Professionalism: Beyond The Tipping Point: Definition of the

Implicit Contract

Barbara Jantausch M.D.

Children’s National Medical Center

Objectives

• To understand and be able to identify The Tipping Point

• To know the Fundamental Principles of Professionalism as set forth in the ABIM: A Physician’s Charter

• To know our Professional Responsibilities as set forth in A Physician’s Charter

• To be able to identify and analyze lapses in Professionalism in medical practice

The Tipping Point

...that magic moment when an idea, trend or social behavior crosses a threshold, tips and spreads like wildfire

Tipping Point in Tuberculosis

• TB on the decline in the U.S. in the 1980s

• Tremendous resurgence in mid 1990s:

- Globalization- influx new cases U.S.

- HIV/AIDS epidemic

- Emergence of MDR TB

- Cutback in Health Dept resources to

trace contacts, perform DOT

Tipping Point: Professionalism

Second half 19th Century (Osler)• Single-handed general practice• Emerging specialists - developing teaching

hospitals• Medicine harmless - treatments ineffective• Good relationship with the patient: Income depended on it; little else to offer Irvine DH. Med J Aust. 2007. 186:256-262

Tipping Point: Professionalism

Post World War II Era• Specialization in high-tech medicine• Glamorous, powerful role model• Paternalism defined patient relationships• Communication was a one way street• Patients “...to do as they were told…”• Consent to treatment - a formality Irvine DH. Med J Aust. 2007. 186:256-262

Tipping Point: Professionalism

Post WW II - 1980s• Self-protective “take it on our terms”• Public content with doctors• Medical successes so reassuring• People trusted profession to do what was

necessary to protect them• Self-regulation of doctors and practice Irvine DH. Med J Aust. 2007. 186:256-262

Tipping Point: Professionalism

Early 1990s• Public mood Western World changing• Consumer revolution took hold• People more questioning about services in all

walks of life• People concerned about doctors’ poor

communication skills and poor practice Irvine DH. Med J Aust. 2007. 186:256-262

Tipping Point: Professionalism

The Bristol Effect High rates of mortality among children undergoing

complex cardiac surgery at the Bristol Royal Infirmary

• Hearing 1997-98 Anaesthetist disclosed audit data re: 2 surgeons

• Personal professional failure and institutional systems failure

Irvine DH. Med J Aust. 2007. 186:256-262

Tipping Point: Professionalism

In 1990s-new millenium• Britain’s General Medical Council: Good

medical practice• Royal College of Physicians of Canada:• CanMEDS document• ABIM, ACP and European Federation of Internal

Medicine Charter on Medical Professionalism• ACGME: Professionalism competency

Professionalism: The Implicit Contract

Basis of medicine’s contract with society

• placing the interests of patients above those of the physician

• setting and maintaining standards of competence and integrity

• providing expert advice to society on matters of health

The Implicit Contract: Fundamental Principles of A Physician’s

Charter• Principle of primacy of patient welfare

• Serve the interest of the patient

• Principle of patient autonomy

• Be honest with patients

• Empower pts to make informed decisions

• Principle of social justice

• Fair distribution of health resources

• Eliminate discrimination in health care Ann Intern Med 2002; 136:243-246

The Implicit Contract: Professional Responsibilities of A Physician’s Charter

1. Commitment to professional competence - commitment to lifelong learning

- profession must see that all of its members are competent

2. Commitment to honesty with patients - patients are honestly informed about tx

- patients are informed of medical errors - profession analyzes medical mistakes Ann Intern Med 2002; 136:243-246

The Implicit Contract: Professional Responsibilities of A Physician’s Charter

3. Commitment to patient confidentiality 4. Commitment to maintaining appropriate relations with patients 5. Commitment to improving quality of care - act collaboratively to reduce medical

error, increase patient safety, minimize

overuse of health care resources and

optimize outcomes of care

Ann Intern Med 2002; 136:243-246

The Implicit Contract: Professional Responsibilities of A Physician’s Charter

6. Commitment to improving access to care - reduce barriers to equitable health care

7. Commitment to a just distribution of

finite resources - cost-effective management of limited

clinical resources Ann Intern Med 2002; 136:243-246

The Implicit Contract: Professional Responsibilities of A Physician’s Charter

8. Commitment to scientific knowledge - create new knowledge and ensure its

appropriate use

9. Commitment to maintaining trust by managing conflicts of interest - recognize, disclose and deal with

conflicts of interest that arise in the performance of professional activities Ann Intern Med 2002; 136:243-246

The Implicit Contract: Professional Responsibilities of A Physician’s Charter 10. Commitment to professional responsibilities - work collaboratively and be respectful of one another - participate in self-regulation including remediation and discipline of members who fail to meet professional standards - organize educational and other standards for members of the profession - accept scrutiny of own performance

