Professional Documents
Culture Documents
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Baton Rouge, LA
September 5, 2003
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ACGME Definitions of Professionalism
a. Patient Care that is compassionate, appropriate, and effective for the treatment of
health problems and the promotion of health
b. Medical Knowledge about established and evolving biomedical, clinical, and cognate
(e.g. epidemiological and social-behavioral) sciences and the application of this
knowledge to patient care
c. Practice-Based Learning and Improvement that involves investigation and
evaluation of their own patient care, appraisal and assimilation of scientific evidence,
and improvements in patient care
d. Interpersonal and Communication Skills that result in effective information
exchange and teaming with patients, their families, and other health professionals
e. Professionalism, as manifested through a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population
f. Systems-Based Practice, as manifested by actions that demonstrate an awareness
of and responsiveness to the larger context and system of health care and the ability
to effectively call on system resources to provide care that is of optimal value
Expanded Language
The residency program must require its residents to develop the competencies in the 6 areas
below to the level expected of a new practitioner. Toward this end, programs must define the
specific knowledge, skills, and attitudes required and provide educational experiences as
needed in order for their residents to demonstrate the competencies.
PROFESSIONALISM
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Professionalism Curriculum Matrix (Modified from The
Charter on Medical Professionalism)
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other social
category.
Commitment to
professional
competence.
Physicians must be
committed to
lifelong learning
and be responsible
for maintaining the
medical
knowledge and
clinical and team
skills necessary for
the provision of
quality care.
More broadly, the
profession as a
whole must strive
to see that all of its
members are
competent and
must ensure that
appropriate
mechanisms are
available for
physicians to
accomplish this
goal.
Commitment to
honesty with
patients.
Patients are
completely and
honestly informed
before the patient
has consented to
treatment and after
treatment has
occurred.
Whenever patients
are injured as a
consequence of
medical care,
patients should be
informed promptly
because failure to
do so seriously
compromises
patient and societal
trust.
Takes
responsibility for
his/her medical
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errors.
Commitment to
patient
confidentiality.
Effectively
balances a
commitment to
patient and
overriding
considerations in
the public interest
(for example,
when patients
endanger others).
Commitment to
maintaining
appropriate
relations with
patients.
The physician
never exploits
patients for any
sexual advantage,
personal financial
gain, or other
private purpose.
Commitment to
improving
quality of care.
Demonstrates
dedication to
continuous
improvement in
the quality of
health care in
regards to
maintaining
clinical
competence.
Demonstrates
dedication to
continuous
improvement in
the quality of
health care in
regards to working
collaboratively
with other
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professionals to
reduce medical
error, increase
patient safety,
minimize overuse
of health care
resources, and
optimize the
outcomes of care.
Actively
participates in the
development of
better measures of
quality of care and
the application of
quality measures
to assess routinely
the performance of
all individuals,
institutions, and
systems
responsible for
health care
delivery.
The physicians
assists in the
creation and
implementation of
mechanisms
designed to
encourage
continuous
improvement in
the quality of care.
Commitment to
improving
access to care.
The physician
works to eliminate
barriers to access
based on
education, laws,
finances,
geography, and
social
discrimination.
The physician
promotes public
health and
preventive
medicine.
The physician is a
public advocate,
without concern
for the self-interest
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of the physician or
the profession.
Commitment to
a just
distribution of
finite
resources.
Provides health
care that is based
on the wise and
cost-effective
management of
limited clinical
resources.
Works with other
physicians,
hospitals, and
payers to develop
guidelines for cost-
effective care.
Avoids ordering
superfluous tests
and procedures.
Commitment to
scientific
knowledge.
The physician
upholds scientific
standards,
promotes research,
and creates new
knowledge.
The physician
practices evidence-
based medicine.
Commitment to
maintaining
trust by
managing
conflicts of
interest.
Does not accept
gifts or personal
advantages from
for-profit
industries,
including medical
equipment
manufacturers,
insurance
companies, and
pharmaceutical
firms.
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The physician
recognizes,
discloses to the
general public, and
deals with
conflicts of interest
that arise in the
course of their
professional duties
and activities.
Commitment to
professional
responsibilities.
Works
collaboratively to
maximize patient
care.
Is respectful of
other physicians.
The physician
participates in the
development of
quality and
educational
programs.
The resident is
receptive to
external evaluation
and scrutiny of
their performance.
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Professionalism Evaluation Item Matrix
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and dying in a professional
manner with patient and
family members
Demonstrates integrity Admits errors
Admits omissions (e.g.,
forgot a question/did not do
a rectal examination)
Follows through – does
what they say they are
going to do.
Accurately expresses time
commitment (e.g., I’ll be
down in 30 minutes)
Calls when detained
Maintains privacy
Does not withhold
information from patient
Does not use coercive
language when obtaining
consent
Informs others when not
available (e.g., ill) and
secures replacement
Take on appropriate share
of teamwork
Arrives on time
Completes assignments on
time
Answers pages promptly
Responsive to patients Avoids medical–ese
needs Answers patient call lights
Get patients simple needs
(e.g., water) when asked
Is truth-telling with patients
Response to societies needs Involved in the community
(e.g., volunteerism)
Graciously cares for
socially disadvantaged (e.g.,
homeless, alcoholic)
Attentive to his/her own
family needs
Accountable to patients Follows-up on promises to
patients
Tells the truth
Makes certain that patients
understand them
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Accountable to society Personal life reflects moral
integrity
Accountable to the Supports a balance in
profession personal and professional
activity for peers and
subordinates
Dresses appropriately
Professional appearance
(avoids tattoos, piercing
etc.)
