Professionalism

Frantz Duffoo

Adrian Cristian

6: Professionalism

GOALS

Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population applicable to rehabilitation medicine.

OBJECTIVES

1. Demonstrate compassion, integrity, and respect for others, as well as sensitivity and responsiveness to diverse patient populations, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.

2. Role model respect for, beneficence, least harm, respect for autonomy, and justice as applicable and relevant to the practice of medicine.

3. Exhibit qualities of accountability to self, patients, society, and the profession.

4. Demonstrate how to conduct patient-centered care and patient-centered decision making.

5. Identify and discuss the 10 professional responsibilities from the Physician Charter.

6. Describe the key components of the American Academy of Physical Medicine and Rehabilitation (AAPM&R) Code of Conduct.

7. Define the terms financial conflict of interest, impaired physician, and disruptive physician.

Picture this scenario. A physician comes to work late and proceeds to walk into his office, sloppy in appearance. He lounges at his desk, which is cluttered with patients’ files he has not reviewed yet. Then, the physician proceeds to make his morning rounds while showing a lack of interest and caring toward his patients. The physician ignores his mistakes, does not accept the advice of his colleagues, and basically does just enough to get by until he goes home. If this physician were a machine, he would meet the criteria to be recalled by his manufacturer, the way cars and other machines are recalled when they are found to be defective. Unfortunately, poorly trained physicians cannot be removed from circulation that easily.

The Merriam-Webster Dictionary defines professionalism as the skill, good judgment, and polite behavior that is expected from a person who is trained to do a job well. It also defines professionalism as the conduct, aims, or qualities that characterize or mark a profession or a professional person. The ACGME/ABMS’s expectation of professionalism as a core competency is “reflecting a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.” The ACGME requires that program directors attest to a trainee’s competence in those qualities and mode of conduct that are important to medical professionalism. The attestation can be done by documenting the abilities the trainee possesses at a given stage of his or her training (milestones) and/or by documenting what tasks the resident can be trusted to perform (entrustable professional activities). In order for program directors to attest to a trainee’s competence in the medical profession (1), the trainee must first be taught how to provide compassionate care; how to show respect for patients and their relatives; and how to communicate with integrity, trust, and honesty.

Compassionate care is patient centered. Patient-centered care ensures patient safety and addresses the needs of patients rather than the self-interest of the treating physician. This model of care also takes advantage of the latest information technology to prescribe, communicate, track results, monitor performance, and facilitate performance improvement projects. Effective communication and interpersonal skills are cornerstones of physicians’ professional identities, and constitute an expected ACGME/ABMS core competency (Interpersonal and Communication Skills). The successful physician must be able to establish therapeutic doctor–patient relationships.

Residents must learn to advocate for their patients, superseding self-interests and motivations, and maintain excellent patient relationships; work as a team with other providers; integrate and coordinate patient care across multiple settings; manage population health; enhance access by meeting patient needs in a timely manner; use data to improve patient care; and lead practice change and improvement. This must be done with empathy and concern for a diverse patient population without bias toward a patient’s race, culture, religion, gender, or sexual orientation. In addition, residents at any institution must act as teachers of other residents and students, a role facilitated by the same skill set. They must learn how to form therapeutic physician–patient relationships via patient interviewing and physical examination. As they learn, they will show an increasing ability to communicate with other members of their health care team, including nurses, care managers, respiratory therapists, physical therapists, pharmacists, and social workers. Focused care coordination contributes to developing the ACGME/ABMS core competencies of professionalism, patient care, systems-based practice, and interpersonal and communication skills. The medical residents will learn that the patient-centered model of care strengthens the clinician–patient relationship, leading to a safer, higher quality of care; more empowered patients; and a renewal of the patient–provider relationship.

Respect comes from respectare, a Latin word meaning to “look again” or to “look with new eyes.” Respect, along with courtesy, compassion, integrity, and trust, is part of the constellation of professionalism traits. To look with new eyes means asking clinical questions designed to elicit information from patients about their ideas regarding what they think might be wrong with them; their feelings and fears about their illness, rather than the standard questions used in everyday practice.

