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 self-interest”

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 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 theperceived 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

For economic competition Failure to act even in light of

problems

Culture is a contributor

American culture 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.”TrotterThere 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

Uphold professional values Accountability Responsibility

Intervene in the system 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 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 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, 2004FOR IMMEDIATE RELEASE

Scott & White Among Nation's 100 Best Hospitals

College of Medicine Presents Teaching Award in TempleA 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.htmBarondess JA. Medicine and professionalism. Archives of Internal Medicine. 2003; 163:145-

149.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/htmlHafferty 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: 71-

78.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. The primacy of patient welfare

2. The principle of patient autonomy

3. The principle of social justice

4. 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 theunprofessional behavior of a learner or colleague,what steps will you avoid in responding tohim/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