Commitment to excellence Uses neat hand-writing
Does not cut corners
Sets own goals
Commitment to Committed to reading core
professional development material in discipline
Masters techniques and
technologies of learning
Self critical
Commitment to ethical Tells patients what is going
principles regarding to happen to them
providing care Clarifies CODE status
Commitment to ethical Family (appropriately)
principles regarding involved in patient care
withholding care decisions
Confidentiality of patient Does not talk about patients
information beyond the patient care
area
Obtains informed consent Provides sufficient
information for decision
making
Ethical Business practices Does not incorrectly
document
Does not discuss patient
insurance status
Adheres to HIPAA
guidelines
Sensitive and responsive to Does not shout slowly to
patient’s culture non-English speaking
patients
Demonstrates tolerance to
various sexual orientations
Sensitive and responsive to Does not call elderly
patient’s age patients by heir first name
Sensitive and responsive to Avoids sexists remarks,
patient’s gender jokes, etc.
Avoids unflattering terms
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for men and women
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Ingham Regional Medical Center
Professionalism Evaluation Exercise
Interns will be directed that the purpose of this exercise is to watch how they provide feedback and patient
education on a newly diagnosed, mildly retarded 60 y/o female patient. Intern is limited to 20 minutes for
the history taking visit.
Interns are told that the purpose of the exercise is to watch how they gather a medical
history. They will be time limited (20 minutes).
Setting; direct admit patient with Type II diabetes, showing signs of peripheral
neuropathy. The patient is a 60 something year-old female, mildly retarded and is hard of
hearing. Her female “partner” is in the waiting room.
(Describe scoring 0-1 unsatisfactory; 2-3 satisfactory; 4-5 very good to excellent)
Item Score
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Scoring guidelines defined;
#1 0 = Does not do
1 = Does introduce self but not so pt. can hear or acknowledge
2 = During introduction and one other time
3 = Introduction and two more
4 = Introduction and three more
5 = Introduction and four or more times
#2 0 = Does not do
1 = Only during introduction
2 = During introduction and one other time
3 = Twice
4 = Three times
5 = Introduction and several more with empathy
#3 0 = Does not do
1 = Only during introduction
2 = During introduction and one other time
3 = Twice
4 = Introduction and several more with empathy
5 = During entire discussion, keeps discussion at level of pt. understanding
#4 0 = Never
1 = Only during introduction
2 = During introduction and one other time
3 = Introduction and two more
4 = Introduction and three more
5 = Introduction and four or more times
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#6 0 = Disaffirms, “Oh you don’t mean that”, etc.
1 = Does not direct history, pt. rambles, interns shows little interest in process
2 = Follows form, gets lost without prompts
3 = Follows form, helps pt. stay on track
4 = Makes statements; eg, I’m sorry to hear that
5 = Makes statements and asks for clarification, eg, when did you first notice it?
#8 0 = Never
1 = non-verbal recognition, eg., makes eye contact when pt. discusses
2 = Repeats what pt. has stated
3 = Verbally acknowledges, eg, “oh, you have a pain right there?”
4 = Repeats, acknowledges, asks for description
5 = Repeats, acknowledges, asks for description, gives idea for control
#9 0 = Never
1 = non-verbal recognition, eg., makes eye contact when pt. discusses
2 = Repeats what pt. has stated
3 = Verbally acknowledges, eg, “oh, having ‘sugar’ is scary to you?”
4 = Repeats, acknowledges, asks for description of fear
5 = Repeats, acknowledges, asks for description, gives idea for control
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Full text:
Recently, voices from many countries have begun calling for a renewed sense of
professionalism, one that is activist in reforming health care systems. Responding to
this challenge, the European Federation of Internal Medicine, the ACP-ASIM
Foundation, and the ABIM Foundation combined efforts to launch the Medical
Professionalism Project (www.professionalism.org) in late 1999. These three
organizations designated members to develop a "charter" to encompass a set of
principles to which all medical professionals can and should aspire. The charter
supports physicians' efforts to ensure that the health care systems and the
physicians working within them remain committed both to patient welfare and to the
basic tenets of social justice. Moreover, the charter is intended to be applicable to
different cultures and political systems.
Preamble
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Fundamental Principles
Principle of patient autonomy. Physicians must have respect for patient autonomy.
Physicians must be honest with their patients and empower them to make informed
decisions about their treatment. Patients' decisions about their care must be
paramount, as long as those decisions are in keeping with ethical practice and do not
lead to demands for inappropriate care.
Principle of social justice. The medical profession must promote justice in the health
care system, including the fair distribution of health care resources. Physicians should
work actively to eliminate discrimination in health care, whether based on race,
gender, socioeconomic status, ethnicity, religion, or any other social category.
Commitment to honesty with patients. Physicians must ensure that patients are
completely and honestly informed before the patient has consented to treatment and
after treatment has occurred. This expectation does not mean that patients should be
involved in every minute decision about medical care; rather, they must be
empowered to decide on the course of therapy. Physicians should also acknowledge
that in health care, medical errors that injure patients do sometimes occur. Whenever
patients are injured as a consequence of medical care, patients should be informed
promptly because failure to do so seriously compromises patient and societal trust.
Reporting and analyzing medical mistakes provide the basis for appropriate
prevention and improvement strategies and for appropriate compensation to injured
parties.
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Commitment to improving quality of care. Physicians must be dedicated to
continuous improvement in the quality of health care. This commitment entails not
only maintaining clinical competence but also working collaboratively with other
professionals to reduce medical error, increase patient safety, minimize overuse of
health care resources, and optimize the outcomes of care. Physicians must actively
participate in the development of better measures of quality of care and the
application of quality measures to assess routinely the performance of all individuals,
institutions, and systems responsible for health care delivery. Physicians, both
individually and through their professional associations, must take responsibility for
assisting in the creation and implementation of mechanisms designed to encourage
continuous improvement in the quality of care.
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should also define and organize the educational and standard-setting process for
current and future members. Physicians have both individual and collective
obligations to participate in these processes. These obligations include engaging in
internal assessment and accepting external scrutiny of all aspects of their
professional performance.
