PROFESSIONALISMPROFESSIONALISM

Richard Cruess OC, MD, FRCSCRichard Cruess OC, MD, FRCSC

Sylvia Cruess MD, CPSQSylvia Cruess MD, CPSQ

McGill UniversityMcGill University

How to reference this document: Cruess R., Cruess S., Professionalism. CanMEDS Train-the-Trainer Program on Professionalism. 2009

What Is It?

PROFESSIONALISMPROFESSIONALISM

Definition Before Diagnosis

TAKE AWAY MESSAGESTAKE AWAY MESSAGES

1. Professionalism has a cognitive base which includes definable attributes

2. Professionalism is the basis of medicine’s social contract with society

3. Both medicine and society have legitimate expectations- “each of the other”

4. Medicine’s obligations arise from societal expectations5. There are consequences if these expectations are not met6. Linking professionalism to the social contract is beneficial

to the teaching of professionalism

VIGNETTEVIGNETTE

Your daughter is scheduled to graduate from high school this afternoon. As you are preparing to sign out to a colleague, one of your long time patients present in the ER with chest pain. You enter the ER and a partner in your group practice is already there to evaluate the situation. As you know that he is competent and conscientious, you go to reassure your patient. He pleads with you to stay.

Think about what aspects of professionalism are demonstrated by this situation

Professional Status is Professional Status is NotNot an Inherent an Inherent RightRight

IT IS GRANTED BY SOCIETYIT IS GRANTED BY SOCIETY

It Must Be Constantly Earned by It Must Be Constantly Earned by Meeting the Obligations Expected Meeting the Obligations Expected

of a Professionalof a Professional

IF MEDICINE FAILS TO MEET ITS IF MEDICINE FAILS TO MEET ITS OBLIGATIONSOBLIGATIONS

SOCIETY WILL CHANGESOCIETY WILL CHANGE

ITS STATUSITS STATUS

• IT CONFERS»Prestige and Respect»Trust»Autonomy in Practice»Physician-Led Regulation»Financial Rewards

PROFESSIONAL STATUS ISPROFESSIONAL STATUS ISIMPORTANT TO MEDICINEIMPORTANT TO MEDICINE

“ Neither economic incentives, nor technology, nor administrative control has proved an effective surrogate for the commitment to integrity evoked in the ideal of professionalism ”

Sullivan, 1995

PROFESSIONALISM ALSO BENEFITS PROFESSIONALISM ALSO BENEFITS SOCIETYSOCIETY

• A questioning society• A complex health care system• The commodification of health• Failure of the professions to

meet their obligations•

PROFESSIONALISM IS PROFESSIONALISM IS THREATENEDTHREATENED

WHAT IS A PROFESSIONAL?WHAT IS A PROFESSIONAL?

PROFESSION

PROFESS

PROFESSIONAL PROFESSIONALISM

DEFINITIONS-PROFESS(ION)DEFINITIONS-PROFESS(ION)

• Healer

• Professional

• Served simultaneously

• Analyzed separatelyProfessionalism as the word is used generally

includes both roles

PHYSICIANS HAVE TWO ROLESPHYSICIANS HAVE TWO ROLES

Antiquity

technology“curing”

THE HEALER THE PROFESSIONAL

Code of Ethics

Middle ages“Learned professions”clergy, law, medicine

1850:Legislation monopoly

1900:University linkageScience

AsclepiusHippocrates

THE PRESENT

HEALING AND HEALING AND PROFESSIONALISMPROFESSIONALISM

Autonomy

MD-led regulation

associations

institutions

Responsibility to society

Team work

Caring/ compassion listening

Insight

OpennessRespect for the healing functionRespect patient dignity/ autonomy

Presence/Accompany

PHYSICIANHEALER PROFESSIONALL

Based on the Literature

ATTRIBUTESATTRIBUTES

Competence

CommitmentCommitment

ConfidentialityConfidentiality

AltruismAltruism

TrustworthyTrustworthy

Integrity/HonestyIntegrity/Honesty

code of ethicscode of ethics

Morality/Ethical Morality/Ethical

Behavior Behavior

Responsibility to Responsibility to professionprofession

• Definition: As professionals, physicians are committed to the health and well-being of individuals and society through ethical practice, professional-led regulation, and high personal standards of behavior

-RCPSC, 2005

DEFINITION AND DESCRIPTION DEFINITION AND DESCRIPTION PROFESSIONALPROFESSIONAL

Description: • Physicians have a unique societal role as professionals who are

dedicated to the health and caring of others. Their work requires the mastery of a complex body of knowledge and skills, as well as the art of medicine. As such, the professional role is guided by codes of ethics and a commitment to clinical competence, the embracing of appropriate attitudes and behaviors, integrity, altruism, personal well-being, and the promotion of the public good within their domain.

