PROFESSIONALISM IN MEDICAL PRACTICE(KFMC, MAY 9, 2016)

Ghaiath Hussein, MBBS, MHSc. (Bioethics)

Outline of the session■ Professionalism:

– Approaches and Dimensions of professionalism– Doctor’s Professional Relationships and Duties

■ Saudi Code of Ethics for Medical Practitioners■ Conflict of Interests (COI)

■ DISCLAIMER:This presentation is based on the Professionalism and Ethics Handbook for Residents Citation: Hussein GM, Kasule OH, Al-Kaabba AF. Professionalism and Ethics Handbook for Residents. Ware J, Kattan T, editors. Riyadh, Saudi Arabia 2015

PROFESSIONALISMDoctor’s Professional Duties & Relationships

Clinicians Beyond Hospitals!COUNTRY/REGION

Policy maker

Planner

Manager

COMMUNITYAdvocate

Researcher

Educator

CLINIC/HOSPITALProvider Manager Educator Research

er

Levels of Behavioural ‘Control’Morality

Ethics

Laws & Regulations

Institutional Policies

Professional standardsPersonal beliefs &

preferences

• General unchallenged community value; voluntarily followed

• Inherited as is; not argued• Not written; changes slowly with time• Argued; logically established (moral philosophy)• Voluntarily; not universal• Inspires codes, policies, & laws

• Binding to everyone• Legal actions may follow, if not followed

• Binding to those in the institution• Should be followed; disciplinary action might

follow if not followed• Binding to those in profession• Mostly voluntary; disciplinary action might follow if

not followed• Written as Codes• Varies individually• Commits only you (and dependents)

So your expected roles are…CanMEDS (http://www.royalcollege.ca/) SaudiMEDS

Saudi Meds: A competence specification for Saudi medical graduatesRania G. Zaini , Khalid A. Bin Abdulrahman , Abdulaziz A. Al-Khotani , Abdol Monem A. Al-Hayani , Ibrahim A. Al-Alwan , Saddig D. Jastaniah Medical Teacher , Vol. 33, Iss. 7, 2011

SAUDI CODE OFETHICS FOR HEALTHCARE PRACTITIONERS

http://www.scfhs.org.sa/Reglations/CR/Documents/%D8%A3%D8%AE%D9%84%D8%A7%D9%82%D9%8A%D8%A7%D8%AA%20%D8%A7%D9%84%D9%85%D9%85%D8%A7%D8%B1%D8%B3%20%D8%A7%D9%84%D8%B5%D8%AD%D9%8A.pdf

Overview on the Saudi Code of Ethics (1)■  Introduction .. (A) Medical Profession Ethics and Regulations (B) Honour of the Healthcare Professions (C) Sources of Healthcare Professional Ethics (D) Healthcare Profession Honour . (E) Role of Role-Models ■ Healthcare Practitioner Ethics

(A) Devotion and Feeling the Worship of Allah (SWT)(B) Demonstration of the Best of Manners (C) Self-accountability (D) Avoidance of Trivialities and Pettiness

■ Healthcare Practitioner’s Duties Towards Patients

(A) Good Treatment of Patient . (B) Achieving Patient’s Interest and Guarding His/Her Right (C) Patient’s Consent (D) Reassurance of Patient (E) Maintaining Patient’s Secrets - Confidentiality(F) Photographing Patients and Recording Their Voices (G) Dealing with Patients Who Refuse a Medical Procedure (H) Conscientious Objection to Refrain from Treating a Patient■ Healthcare Practitioner’s Duties

Towards Community . ■ Healthcare Practitioner’s Duties

Towards Professional Colleagues ■ Healthcare Practitioner’s Duties

Towards Him/Herself

Overview on the Saudi Code of Ethics (2)■ Healthcare Practitioners’

Duties Towards His/Her Profession

■ Observance of Religious Rulings

(A) Ruling on Exposing Private Parts of the Body (Awra) (B) Rulings in Abortion (C) Relation Between the Opposite Sexes (D) Healthcare Practitioner’s Relations Outside the Limits of the Profession(E) Religiously Forbidden Procedures and Treatment Methods■ Ethics of Teaching and

Learning on Patients

■ Ethics of Documentation and Authentication ..

(A) Medical Record .... (B) Certificates and Reports .... (C) Medical Prescriptions . ■ Ethics of Financial Affairs in

the Healthcare Field . (A) Healthcare Practitioner’s Fee .... (B) Practicing in Private Sector . (C) Advertisements and Publicity ... (D) Participation in the Media (E) Gifts and Benefits (F) Relationships with Pharmaceutical and Medical Equipment Companies(G) Insurance

Overview on the Saudi Code of Ethics (3)■ Ethics of Conducting

Biomedical Research(A) Conducting Biomedical Research on Humans(B) Conducting Research and Experiments on Animals(C) Regulations for Accepting Scientific Research Grants (D) Regulations for Innovative Interventional Procedures■ Ethics of Dealing with

Communicable Diseases ■ Ethics of Dealing with the

Developments in Healthcare Practices

■ Ethics of Dealing with Emergency Situations

■ Ethics of Dealing with Life-threatening and Incurable Diseases

(A) Does the Patient Have the Right to Refuse Treatment in Incurable Conditions? . (B) Should Medical Treatment Be Stopped? (C) Cardiopulmonary Resuscitation(D) Conditions of Prolonged or Terminal Coma due to Cerebral Cortical Damage

Professionalism“constituting those attitudes and behaviors that

serve to maintain patient interest above physician self-interest.”

American Board of Internal Medicine

Professional competence is the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served.