Summary
The practice of medicine in the modern era is beset with unprecedented challenges
in virtually all cultures and societies. These challenges center on increasing
disparities among the legitimate needs of patients, the available resources to meet
those needs, the increasing dependence on market forces to transform health care
systems, and the temptation for physicians to forsake their traditional commitment to
the primacy of patients' interests. To maintain the fidelity of medicine's social
contract during this turbulent time, we believe that physicians must reaffirm their
active dedication to the principles of professionalism, which entails not only their
personal commitment to the welfare of their patients but also collective efforts to
improve the health care system for the welfare of society. This Charter on Medical
Professionalism is intended to encourage such dedication and to promote an action
agenda for the profession of medicine that is universal in scope and purpose.
Source: "Medical Professionalism in the New Millennium: A Physician Charter", Annals of Internal
Medicine, 5 Feb 2002, 136:3, pp 243-246.
A Curmudgeon’s View
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For convenience, for the rest of this article I shall refer to these as the
"Oath" (Hippocratic Oath) and the "Charter" (The Charter on Medical
Professionalism) .
Similarities
1. Both say that a doctor should always put what is best for the patient above his
own personal gain.
2. Both say that a doctor should not divulge private information about his patients.
(The Charter adds an exception in cases of "overriding ... public interest", such as
when a patient endangers others.)
3. Both prohibit taking sexual advantage of patients.
Differences
1. The Oath is very specific. For the most part, if someone claimed that a doctor had
violated the Oath, the only thing to debate would be the facts: did he really
commit the claimed violation or not? For example, the Oath prohibits a doctor
from participating in physician-assisted suicide or performing abortions. These
are specific acts: the doctor did one of these things or he didn't.
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health care that is based on the wise and cost-effective
management of limited clinical resources". Even if you knew
exactly what a doctor did every minute of every day, it could still
be quite difficult to say whether or not he had lived up to this
Charter. Exactly what is an individual doctor supposed to do to
improve the quality of health care ... "continuously"? How do we
determine whether a given treatment plan is "wise" and "cost-
effective"? There's lots of room for interpretation and judgement
calls here.
2. The meaning and goals of the Oath are plain: Hippocrates opposed specific
practices that other doctors engaged in or that he feared they might engage in, and
he spells them out: euthanasia, abortion, sexual relations with patients, violating
patient confidentiality, and failing to refer to a specialist. (That last one strikes me
as being of a different character from the rest. I guess that he feared that a doctor,
through arrogance and/or greed, might attempt procedures that he was not
qualified to perform, with obvious potential harm to the patient.) (A tangential
thought: I am, of course, referring back to the Oath as I write this to get the list
right, and as I do so it suddenly occurs to me that the issues that concerned
Hippocrates are almost all issues that are still in the news regularly today. Perhaps
things haven't changed so much in 2,500 years after all.)
The Charter, on the other hand, plays word games that leave us
guessing what they really mean. The example of this that I find
the most puzzling, perhaps disturbing: There is a section on
respecting a patient's right to make decisions about his own care
that concludes, "Patients' decisions about their care must be
paramount, as long as those decisions are in keeping with ethical
practice and do not lead to demands for inappropriate care".
What in the world is "inappropriate care"? If we just take the
ordinary, literal English meaning of these words, I guess it would
mean, "treatment that is not a good idea". But then what are we
left with? Something like: Doctors should not try to make medical
decisions for a patient, but should give the patient whatever
treatment he asks for ... unless the doctor thinks that the
patient's decision is wrong, in which case the doctor should
ignore the patient's wishes and do what he thinks is best. But
then, how is that different from the doctor just doing what he
thinks is best all the time? I'd be happy to promise anyone that I
would obey every order he gives me as ... long as I agree that it's
a good idea and it's what I would have done anyway. Thus, I can't
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help but suspect that "inappropriate care" is a code word. I
notice a couple of other similarly vague statements that I can't
help but wonder might be related, namely: Another section talks
about "wise and cost-effective" health care and a "just
distribution of finite resources". And in two places they warn of
the danger that "market forces" might pressure a doctor to
"compromise" his "principles". Put this all together and -- and I
freely admit that I am speculating here, but it seems to fit -- I
think what they mean is this: If a patient asks for life-saving
treatment and the doctor decides that this patient is not worth
saving, that his quality-of-life is too poor, or that further care is
too expensive, then the patient's wishes should be ignored and
he should be left to die. That would be "wise and cost-effective".
The fact that the patient has insurance or personal financial
resources to pay for treatment is irrelevant, because that would
be allowing "market forces" to pressure the doctor into
"compromising his principles". I'm not making this up out of
whole cloth: the idea of rationing medical care -- with decisions
made either by government officials or hospital ethics
committees -- has been floated a number of times in the last few
decades, perhaps most dramatically in the "Clinton health care
plan" proposed in the US in the early 90's that would have made
it a federal crime for a doctor to give a patient treatment that
was not approved by the government. (The proposal labeled this
"graft and corruption in medical care".) If you have another idea
what this might mean, I'm happy to hear it.
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Medical Professionalism — Focusing on the Real
Issues
The New England Journal of Medicine
David J. Rothman, Ph.D.
April 27, 2000, Number 17
Because the focus on the threats from managed care is so intense, the thorny
question of whether professionalism is more or less vibrant or effective today than it
was under fee-for-service medicine has been slighted. Commentators do not consider
whether professionalism has to be revived or, more dauntingly, created. Why is there
such steadfast inattention to the past? Perhaps the reason is that an analysis of the
historical record would severely complicate the agenda, forcing a shift of attention
from managed care to the more fundamental problem of professionalism in American
medicine.