Professionalism

• Disciplinary action against practicing physicians is associated with prior unprofessional behavior in medical school

Professionalism

• Disciplinary action by a medical board was strongly associated with prior unprofessional behavior in medical school

• Odds ratio, 3.0• 95% confidence interval 1.9 to 4.8• Students with strongest association were described

as irresponsible or having diminished ability to improve their behavior

Papadakis MA et al. NEJM. 2005. 353:2673

Professionalism

• Case control study

• 235 disciplined physicians

• 3 medical schools 1970-1999

• - U. Michigan, Jefferson Med Coll, UCSF

• - 40 state boards

• - 2 controls/physician

• - 1 control matched to specialty

Professionalism: Behavior displayed by disciplined physicians in school

Independent predictors for board action:Irresponsibility1. Unreliable attendance at clinic2. Failure to follow-up patient care activitiesDecreased capacity for self-improvement1. Failure to accept constructive criticism2. Argumentativeness3. Poor attitude4. Poor initiative

Professionalism: Disciplined physicians vs. % in specialty:

• Internal medicine 20% vs. 23%

• Family practice 19% vs. 12%

• Pediatrics 3% vs. 8%

• Surgery 8% vs. 8%

• Psychiatry 4% vs. 5%

• OB-GYN 9% vs. 5%

• Anesthesia 8% vs. 5%

Professionalism:A learnable and teachable skill

What should we do? 1. Admission standards should contain explicit language

about professional behavior 2. Graduation objectives should contain explicit

language about professional behavior 3. Identify students who display unprofessional behavior 4. Professionalism can and must be taught and modeled Papadakis MA et al. NEJM. 2005. 353:2673

Maslow’s Hierarchy

Self-actualization

Esteem

Love/Belonging

Safety

Physiological

The Final Reflection….

• Intentions vs. perceptions

• Learned behavior

• Can improve Professionalism

Scenerio1

• Dr. JP is a critical care fellow who is on call in the PICU. Dr. JP is admitting a new patient in PICU BLUE when called by the nurse in PICU GREEN to come and speak to a family member of patient Smith who wants to know what is going on. Patient Smith is a 3 year old girl who experienced multiple trauma following a fall from a third floor window. Patient Smith remains on a ventilator and has multiple problems.

Scenerio 1 (continued)

• The family member of patient Smith is her grandmother who is her legal guardian. The nurse goes on to say that the grandmother reeks of alcohol and she hopes that Dr. JP will come soon. Dr. JP states that he will come as soon as he can.

• The nurse calls back 30 minutes later to report that the grandmother is still waiting for someone to speak to her.

Scenerio 1 (continued)

• Dr. JP gets angry with the nurse and tells her he will come as soon as he can.

• The nurse pages Dr. JP an additional 30 min later. After the nurse identifies herself, Dr. JP does not let the nurse say anything further and hangs up the phone.

• Dr. P has repeatedly failed to enter his duty hours in the E-value system when requested for a program survey by the DIO. As a result, the other trainees in his program have had to enter their duty hours multiple times in order to achieve the 100% division compliance.

Scenerio 2

• Dr. P was also noted to have missing dictations when the attendings went to sign his clinic letters. Missing charts were found in the corners of Dr. P’s cubicle. Two charts of Dr. P’s patients were never located.

Scenerio 2

Scenerio 3

You are in private practice and invited to enroll patients in a clinical trial sponsored by a local pharmaceutical company. The company offers you an all expense paid trip to Hawaii for four days for an orientation to the trial. In addition, you will be given $1000 for attending the orientation and may bring a guest. The company will provide you with a free study nurse and $ 500 for each patient that you enroll. Your partner thinks the study is a good idea.

Scenerio 4 Bristol Royal Infirmary

• Numerous children referred for cardiovascular surgery procedures including switching procedures and repair of AV canal. Outcome of children at this facility far poorer that at other centers.

• Anaesthetist released case logs to supervisory authorities.

Scenerio 4 (continued)

• Out of 100 operations analyzed, poor outcomes could only be attributed to the surgeons in 6. Problems also existed in care rendered by cardiologists, anaesthetists and post-surgical care units.

• Local practicing physicians aware of poor outcomes.

Scenerio 4 (continued)

• It was felt that one of the two surgeons should have stopped operating earlier.

• The second surgeon traveled to Birmingham to improve his skills with these procedures. He was not able to improve his outcomes.

• Community very convinced of surgeons’ concern and dedication to patients and formed action group to support them.

• What is your analysis and how would you proceed?

Objectives

• To understand and be able to identify The Tipping Point

• To know the Fundamental Principles of Professionalism as set forth in the ABIM: A Physician’s Charter

• To know our Professional Responsibilities as set forth in A Physician’s Charter

• To be able to identify and analyze lapses in Professionalism in medical practice

Professionalism is…