Epstein and Hundert

What is professionalism about?Undesirable

conductDesirable Behaviors

Abuse of powerBias(Sexual) harassmentBreach of confidentialityArroganceGreedMisrepresentationImpairmentLack of conscientiousness and Conflicts of interest

AltruismAccountabilityExcellenceDutyHonorIntegrityRespect for others, and A commitment to lifelong learning

Source:http://www.med.uottawa.ca/students/md/professionalism/eng/what_is_professionalism.html

Muslim Doctors’ Duties Towards Patients

Respect for Patient المريض احترام Respect for Privacy المريض خص[وصية ضمان Comprehensive care للمريض الشاملة الرعاية Respect for patient’s autonomy المريض استقاللية احترام Inform the patient about his/her condition بطبيعة المريض تبصير

مرضه Protect patient's interests المريض مص[لحة حماية Keep the patients’ secrets (confidentiality) المريض سر كتمان

Source: Islamic Code of Medical & Health Ethics

Physician's Duties Towards Colleagues To deal with, and act towards his colleagues in a good manner and in the same way he would prefer to be treated

To avoid direct criticism to his colleague in front of patients

Not to indulge in defaming the honor of his colleagues

To exert every possible effort to educate the colleagues

Respect the differences with colleagues (sex, culture, belief…).

The physician should respect other non-physician medical profession colleagues, and appreciate their roles in healthcare of the patient

She/he must report the incidence in which a colleague could be dangerous to the authority concerned

Doctor’s Duties Towards his/her Profession

Respect the honour of the profession;Develop him/herself to develop the

profession through CME, research, and publications;

Adhere to the standards of practice (GCP, EBM, guidelines, etc.)

Abstain from any behaviour/action that would question his/her credibility, or establish dishonest affairs with patients or their families;

Avoid the request of fame on the account of the professional ethics and standards

To provide role model for his colleagues and patients

Source: Islamic Code of Medical & Health Ethics

Doctor’s Duties Towards his/her ProfessionReflect sincere devotion and dedication to

the medical profession.To avoid any action that could lead to

contempt of the medical profession and to maintain the standards of medical profession

To contribute in the development of the profession through research and continuous learning.

The physician should not take advantage of his profession position for obtaining any material or moral gains, which are not in conformity with or violate the laws and tradition.

Doctor’s Duties Towards his/her ProfessionTo take the appropriate procedure when he

comes to know that one of the members of the health team is sick, ignorant or negligent of his duties; in furtherance of protecting the patient in the first place and the medical profession next.

The physician should refrain, when dealing with the patient, from any act or conduct that would infringe his honesty and integrity.

To avoid seeking fame at the expense of the profession ethics and principles.

Doctor’s Role Towards Community

Positive interaction with the community’s affairsProtect the community by reporting

reportable/epidemic diseases Improve health in the community through

advocacy and health education, and involvement in community health activities

Rational use of the healthcare institutions’ resources

Effective contribution to the development of policies and health systems that respond to the community needs and facilitates easier access to health care.

Source: Islamic Code of Medical & Health Ethics

Doctor’s Role Towards Community

To be as a role model in his/her attitude and religion

Promotion of health equity among the society members

Maintenance of health resources and the ideal utilization of such resources.

Use his skills, knowledge and expertise to improve the standards and quality of health services rendered to the society.

Lack of ProfessionalismSigns of lack of professionalism (ABIM, 2001)1. Abuse of power:

– Abuse while interacting with patients and colleagues; – Bias and sexual harassment; and – Breach of confidentiality

2. Arrogance (offensive display of superiority and self-importance); 3. Greed (when money becomes the driving force); 4. Misrepresentation (lying, which is consciously failing to tell the

truth; and fraud, which is conscious misrepresentation of material fact with the intent to mislead);

5. Impairment (any disability that may prevent the physician from discharging his/her duties); 6. Lack of conscientiousness (failure to fulfill responsibilities); 7. Conflicts in interests (self-promotion/ advertising or unethical

collaboration with industry; acceptance of gifts; and misuse of services – overcharging, inappropriate treatment or prolonging contact with patients).

CONFLICT OF INTERESTS

COI in research and clinical practice

What is an interest?• An interest may be defined as a

commitment, goal, or value held by an individual or an institution.

• Examples include a research project to be completed, gaining status through promotion or recognition, and protecting the environment. Interests are pursued in the setting of social interactions.

Conflict of Interests (COIs)■ In research:

“situations in which financial or other personal considerations may compromise, or have the appearance of compromising, an investigator’s judgment in conducting or reporting research.” AAMC, 1990

■ In clinical care:“a set of conditions in which professional judgment concerning a primary interest tends to be unduly influenced by a secondary interest” (Thompson, 1993).

Potential causes of COI In research:• Stock ownership in

pharmaceutical or equipment companies

• Paid board membership • Patent applications (pending or

actual) • Research grants (from whatever

source) • Travel grants and honoraria• Gifts Membership of lobbying

organizations• Relationship with the Research

Review Committees, or with possible reviewers of the paper

• Relationship with organizations and funding bodies

■ In clinical practice (Sade, 2007):■ Financial relationships with

pharmaceutical or medical equipment’s companies

■ provision of a free lunch and drug samples

■ reimbursement for costs associated with professional meetings

■ receiving payments for consulting, giving lectures, or enrolling patients in trials.

■ Dual practice (working in Private & Public facilities)

Are such relationships problematic? Why? ■ Advantages

– Research needs financial and technical support

– Free samples can help some patients who cannot afford the drug

■ Disadvantages:– Researchers might feel

committed to provide ‘something’ in return

– Reordering of priorities towards applied research

– Pharma rep.s emphasize selective positive effects of drugs citing selective literature

– Clinicians'’ decisions are not/ill-informed

– Exploitation of trainees – Loss of public trust

What do you think?

Discussion of Cases

■ Case of Dr Butcher, the well-known surgeon (Module 3)■ Cases of COI (Module 10)