Take the question of how well physicians met the demands of professionalism during
the period from 1910 to 1980. Did they put their patients' interests first? That some
physicians did is clear, but given the compelling evidence of overtreatment of
patients and such practices as self-referral and fee splitting, it would be difficult to
conclude that before managed care was introduced the profession as a whole
unequivocally gave precedence to the interests of patients.7 At least since the
inception of Medicare, which led to the extraordinary rise in physicians' incomes,
some (perhaps many) physicians acted in ways that were designed to enhance their
financial positions.
Thus, to the degree that managed care does not pose the initial or exclusive
challenge to the precept of putting the interests of patients first, it is necessary to
examine the internal, not the external, factors that have weakened professionalism.
The problem involves medical norms and practices more than reimbursement
formulas under managed care. The most pressing question is not how to redraft
contracts between physicians and health maintenance organizations (HMOs) but how
to reduce physicians' financial interests and better monitor their behavior. Concepts
of professionalism are particularly relevant to this task, as a charge to physicians to
make their financial compensation secondary to the welfare of their patients. In fact,
professionalism may well require some financial sacrifices.
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technical expertise among physicians has been exceptionally well met. Board
certification has proved so effective a mechanism that problems involving technical
expertise have almost disappeared from discussions of professionalism.
This proposition is even more true of the current effort to make civic and social
obligations central to medical professionalism. Over the past century, physicians have
been extraordinarily reluctant to enter the public arena. A few exceptions aside, most
physicians have not taken part in national politics (even when health care reform was
debated), let alone in state or local politics (e.g., serving on school boards). If the
historical record of civic engagement is so bleak, how can it be changed? Why expect
doctors to engage in public service now if they have rarely done so in the past?
Just as the recent literature on professionalism ignores history, it slights the structural
barriers, apart from managed care, to the accomplishment of the principles of
professionalism. Most of the authors, for example, pay little attention to the
interactions between pharmaceutical companies and physicians or the influence of
such companies on undergraduate medical education and residency training. Despite
the evidence that this influence is far-reaching, the few analysts who do remark on
the issue fail to convey its importance. Pellegrino and Relman, 1 for example, assert
that contributions from pharmaceutical companies should not dominate the budgets
of professional associations. But they do not cite the data showing how extensive
these contributions are or discuss what the associations might have to do to survive
without them.
To select one example from an organization that specifies in its budget reports the
contributions of pharmaceutical companies, all 21 major donors to the American
Academy of Family Physicians in 1995 were drug companies.9 If more professional
societies divulged information about such contributions, this example might be
multiplied many times over. There is also substantial evidence that gifts from
pharmaceutical companies (such as subsidies for meetings and travel) influence the
prescribing practices and formulary choices of physicians.10 A discussion of threats to
professionalism that does not address the influence of pharmaceutical companies
omits a critical consideration, one that, unlike managed care, is largely subject to the
control of physicians.
Perhaps the most important omission from the recent discussions of professionalism
is the question of how to implement and enforce professional standards. There are
calls to expand the teaching of professionalism in medical schools and in residency
programs and to have professional societies become more explicit about the norms
they espouse. But the limitations of these two approaches are apparent. Ludmerer
observes that lectures in the preclinical curriculum are no match for the rough-and-
tumble lessons of clinical training.3 The rhetoric on respect for patients is too easily
undercut by the reality of exhausted residents teaching medical students how to
avoid a "hit." But Ludmerer does not suggest how to implement a change. He is eager
25
"to make the internal culture of academic medical health centers less commercial and
more service oriented," but he has no more specific strategy for accomplishing this
goal than to appeal to the "courage" of medical leaders.
In what other ways might professionalism be promoted and implemented? There are
a range of possible strategies, many requiring fundamental departures from current
procedures. First, professional and board-certifying societies could require rather than
recommend standards of behavior, including service. One could imagine that, like
continuing medical education, service to vulnerable groups of people would be
required to maintain certification. A number of community organizations already
attempt to meet the medical needs of uninsured patients by coaxing physicians, more
or less successfully, to provide care to such patients without charging fees. A minimal
requirement to render free care might improve the health of poor patients and
promote medical practice that exemplifies the precepts of professionalism. The
controversy that would greet such a proposal cannot be underestimated, especially
since physicians are under pressure to see larger numbers of insured patients. But
controversy may be the price that has to be paid for taking professionalism seriously.
Third, the medical school and residency curriculum should be altered, not only by
including lectures on professionalism but also by inculcating the skills necessary to
promote it. To the degree that the profession accepts a commitment to social
engagement, the curriculum should teach advocacy skills along with diagnostic skills.
Once again, this would constitute a startling break with established patterns. Medical
school faculty would have to include persons trained in advocacy and community
organization. The clash of cultures would be great, but so would the benefits.
Fourth, medicine in its organized capacity must encourage and protect whistle-
blowers, so that the profession is not so dependent on outsiders to identify and
publicize problems. Whether the problem is specific instances of conflict of interest or
abuses by managed-care companies, journalists and government officials have taken
the lead in uncovering abuses and providing remedies. Thus, when HMOs imposed
restrictions on the length of hospital stays for new mothers and women recovering
from mastectomy, the press — not organizations representing obstetricians or
oncologists — spearheaded the protests and brought about corrective legislation.12
26
Journalists have been especially active in ferreting out instances of conflict of interest.
To be sure, many medical journals have reported on the overall dimensions of the
problem, and universities and medical schools have established useful oversight
procedures. But it is the press that continues to highlight the failures of the existing
system to control the behavior of physicians. A recent article in the New York Times
on the development and testing of new cardiac devices is a telling case in point.13
Fifth, professional organizations must be persuaded to expand the agenda for which
they lobby and advocate. Nearly all these organizations engage in extensive
lobbying, with many spending over $500,000 annually on such activities.14 Through
lobbying firms or their own staff, they attempt to influence legislation on various
matters, including health insurance, drug regulation, managed care, antitrust
violations, and liability reform. But in most, if not all, cases, these efforts conform to
the special interests of the organization's members.
