Preceptors

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Preceptors EthicsEducating for Professionalism

• Nancy W. Dickey, MD
• President Vice Chancellor
• Texas AM University Health Science Center
• July 15, 2004

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Professionalism what is it?

• Principles of professionalism entail not only
  personal commitment to the welfard of the patient
  but also collective effort to improve the health
  care system for welfare of society. Hafferty
• ABIM defines professionalism as requiring the
  physician to serve the interests of the patient
  above his or her self-interest
• Broadly speaking, ethics concerns itself with why
  and how one ought to act. Candiles
• Despite all of this attention, a core
  understanding of what it mean to be a
  professional remains elusive. Hafferty

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Professionalismwhat is it?

• For the individual physician professionalism is
  expressed primarily in the clinical transaction.
• Professionalism is the basis of medicines
  contract with society
• Establishes standards of competence integrity
• Essential is public trust in physicians
• Professional responsibilities of honesty,
  confidentiality, commitment to quality, caring,
  maintaining trust
• ACP-ASIM defines 3 principles
• The primacy of patient welfare
• The principle of patient autonomy
• The principle of social justice promotion of a
  fair distribution of health care resources

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Professionalism why does it matter?An Emerging
Consensus

• AAMC 1998 Initiative on Professionalism created
  in response to growing concern among the public
  and even the profession
• ABIM/ACP-ASIM 2002 Medical Professionalism
  Project, Changes in the delivery
  systemsthreaten the values of professionalism.ww
  w.annals.org/cgi/content/full/136/3/243
• AMA initiated the STEP program (2003) to fund
  selected medical schools in designing innovative
  methods for educating the next generation of
  physicians in the competencies that constitute
  professionalism

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Why the changeperceived change?

• Changes in the health care delivery systems in
  countries throughout the industrialized world
  threaten the values of professionalism. Sox
• Deprofessionalization has been attributed in part
  to specialization, with fragmentation of clinical
  care and loss of an effective single voice for
  the professionthe image of physician
  selflessness has been marred by perceived
  increased emphasis on rewardand impact on
  preceived priorities and trustworthiness of
  physicians with regard to the primacy of the
  patient in the clinical transaction. Barondess

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Why the change?

• A third pressure relates to health care costs and
  their continuing escalation.which will
  ultimately threaten the care of patients through
  a variety of controls, reentrenchments, erosion
  of clinical qualityadditional efforts might
  address especially a focus on exuberant and not
  infrequently inappropriate use of expensive
  technologies, which are estimated to contribute
  2/3 of annual increases in rising health care
  costs. Barondess

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Professionalism why does it matter?

• Students who received comments about
  unprofessional behavior were twice as likely to
  be disciplined by the medical board when they
  became practicing physicians.
• Medical students are routinely exposed to a range
  of deleterious influencesand almost 2/3 of the
  study respondents thought their ethical
  principles had eroded because of their clinical
  experiences.

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Professionalism why does it matter?

• Trust is widely recognized as being central to
  the doctor-patient relationshipresonating with
  both doctors and patients and distinct from
  satisfaction.
• In the healthcare marketplace, the absence or
  presence of trust in patient-provider relations
  can have life-changing consequences.
• A person who trusts his provider is more likely
  to seek care, to comply with treatment
  recommendations, and to return for follow-up care
  than a person who has little trust in a specific
  provider or a health care system. Thom
• In the words of Galen, one of the founders of
  modern medicine, He cures most in whom most are
  confident.

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Failure to respond

• We are not aloneA decade ago Senator Daniel
  Patrick Moynihan warned that the level of deviant
  behavior in our society had surpassed what the
  community could afford to recognize and as a
  result we have been redefining deviancy down so
  that conduct previously stigmatized is now
  acceptable.Harvard Business Review 2004

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We are not in this alone

• Peers dont report peers
• Faculty dont fail learners
• Administrators cast a blind eye
• (sham peer review???)

