE SHOULD ADMIT THAT ARE SOME WE SHOULD ADMIT THAT ARE SOME UNDENIABLE NEGATIVE ISSUES, BUT THOSE UNDENIABLE NEGATIVE ISSUES, BUT THOSE ARE INDIVIDUAL CASES, NOT A GENERAL ARE INDIVIDUAL CASES, NOT A GENERAL PICTURE OF MEDICAL PROFESSIONPICTURE OF MEDICAL PROFESSION

THEREFORE IT IS OUR DUTY COUNTERACT IT BY THEREFORE IT IS OUR DUTY COUNTERACT IT BY IMPROVING OURSELVES, INDIVIDUALLY AS IMPROVING OURSELVES, INDIVIDUALLY AS WELL AS INSTITUNIONALLYWELL AS INSTITUNIONALLY

IT WILL NOT BE EASY, BUT IS CHALLENGINGIT WILL NOT BE EASY, BUT IS CHALLENGING

CONCLUSIONS CONCLUSIONS Doctors are professionals : Doctors are professionals : scientific and scientific and

biotechnologically accountable, skillful, biotechnologically accountable, skillful, Ethically Acceptable, and good manager.Ethically Acceptable, and good manager.

Current Issues in Clinical Ethics : Current Issues in Clinical Ethics : People People has Ambivalent Feeling toward Medical has Ambivalent Feeling toward Medical Profession, positive as well as negative.Profession, positive as well as negative.

Some of negative issues are true, hence Some of negative issues are true, hence introspection and contemplation are introspection and contemplation are imperativeimperative

PROGRAN PENDIDIKAN PROGRAN PENDIDIKAN DOKTER SPESIALISDOKTER SPESIALIS

Peserta : Peserta : Dokter, profesional Dokter, profesional (postgraduate), mandiri, lebih (postgraduate), mandiri, lebih bertanggung jawabbertanggung jawab

Materi keilmuan : Materi keilmuan : kognitif, kognitif, psikomotor dan afektifpsikomotor dan afektif

Tujuan : Tujuan : Pembekalan kompetensi Pembekalan kompetensi klinik (IQ) dan kompetensi Etik klinik (IQ) dan kompetensi Etik (EQ)(EQ)

lanjutanlanjutan Sumber ilmu dan ketrampilan : Sumber ilmu dan ketrampilan : dosen, dosen,

kepustakaan dan penderita.kepustakaan dan penderita. Kegiatan :Kegiatan : belajar dan memberikan belajar dan memberikan

pelayanan.pelayanan. Tanggung jawab : Tanggung jawab : terhadap diri terhadap diri

sendiri, institusi dan penderita.sendiri, institusi dan penderita. Lulusan : Lulusan : Dokter Spesialis (Umum), Dokter Spesialis (Umum),

Profesional.Profesional.

REFERENCESREFERENCES

1.1. Martaadisoebrata D. Pengantar ke Dunia Martaadisoebrata D. Pengantar ke Dunia Profesi Kedokteran. Edisi Pertama. Profesi Kedokteran. Edisi Pertama. Yayasan Bina Pustaka SW, Jakarta, 2004Yayasan Bina Pustaka SW, Jakarta, 2004

2.2. Dorlan’s Medical DictionaryDorlan’s Medical Dictionary3.3. Welch WH. Quoted from “A Practical Guide Welch WH. Quoted from “A Practical Guide

For Medical Teachers”. Eds. Dent JA, For Medical Teachers”. Eds. Dent JA, Harden RM. Harcourt Publishers LimitedHarden RM. Harcourt Publishers Limited

4.4. Jonsen AR, Siegler M, Winsdale WL. Jonsen AR, Siegler M, Winsdale WL. Clinical Ethics, A Practical Approach to Clinical Ethics, A Practical Approach to Ethical Decision in Clinical MedicineEthical Decision in Clinical Medicine. 5. 5thth ed. McGraw Hill, 2002ed. McGraw Hill, 2002