Thus, the American Academy of Dermatology has fought to maintain direct access to
specialists because it is the "most efficient and cost-effective method of providing
quality dermatologic services."15 By the same token, the American Academy of
Ophthalmology has strongly opposed the creation of "centers of excellence as they
apply to cataract surgery," as well as "single surgery payment provisions,"16
apparently because they would reduce earnings for ophthalmologists. And when
Medicare benefits were being debated by Congress, the American College of
Gastroenterology lobbied to include screening for colorectal cancer as a benefit. 17
Imagine what could have happened if these societies had advocated for the well-
being of patients without regard for their own special interests. Support by
dermatologists and ophthalmologists for colorectal-cancer screening would carry
great weight in the debate over whether to include it as a benefit. Again, the barriers
to such activities are formidable. Members of professional organizations do not want
their dues spent on advancing the other fellow's specialty, and they may believe that
only subspecialists can determine what patients need. But think of how the public
might respond to advocacy that was driven not by narrow self-interest but by a
broader professional vision of patients' welfare.
Sixth, professional societies, medical schools, and teaching hospitals should adopt
policies to minimize the influence of pharmaceutical companies and their
representatives. If professional societies raised annual membership dues and
registration fees for meetings, they would reduce their dependence on underwriting
and advertising by drug companies. At the very least, these organizations should
refrain from such practices as identifying drug-company donors in programs for
meetings according to the level of support (platinum, gold, silver, and so forth); this
suggests a degree of venality that is inconsistent with professionalism. 18 Societies
may not wish to ban drug-company booths from annual meetings on the grounds that
such a restriction might hamper the spread of new information, but no educational
purpose is served by allowing the booths to dispense such "brand reminders" as pens,
note pads, briefcases, flashlights, and golf balls.19
In the same spirit, medical schools should adopt formal rules that prohibit all gifts
from drug companies to students, whether books, stethoscopes, or meals. Medical
training should not include acquiring a sense of entitlement to the largesse of drug
companies. Finally, teaching hospitals should enforce these same restrictions,
proscribing drug-company sponsorship of lunches, conferences, and travel for house
staff, and should also make it clear that accepting birthday presents, Christmas gifts,
27
or food and drink off the premises from drug-company representatives violates the
ethical norms of the profession.
However fanciful, impractical, or misguided these suggestions may seem, they make
it clear that physicians have avoided the admittedly tough question of how
professionalism is to become more central to their thinking and behavior. A general
call to embrace the ethic may be appealing and may even exert some influence in the
long run, but it is not sufficient to bring about substantial change in the near future.
Professionalism is too important for an exclusive reliance on such tactics. An infusion
of strength and relevance is needed. By one means or another, professionalism must
become a vital part of American medicine today.
References
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1. Sullivan WM. What is left of professionalism after managed care? Hastings Cent Rep 1999;29:7-
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1. Rodwin MA. Medicine, money, and morals: physicians' conflicts of interest. New York: Oxford
University Press, 1993.
1. Derbyshire RC. How effective is medical self-regulation? Law Hum Behav 1983;7:193-202.
1. AAFP Foundation corporate members. Bull Am Acad Fam Physicians 1995;10:4.
1. Chren MM, Landefeld CS. Physicians' behavior and their interactions with drug companies: a
controlled study of physicians who requested additions to a hospital drug formulary. JAMA
1994;271:684-689.[Abstract]
1. Cleary PD, Edgman-Levitan S. Health care quality: incorporating consumer perspectives. JAMA
1997;278:1608-1612.[Abstract]
1. Kassirer JP. Our endangered integrity -- it can only get worse. N Engl J Med 1997;336:1666-1667.
[Full Text]
1. Eichenwald K, Kolata G. Hidden interests — a special report: when physicians double as
entrepreneurs. New York Times. November 30, 1999:A1.
1. Washington Representatives (a directory of lobbyists and organizations) 1996, pursuant to 1995
Lobbying Disclosure Act (Public Law 104-65). The Center for Responsive Politics maintains a file
on each organization. (Or see: http://opensecrets.org/lobbyists/98lookup.htm.)
1. American Academy of Dermatology Web site. (See: http://www. aad.org.)
28
1. Program and abstracts of the 32nd Annual Meeting of the American Society of Nephrology.
Washington, D.C.: American Society of Nephrology, 1999.
1. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA
2000;283:373-380.[Abstract/Full Text]
29
Selected Professionalism References
Anonymous. Medical professionalism in the new millennium: a physicians' charter*.
Clin-Med. 2002 Mar-Apr; 2(2): 116-8.
The practice of medicine in the modern era is beset with unprecedented challenges in virtually all
cultures and societies. These challenges centre on increasing disparities between the legitimate
needs of patients, the available resources to meet those needs, the increasing dependence on
market forces to transform healthcare systems, and the temptation for physicians to forsake their
traditional commitment to the primacy of patients' interests. To maintain the fidelity of medicine's
social contract during this turbulent time, we believe that physicians must reaffirm their active
dedication to the principles of professionalism, which entails not only their personal commitment
to the welfare of their patients but also collective efforts to improve the healthcare system for the
welfare of society. This Charter on Medical Professionalism is intended to encourage such
dedication and to promote an action agenda for the profession of medicine that is universal in
scope and purpose.
Ber,-R; Alroy,-G. Teaching professionalism with the aid of trigger films. Med-Teach.