• These commitments form the basis of a social contract between a physician and society. Society in return grants physicians the privilege of profession-led regulation with the understanding that they are accountable to those served, to the profession, and to society.

-after RCPSC, 2005

DEFINITION AND DESCRIPTION DEFINITION AND DESCRIPTION PROFESSIONALPROFESSIONAL

• Cruess, Johnston, & Cruess

• Swick

• Royal College/CMA/ABIM/ ACGME

• The International Charter

• Self-generated: must be based on the literature

ALL ARE ACCEPTABLE

OTHER DEFINITIONSOTHER DEFINITIONS

• Specialized knowledge

Science

Art• Service to others

• Morality

CORE OF PROFESSIONALISMCORE OF PROFESSIONALISM

The Primary Role is that of The Primary Role is that of the Healerthe Healer

• Society uses the concept of the profession as a means of organizing the delivery of complex services which it requires, including that of the healer.

““The Professional Model”The Professional Model”

•Bureaucratic

•Free Market

Neither Share the Values of the Healernone pure>

OTHER MODELS ARE AVAILABLEOTHER MODELS ARE AVAILABLE

• The Social Contract in health care hinges on professionalism.

• It serves as the basis for the expectations of medicine and society.

“The rights and duties of the state and its citizens are reciprocal and the recognition of this reciprocity constitutes a relationship which by analogy can be called a social contract”

-Gough, “The Social Contract”, 1957

•

SOCIAL CONTRACT

• PROPOSES RIGHTS, PRIVILEGES, AND OBLIGATIONS ON BOTH SIDES

• “BARGAIN” (Klein)

• Professions are given prestige, autonomy, the privilege of physician-led regulation, and rewards on the understanding that they will be altruistic, regulate well , be trustworthy, and address the concerns of society

•

THE SOCIAL CONTRACTTHE SOCIAL CONTRACT

• A Mix of: • The explicit and the implicit • The written and the unwritten

licensing laws certification standards health care legislation

codes of ethics • Legal and moral obligations • The universal and the local

•

THE SOCIAL CONTRACTTHE SOCIAL CONTRACT

ExpectationsObligations

PROFESSIONALISMTHE MEDICALPROFESSION

SOCIETY

IndividualPhysicians

Medicine’sMedicine’sInstitutionsInstitutions

Patients

GeneralGeneral PublicPublic

GovernmentPROFESSIONALISM

PoliticiansCivil Servants

Managers

POLITICAL

Cruess & CruessPerspectives in Biol & Med. 2008

THE SOCIAL CONTRACTTHE SOCIAL CONTRACT

1. Health Care System2. Regulatory Framework3. The Commercial Sector4. Other Stakeholders5. The Media

after Rosen & Dewar, 2004

MEDIATORS OF THE SOCIAL MEDIATORS OF THE SOCIAL CONTRACTCONTRACT

Society’s Expectations of Medicine

• to fulfill the role of the healer• assured competence

• timely access to care

• respect for patient autonomy

• altruistic service

• morality, integrity, & honesty

• accountability and transparency

• team health care

• source of objective advice

• promotion of the public good

Medicine’s Expectations of Society

• trust • autonomy• MD-led regulation• reasonable lifestyle• health care system

-value-laden -adequately funded & staffed - reasonable freedom• role in public policy• monopoly• rewards

- financial- non-financial

• respect• status•

THE SOCIAL CONTRACTTHE SOCIAL CONTRACT

NOTELinking professionalism with the social contract

provides a rational basis for medicine’s obligations, both individual & collective

It seems empowering to students and residents.The concept implies that medicine can negotiate the

terms of the contract

•Mandate

•state sanctioned authority

•Collegiality

•major regulatory role

•set and maintain standards

•discipline

•advise public

•They Must•demonstrate morality and virtue

•assure competence

•be open and transparent

• be governed by an institutional code

LICENSING BODIES AND LICENSING BODIES AND PROFESSIONAL ASSOCIATIONSPROFESSIONAL ASSOCIATIONS

• MUST MANAGE CONFLICT OF ROLES

• altruism vs self-interest

• public good vs union function

POTENTIAL TO PROMOTE OR SUBVERT THE IMAGE

OF MEDICINE

LICENSING BODIES AND LICENSING BODIES AND PROFESSIONAL ASSOCIATIONSPROFESSIONAL ASSOCIATIONS

Self-RegulationSelf-Regulation

•Obligation (individual)•maintain competence •participate in and submit to the process of self regulation•support professional associations and regulatory bodies