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Culture is a contributor

• American culture
• Taboo on whistle blowing
• Who am I to judge other peoples values
• (even today, I am not allowed to judge other
  people values and I have to keep mine neutral so
  I dont offend)
• Professional issues
• Help others
• There but for the grace of God go I

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Professionalism matters.
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Educating for professionalism

• To be good is noble to teach others to be good
  is nobler and less trouble.Mark Twain
• For medical educators, the reverse may be true
• The challenge of living up to the professional
  standards set for ourselves is great
• The challenge of setting our students on the path
  to professionalism is even greater.

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A tough message

• Where ignorance is the problem, then education,
  not punishment or discipline, is the answer.
  Where poor ethics is simply misguided, not evil,
  then (ethics) education may be in order. For
  deliberate exploitation of patients for personal
  gain, then responsibility and retribution are
  appropriate.
• Morreim EH. Am I my brothers warden? Hastings
  Center Report,. 1993 23 19-27.

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What can we do?

• Institutions do not change on their own
• Individuals must act
• Recognize our obligation to
• Uphold professional values
• Accountability
• Responsibility
• Intervene in the system
• Accountability
• Responsibility

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What can we do? You are in the vanguard

• becoming a professional takes shape more within
  medicines informal and hidden curriculum than
  within its formally identified modules.Furthermor
  e, and perhaps most disconcerting, the norms and
  value orientations encountered by students during
  their training are not always the standards
  medicine realistically identifies as defining
  medical practice.

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What can we do?

• Maintain character
• Mold character
• Transform technical education into
  moral/professional education

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How do we do that?

• Provide a role model
• Albert Schweitzer is credited with saying,
  Example is not the main thing in influencing
  others, it is the only thing.
• what teachers themselves do with their knowledge
  and lives is educationally and morally
  significant.

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What can we do?

• When concerning behaviors, attitudes, or
  communications occur, do not ignore them but
  directly address them.
• Consider asking either the Faculty Development
  Center or your medical school to offer some
  training/role playing to practice these difficult
  interchanges
• Seek a balance between validation and challenge

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How do we do that?

• Discuss negative models
• Preceptors often offer an early opportunity to
  ask questions, have discussions,

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What can we do?

• When you next encounter the unprofessional
  behavior of a learner or colleague, outline what
  steps will you take in responding to him/her?
• Discuss problem with academic administration

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What should your school do for you?

• Create a culture that is supportive and
  challenginghelp you perform better every year
• Publicly and substantially thank you for the
  important role you perform
• Support you and follow-through when you identify
  a student who is challenged by the demands of
  professionalism

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When all else fails.

• When a student does not attain these skills,
  then the student should not finish medical
  school.
• D. Papadakes

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Bibliography

• Adams D. Professionalism starts in medical
  school. AMNews. Mar 15 2004.
• http//www.ama-assn.org/amednes/2004/03/15/p
  rsa0315.htm
• Barondess JA. Medicine and professionalism.
  Archives of Internal Medicine. 2003
  163145-149.
• Candiles PJ. Distinguishing law and ethics a
  challenge for the modern practitioner.
  Pychiatric Times XIX no 12 (Dec 2002)1-6.
• http//www.psychiatrictimes.com/ethics/html
• Hafferty FW. In search of lost cord. Educating
  for Professionalism. Ed. Wear ED Bickel J.
  University of Iowa Press. 2000.
• OBrien L. How to restore the fiduciary
  relationship. Harvard Business Review. May
  2004 71-78.
• Reiser, SJ. The moral order of the medical
  school. Educating for Professionalism. Ed. Wear
  ED Bickel J. University of Iowa Press. 2000.
• Sox, HC. Medical Professionalism in the new
  millenium a physician charter. Annals of
  Internal Medicine. 136no3 Feb 2002243-246.
• Thom DH, Hall MA, Pawlson LG. Measuring patient
  trust in physicians when assessing quality of
  care. Health Affairs. 2004 23 no3124-132.