2002 Sep; 24(5): 528-31.
Medical professionalism includes expert knowledge, self-regulation and fiduciary responsibility to
place the needs of patients ahead of the self-interest of physicians. In teaching medical
professionalism to our medical students only the behavioural elements are dealt with. One of the
challenges facing medical educators today is how medical professionalism can be taught. At the
authors' faculty of medicine brief videotapes (trigger films) of amateur actor physician-patient
encounters in various clinical settings (taken from genuine encounters) are used as a stimulus for
30
discussion and instruction of medical professionalism. A series of 16 trigger films has been
produced that raise many medical professional issues. The films and the issues raised are
described in brief. These trigger films are viewed by small groups of medical students together
with a physician tutor facilitator at various stages of their studies. It is noteworthy how fast the
transition occurs in students, from observing the trigger films in their pre-clinical stage as a
client, to observing them in their clinical years from the angle of a provider; from identifying with
the patient's concerns to identifying with the physicians' behaviour; from being a critical person
to becoming a person who accepts the rules and regulations of the guild. Most probably the
power of the teaching of ethical and professional rules is overruled by the power of everyday
clinical experience during their clinical clerkships. It is planned to run a series of trigger film
sessions with senior and junior physicians of the major clerkships, in an attempt to promote an
institutional environment/atmosphere/culture of professional behaviour.
31
Chisholm,-C-D; Whenmouth,-L-F; Daly,-E-A; Brizendine,-E-J; Cordell,-W-H. A
comparison of faculty contact time with emergency medicine residents in different
teaching venues. Acad-Emerg-Med. 2003 May; 10(5): 472.
AB: OBJECTIVE: Emergency Medicine (EM) residencies must implement the 6 ACGME core
competencies by 2006. EM educators recommend direct observation (DO) as the optimal
evaluation tool for 4 of the 6 core competencies (Patient Care, Systems-Based Practice,
Interpersonal and Communication Skills, and Professionalism). The 24/7 faculty presence in the
Emergency Department (ED) is believed to facilitate DO as an assessment technique. METHODS:
Observational study of faculty contact in 2 EDs, 2 trauma services, inpatient medicine, adult &
pediatric ICUs, and a pediatric outpatient clinic (UVC). Faculty contact was categorized as DO of
patient care, indirect patient care, or non-patient care activities using a priori definitions. EM
residents were shadowed for 2-hour intervals. Subjects were blinded to the nature of the study
and data gathering was encrypted. RESULTS: 270 observation periods of 2 hours each were
conducted, sampling 32 EM R1, 33 EM R2-3, 41 EM and 38 non-EM faculty. Total faculty contact
time ranged from a maximum of 30% (95% CI = 20, 41) in the pediatric ICU to a minimum of
10% (3, 16) on internal medicine wards. Overall ED faculty contact was 20% (18, 22). DO by
faculty ranged from a high of 5% (3, 8) in the pediatric UVC to a low of 1% (0, 2) on internal
medicine wards. Overall ED DO was 3.6% (2.6, 4.7). ED DO did not vary across EMR level or by
site. DO varied by treatment area within the ED with the critical area being substantially higher
(6%) when compared with the non-critical care areas (1%). CONCLUSIONS: Direct observation
of EM residents was low in all training venues studied. Overall DO was the highest in ED critical
care areas and lowest on medicine ward rotations. EM faculty who are already involved in routine
teaching, supervision, and patient care rarely performed DO in spite of their immediate physical
presence 24/7. This suggests that alternative strategies may be required to assess core
competencies through direct observation in the Emergency Department.
Davis,-M-H. OSCE: the Dundee experience. Med-Teach. 2003 May; 25(3): 255-61.
The Dundee Medical School has bean running OSCEs since 1977. In 1995, an integrated systems-
based spiral curriculum on the core and options model was introduced. In 1997, outcome-based
education was introduced as the basis for instruction, with a task-based educational strategy
employed for students in years 4 and 5. This blend of educational strategies was considered in
the design of the student assessment process. Assessment instruments, appropriate for use at
each of the four levels of Miller's pyramid, were identified and included in the assessment
process. The OSCE was used for summative assessment of students at the level of 'shows how'
32
or simulation in years 2, 3 and 4. A year 2 OSCE is described here. Features of the Dundee OSCE
are identified, relating to number and length of individual stations, practicalities or assessing a
year group of students without student contamination with examination information and the
blueprints used to design the examinations. Suggestions made for future development of the
OSCE include the OSSE, the Objective Structured Selection Examination, and an exploration of
the potential of the OSCE to assess attitudes, personal attributes and professionalism. The need
is identified for a platform to debate issues such as should individual medical schools attempt to
achieve national test centre standards with their examinations.
33
communicate in an effective and humanistic manner, and articulate models of patient-centered
advocacy. The clerkship fosters professionalism in patient care, appreciation of cultural diversity,
and the student's ability to assume responsibility for developing competency in these areas.
Although it is too early to know whether this clerkship will ultimately affect the practice patterns
of students who experience it, short-term evaluation has been very favorable.
Glannon,-W; Ross,-L-F. Are doctors altruistic? J-Med-Ethics. 2002 Apr; 28(2): 68-9;
discussion 74-6.
There is a growing belief in the US that medicine is an altruistic profession, and that physicians
display altruism in their daily work. We argue that one of the most fundamental features of
medical professionalism is a fiduciary responsibility to patients, which implies a duty or obligation
to act in patients' best medical interests. The term that best captures this sense of obligation is
"beneficence", which contrasts with "altruism" because the latter act is supererogatory and is
beyond obligation. On the other hand, we offer several examples in which patients act
altruistically. If it is patients and not the doctors who are altruistic, then the patients are the gift-
bearers and to that extent doctors owe them gratitude and respect for their many contributions
to medicine. Recognizing this might help us better understand the moral significance of the
doctor-patient relationship in modern medicine.
34
and values that are important to them and relevant to the PPD theme. A confidential interview,
based on the PPD goals, is held with a faculty member who has read the student's portfolio.