•ensure their integrity

•Obligation (collective)•demonstrate morality and virtue•assure competence•be open and transparent•be governed by an institutional code

THEORY OF COUNTERVAILING FORCES

PROFESSIONS

STATECORPORATE SECTOR

THE EVOLUTION OF THE EVOLUTION OF PROFESSIONAL STATUSPROFESSIONAL STATUS

1850-1960: PROFESSIONS DOMINANT

“NOSTALGIC PROFESSIONALISM”

Solo Practitioner-Single Payer

Modest Income

Accountable to Patient

Altruism-Indigent

High Trust & Influence

THE EVOLUTION OF THE EVOLUTION OF PROFESSIONAL STATUSPROFESSIONAL STATUS

• 1960- Present: STATE/CORPORATE SECTOR DOMINANT

• PROFESSIONALISM HAD TO EVOLVE

THE EVOLUTION OF THE EVOLUTION OF PROFESSIONAL STATUSPROFESSIONAL STATUS

THE NEW PROFESSIONALISM Accountability Autonomy Patient Autonomy

Transparency Financial rewards/conflicts of interest Team Health Care Altered Expectations (society & professionals)

A NEW SOCIAL CONTRACTMust Preserve Core Values of the HEALER

THE EVOLUTION OF THE EVOLUTION OF PROFESSIONAL STATUSPROFESSIONAL STATUS

THERE ARE CONSEQUENCES WHEN EXPECTATIONS ARE NOT MET

BREACHES IN THE CONTRACT

THE SOCIAL CONTRACTTHE SOCIAL CONTRACT

MEDICINE FAILS TO MEET SOCIETAL EXPECTATIONS

THE RESULT- A CHANGE IN THE CONTRACT public trust in the “system” (contract) trust in physician/profession medical influence on public policy self-regulation external regulation autonomy

BREACHING THE SOCIAL BREACHING THE SOCIAL CONTRACTCONTRACT

• Altruism

individual -lifestyle financial gain

collective -union• Flawed MD-led regulation• Badly managed conflicts of interest• Lack of attention to social justice

BREACH ??BREACH ??

MEDICINE’S PERCEIVED MEDICINE’S PERCEIVED FAILURESFAILURES

Medicine’s Response-Two Poles

Trust in the “system” (contract) Cooperation Withdrawal Job vs Calling Satisfaction

Involvement community associations stakeholders Negotiation? Satisfaction

Society Fails to Meet Medicine’s Expectations

OPTIMISMPESSIMISM

BREACHING THE SOCIAL BREACHING THE SOCIAL CONTRACTCONTRACT

• Funding of the System

• Personnel

• Personal Freedom

MAJOR CHANGE IN THE CONTRACT

?? BREACH

Trust in the system

CANADA 2009CANADA 2009

• These issues are here to stay• Linked to societal changes

MEDICINE:• Must address issues within its control• Must negotiate issues which it cannot control

• •

WHAT SHOULD MEDICINE DO?WHAT SHOULD MEDICINE DO?

THIS IS IN PART THIS IS IN PART AN EDUCATIONAL ISSUEAN EDUCATIONAL ISSUE

MEDICINE MUST ADDRESS ITS MEDICINE MUST ADDRESS ITS FAILURESFAILURES

Negotiate a Social Contract which Supports the Healer and Professional Roles

• Negotiations must:-Preserve Trust -Satisfy both sides

• Negotiations not Symmetrical- Society (through government has more power

However- MEDICINE’S STRENGTH IS SOCIETY’S NEED FOR THE HEALER!

• •

WHAT SHOULD MEDICINE DO?WHAT SHOULD MEDICINE DO?

“Since time immemorial, a part of human culture has been man’s care for himself, for the body in which the spirit resides - that is for his own health. The culture of healing may be a less visible aspect of life, yet it is perhaps the most important indicator of the humanity of any society”

Vaclav Havel, Summer Meditations, 1993

ACTION PLANACTION PLAN

• Take a few minutes to reflect on this half-day, and complete the relevant section of the action plan