Kleinman and colleagues (2) published more than 30 years ago the key questions that must be asked; they are as follows:

1. What do you think caused the problem?

2. Why do you think it happened when it did?

3. What do you think your sickness does to you?

4. How severe is your sickness?

5. What kind of treatment do you think you should receive?

6. What are the most important results you hope to receive from this treatment?

7. What are the chief problems your sickness has caused for you?

8. What do you fear most about your sickness?

These types of questions will convey to the patient that the resident is able to see the nature of the problem from the patient’s point of view. The residents must also be taught effective listening skills; how to understand silent body language (nonverbal communication); and how to show transparency, receptivity, and openness during communication. They must be taught to be tolerant and to be nonjudgmental about patient preferences; to learn to listen with sympathy and understanding to the patients’ perception of their illness; to avoid confrontation; and to respond to each patient’s unique characteristics and needs.

The 10 professional responsibilities from the Physician Charter published by the American Board of Internal Medicine Foundation and the American College of Physicians Foundation in 2002 (3,4) must be used to guide the education of residents about professionalism. They are subsequently listed in italics and each one is followed by the respective plan of action for the trainees.

1. 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 provision of quality care. The residents must be taught how to identify areas for self-improvement and how to implement strategies to enhance their knowledge, skills, attitudes, and behaviors.

2. 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. Physicians should also acknowledge that in health care, medical errors that injure patients do sometimes occur. An entrustable professional activity based on the process of obtaining informed consent must be documented for all residents after they have been taught the knowledge, skills, attitudes, and behaviors needed to obtain informed consent.

3. Commitment to patient confidentiality. Earning the trust and confidence of patients requires that appropriate confidentiality safeguards be applied to disclosure of patient information. Residents must be taught the key elements of the Privacy Rule including who is covered, what information is protected, and how protected health information can be used and disclosed.

4. Commitment to maintaining appropriate relations with patients. Given the inherent vulnerability and dependency of patients, certain relationships between physicians and patients must be avoided. In particular, physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose. Residents must learn how to advocate for their patients and how to maintain excellent patient relationships with empathy and compassion.

5. 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. Residents must learn the key principles of quality improvement that include W. Edwards Deming’s Plan, Do, Study, and Act (PDSA) cycle. The PDSA cycle was originally developed by Walter A. Shewhart as the Plan-Do-Check-Act (PDCA) cycle. W. Edwards Deming modified Shewhart’s cycle to PDSA, replacing “Check” with “Study” (5).

6. Commitment to improving access to care. Medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Residents must learn the concept of Patient-Centered Medical Home (PCMH). They must learn about National Committee for Quality Assurance (NCQA) standards for PCMH.

7. Commitment to a just distribution of finite resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the resources available for others. Residents must learn about issues of cost–benefit analysis in medical care, fostering the ability to practice in a cost-effective manner. They must learn about the concepts of high-value care.

8. Commitment to scientific knowledge. Much of medicine’s contract with society is based on the integrity and appropriate use of scientific knowledge and technology. Physicians have a duty to uphold scientific standards, to promote research, and to create new knowledge and ensure its appropriate use. The profession is responsible for the integrity of this knowledge, which is based on scientific evidence and physician experience. Residents must learn to cultivate a spirit of inquiry and improvement; this spirit supports both innovations in daily practice that translate into better service to patients, system improvements, and improved patient outcomes.

9. Commitment to maintaining trust by managing conflicts of interest. Medical professionals and their organizations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage. Physicians have an obligation to recognize, disclose to the general public, and deal with conflicts of interest that arise in the course of their professional duties and activities. Relationships between industry and opinion leaders should be disclosed, especially when the latter determine the criteria for conducting and reporting clinical trials, writing editorials or therapeutic guidelines, or serving as editors of scientific journals. Residents must learn how to maintain ethical relationships with industry and how to interact with pharmaceutical representatives and other members of industry.

10. Commitment to professional responsibilities. As members of a profession, physicians are expected to work collaboratively to maximize patient care, be respectful of one another, and participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards. The profession 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. Residents must be taught how to transition the care of their patients both within and outside of their institution. That entrustable professional activity will help to prepare them to interface with their colleagues in various disciplines of health care.