RESULTS: In 1997/98, 96% of students agreed that they had engaged in useful reflection on
their approach to the course and 91% agreed that the experience was worthwhile. A further 76%
of students agreed that they could see opportunities to modify their approach in some ways as
result of this exercise. CONCLUSION: Sustained PPD is essential in equipping doctors for the
varied stresses of careers in medicine. Despite, or perhaps because of, the latitude in the Year 1
assessment, both students and faculty members found the process of value. This form of
assessment acknowledges that the most valid assessment formats cannot always be made
reliable and that in some parts of the curriculum it is more important to demonstrate trust in
students' own motivation to become competent and mindful practitioners. The fact that the
portfolio and interview are the only summative assessments in the first year emphasises the
importance that the Faculty places on PPD.
35
the six competency areas, PDs were most interested in receiving assistance in developing
curricular materials for the competencies of systems-based practice (4.50), professionalism
(4.36), and practice-based learning and improvement (4.27). PDs were most interested in
receiving assistance in developing evaluations for practice-based learning and improvement
(4.59), professionalism (4.59), interpersonal and communication skills (4.45), and systems-based
practice (4.36). PDs responded that they currently use written faculty evaluations to assess all six
general competency areas. DISCUSSION: Results of the survey indicate that PDs require
assistance to comply with the new ACGME requirements. Curricular materials and valid and
reliable evaluation methods need to be developed. In order to assist PDs, the following activities
are under way: (1) PDs are members of a listserve for sharing ideas and examples of curricular
and evaluation materials; (2) PDs attend a monthly seminar series that provides practical
information for curricular material development and specific evaluation methods, including
indications for use and feasibility; (3) educators from our Office of Educational Development
provide individual consultations with each PD; (4) PDs participate in an eight hour workshop with
practical sessions for developing curricular materials and evaluations; and (5) two institution-wide
assessments are being developed: a patient-satisfaction survey and a 360-degree evaluation to
assess communication skills and professionalism.
36
Larkin,-G-L; Binder,-L; Houry,-D; Adams,-J. Defining and evaluating professionalism:
a core competency for graduate emergency medicine education. Acad-Emerg-Med.
2002 Nov; 9(11): 1249-56.
Professionalism, long a consideration for physicians and their patients, is coming to the forefront
as an essential element of graduate medical education as one of the six new core competency
requirements of the Accreditation Council for Graduate Medical Education (ACGME).
Professionalism is also integral to the widely endorsed Model of the Clinical Practice of Emergency
Medicine (Model). Program directors have now been charged with implementing the new core
competencies in training programs and to assess the acquisition of these competencies in their
trainees. To assist emergency medicine (EM) program directors in this endeavor, the Council of
Emergency Medicine Residency Directors (CORD-EM) held a consensus conference in March
2002. A focused Consensus Group addressed the specific core competency of professionalism
during the course of this conference, and the results are highlighted in this article. The definition
and curricular requirements relating to professionalism are highlighted, specific techniques for
evaluating this core competency in EM are reviewed, and recommendations are provided
regarding the most appropriate assessment method for EM programs.
37
(r(2) =.32). CONCLUSIONS: Physicians' dress style in the ED does not affect patients' evaluations
of their performance.
Lie,-D; Rucker,-L; Cohn,-F. Using literature as the framework for a new course.
Acad-Med. 2002 Nov; 77(11): 1170.
OBJECTIVE: The award-winning book The Spirit Catches You and You Fall Down,(1) a true story
of the collision between two cultures (American and Hmong) with heartrending consequences for
the patient, the patient's family, and the medical professionals who care for them, has been
favorably reviewed(2) and used to stimulate teaching of cultural diversity, ethics, and
professionalism to students and residents. We used it as a required text for a new Patient Doctor
Society (PDS) course for 184 first- and second-year medical students. This report describes the
scope and contexts in which the book was used to meet specific course goals. DESCRIPTION:
PDS is a required 90-hour introduction to medical interviewing, which integrates ethics,
communication, clinical reasoning, cultural diversity, humanities, spirituality, integrative medicine,
nutrition, and behavioral science. To provide a common experience among these diverse topics,
faculty members were asked to use examples from the book to achieve their learning objectives.
A required faculty development session illustrated strategies for effectively using the text.
Focusing on chapter 13 ("Code X"), dramatic portrayals of differences in beliefs about end-of-life
care and clinician-family communication, facilitated the introduction of methods including point-
of-view writing, role-plays, and faculty-facilitated discussions as techniques for meeting course
objectives. At PDS orientation, we used the same chapter, and had faculty members lead small
groups of students using the teaching techniques they acquired. About 90% of students read the
book prior to orientation. Students favorably reviewed this three-hour session. For the ethics
session, unfacilitated small groups of students were asked to identify and discuss the ethical
issues in chapter 11 ("The Big One"), which describes a major turning point in the health care
provided to the text's central character, Lia. Each group presented its "moral diagnosis" and
ethical arguments for resolution. Class discussion then focused on the diverse views presented,
to emphasize the importance of justifying decisions and to practice using tools of ethical analysis.
In the communication skills workshop, we excerpted dramatic readings from the book. Faculty
members played the roles of the author, the patient's mother, and one of Lia's physicians. The
interaction became a dialogue to illustrate the points of view of the participants. The dialogue
was used to stimulate discussion about potential pitfalls in physician-patient communication and
understanding. In a medical humanities session, excerpts from the book were compared with
poetry explicating themes of physician arrogance and humility. DISCUSSION: The Spirit Catches
You and You Fall Down provides a context appropriate to teaching students how to listen to, and
learn from patient stories. The story will be reintroduced in the pediatrics clerkship. Caution will
be exercised to (1) avoid overexposure to the text, (2) counteract the potential to interpret the
story too narrowly, and (3) assure that faculty become familiar with the text and its uses. We
intend to track outcomes in knowledge, skills and attitudes for each content area, and observe
the degree that the book facilitates achievement of objectives. We will follow several cohorts of
students to verify longitudinally the learning effects observed.
38
committee ensures that the behaviors examined are appropriate, the communication package is
clear, and the threats posed to individuals are minimized. The instruments that are developed
must be tested to ensure that they are reliable, achieve a generalizability coefficient of Ep2 = .
70, have face and content validity, and examine variance in performance ratings to understand
whether ratings are attributable to how the physician performs and not to factors beyond the
physician's control (e.g., gender, age, or setting). Research shows that reliable data can be
generated with a reasonable number of respondents, and physicians will use the feedback to
contemplate and initiate changes in practice. Performance may be affected by familiarity between
rater and ratee and sociodemographic and continuing medical education characteristics;
however, little of the variance in performance is explained by factors outside the physician's
control. MSF is not a replacement for audit when clinical outcomes need to be assessed.
However, when interpersonal, communication, professionalism, or teamwork behaviors need to
be assessed and guidance given, it is one of the better tools that may be adopted and
implemented to provide feedback and guide performance.
39
three percent of students reported that the course increased their "connectedness" to
classmates, and 61% favored its occurring during all rotations. Fifty-nine percent reported that
their interest in caring for patients improved, and 53% reported their interest in internal medicine
as a field improved. Answers to open-ended questions highlighted the importance of "Talking
Medicine" as a forum to connect with others-both students and faculty. Despite this course's
focus during an internal medicine clerkship, students see a broader definition of professionalism
than the ABIM; the student's definitions were similar in many ways to the Group of Educational
Affairs definition of professionalism. Third-year medical students focus more on tolerance of
difference (e.g., race, socioeconomic status, and varying health beliefs), and the importance of
collegiality and collaboration in the new environment of patient care. Their vantage point early in
training allows them to look critically at the profession they are joining and view its shortcomings
and strengths. Future work is needed that focuses on how these definitions change as students'
progress through fourth year, into residency, and finally continuing medical education.
Nevertheless, we suggest that "Talking Medicine" may be most effective in helping classmates
connect to and learn from each other, thereby setting a foundation for changes in how they
interact with patients.
40
assessments, the difficulty of the examination will vary with the patients that a resident
encounters. This effect is mitigated to a degree by the examiners, who slightly overcompensate
for patient difficulty, and by the fact that each resident interacts with several patients.
Furthermore, the mini-CEX has higher fidelity than these formats, permits evaluation based on a
much broader set of clinical settings and patient problems, and is administered on site.
41
Siegler,-M. Training doctors for professionalism: some lessons from teaching clinical
medical ethics. Mt-Sinai-J-Med. 2002 Nov; 69(6): 404-9.
Medical professionalism encourages physicians to place their patients’ interests above self-
interest. In recent years, many medical organizations, including the American Board of Internal
Medicine (ABIM), Association of American Medical Colleges (AAMC), and the American Medical
Association (AMA), have developed initiatives to strengthen medical professionalism. By
emphasizing professionalism, supporters of these initiatives hope that medicine and physicians
may recapture professional autonomy, decrease public criticism of medicine and physicians, and
help physicians regain the moral high ground in the unending struggle with payers, both public
and private. One crucial question facing medical educators is whether the concepts of
professionalism can be taught to medical students and residents. This paper draws upon the
author s thirty years of experience in teaching clinical medical ethics to provide guidance on how
to teach the concepts of professionalism to students and residents.
42
presented as if the lectures were being given in 1980. Students attended lectures on basic
science principles relevant to these topics, and then met in small groups with librarians, content
experts, and small-group facilitators to begin investigating an assigned topic. For example,
student groups researched the development of EMS and chest pain centers, thrombolysis and
percutaneous coronary intervention, and the psychological implications of acute myocardial
infarction for patients and families. Students were introduced to effective literature-searching
techniques, the tenets of evidence-based medicine, and effective computer skills in the context of
studying their assigned topics. Each group then selected a student presenter to deliver an eight-
minute PowerPoint presentation of its 2001 "state of the art" findings, making particular note of
scientific advances and new therapeutic protocols developed since 1980, such as the use of
artificial surfactant in premature babies, the role of H. pylori in duodenal ulcers, and the
discovery of the genetics of breast cancer. These projects as well as a series of small-group
educational programs enabled students and faculty to develop a strong sense of team-work and
cohesiveness. Students had opportunities to practice components of the history and physical
examination on standardized patients relevant to the four clinical topic areas, such as cardiac and
abdominal examinations with emphasis on anatomic principles. Basic ethical principles and their
application to cases that pertained to the four clinical topics were introduced, and students
participated in a small-group ethics case conference. Throughout the course, students and faculty
were required to wear specially designed nametags. By the time the course concluded with the
White Coat ceremony, the 75 participating faculty and 104 students knew one another, making
the ceremony particularly meaningful. DISCUSSION: The pace at which scientific findings
revolutionize the practice of medicine continues to accelerate. While it is important for
undergraduate medical students to master the basic and clinical science foundations of medical
practice, it may be even more important to teach students how to find and interpret medical
information, form professional relationships with mentors and peers, and make a commitment to
lifelong learning and professionalism. It is critical that students understand that the curricular
program at any college of medicine is only the beginning of a life of study.
Yates,-S. Finding your funny bone. Incorporating humour into medical practice.
Aust-Fam-Physician. 2001 Jan; 30(1): 22-4.
BACKGROUND: Many people confuse seriousness with professionalism. Humour enables you to
separate who you are from the difficult work you do. OBJECTIVE: To illustrate ways humour and
fun can be incorporated into day to day working life. DISCUSSION: People are more productive,
cooperative and flexible when they have fun at work. Becoming a humour consumer of tapes,
jokes, TV shows, movies or funny books, strengthens your sense of humour, relieves stress and
improves relationships.
43