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Presentation for residents

mouza mohammad

on 7 November 2013

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Transcript of Professionalism

by Dr. Mouza Al Sabousi
COI, Behavioral Sciences Institute
& Academic Affairs
Al Ain Hospital

January, 2013

professionalism in medical field
general considerations
Professional behaviour when interacting with others can involve:

• Actively listening
• Maintaining an interested and focused facial expression
• Engaging and participating in topics of discussion and putting
forth one’s own ideas in a respectful, productive fashion
• Behaving in ways that aren’t perceived as rude (eg. If eating
with another person, only starting to eat if the other person
has already got their food)
• Being aware and respectful of different cultures and their
requirements/ideas of what is polite and in-polite
• Being dressed appropriately – in most cases this involves
wearing clothing that reaches a standard of formality which
denotes maturity and respect
• Considering the feelings of others and being conscious of others’
perception of yourself

In a hospital setting, these signs of professional behaviour are especially important. It is crucial that these are displayed by a health professional both to their patients, their patient’s families and to fellow colleagues.
As physicians, we function as healers, as medical professionals,
and as medical scientists. The roles of healer and medical
professional are separate and distinct ones. The authority of
both roles is derived from separate origins and originates at
different points in history. The role as a healer traces back to
the Oath of Hippocrates, originating about 2500 B.C. The
role of medical professional has more recent origins, stemming
from the societal creation of the concept of professions in the
guilds of the Middle Ages. As medical scientists, our expert
authority is based on our knowledge (medical science) and
our expertise (extensive training). The art of medicine is to
bring the science of medicine to the bedside.
Professionalism involves maintaining a set standard of maturity, respectfulness and proficiency in one’s behaviour and attitude. This is especially relevant in the workplace or in any task that demands a certain level of maturity, respectfulness and proficiency. As a result, professionalism is an important part of being a health professional and working in a hospital, as maturity, respectfulness and proficiency are three critical attributes/requirements of a doctor.
Professionalism is evident through the ways we conduct ourselves in our work and through our interactions with others. It draws upon our mannerisms and our appearance (including clothing) and how others perceive this.

Medical professionalism is a behavior that defines our
relationship as a physician to our individual patients and our
relationship to society. It serves as the infrastructure for the trust absolutely necessary to the patient-physician relationship.
Professionalism embodies the relationship between medicine and society as it forms the basis of patient-physician trust. It attempts to make tangible certain attitudes, behaviours, and characteristics that are desirable among the medical profession. Although professionalism has been incorporated into most medical schools across North America, it remains rather difficult to define because it carries many connotations and implied meanings. What is certain, however, is that medicine is a moral endeavor which demands integrity, competence, and high ethical standards among other key attributes.
what is professionalism in medicine?
physician roles
role as a healer
The origin of our role and authority as
healer dates back to the Oath of Hippocrates. It is one of
the most enduring oaths of Western civilization, having
originated in antiquity.
The Oath of Hippocrates or some derivation of it is
taken by most, if not all, medical school graduates. It is
our entry into the medical profession. Taking the “Oath”
is “the moment when the newly graduated physician enters
the profession, not when (he) she receives (his) her degree
‘doctor of medicine’.

The Oath enjoins us as physicians:
To a commitment to service (duty) and to commit to the best
interests of our patient (beneficence). It declares a respect for
human life and as pointed out by the sociologist Margaret
Mead, “a dedication to life under all circumstances
To not take advantage of or exploit the patient-physician
relationship, including any sexual relationship. All forms of
discrimination are to be avoided.
To preserve confidentiality. To be truthful.
To place the needs of the patient above our own needs (altruism).
To suppress our own self-interests when the welfare of
others requires it.
To obtain assistance when greater knowledge is needed. To
be collegial.
To remain current with the medical science (lifelong learning),
to advance the science, and to teach the science.
To conduct our lives and maintain the patient-physician
relationship on the highest level. To sanction and censure
incompetent physicians.

Our role as a healer therefore has its origin and authority
in the public declaration of our principles of conduct
embodied in the Oath of Hippocrates. The Oath serves as
a public statement about our professional obligations, and
it is an affirmation of the social and personal responsibilities
of the profession.
The role and authority of the
medical professional has more recent origins. As society grew
and advanced, the increasingly specialized forms of work,
service, and knowledge evolved into the medieval guilds.
The guilds came to control the work (knowledge, service),
the participants, the productivity, and the costs of service or
work. The guilds would provide the service for society, advance
the knowledge base, and self-regulate their membership in
exchange for autonomy, respect, and a fair livelihood, as long
as society’s needs were met.

Our current medical profession is a derivation of the
guilds and represents a covenant between society and the
medical profession. The covenant is dynamic and evolves
to meet the changing societal medical needs (HIV/AIDS,
diabetes, access to care, obesity, the uninsured, etc). Our
ability or authority to practice our profession is granted
through state licensure, with the state acting in the best
interest of society (the patient).

The covenant changes as the relationship between society
and the medical profession changes. If the profession fails
to meet the needs of society, the privileges granted can be
taken away.

Our medical societies and associations at all levels serve
very important functions. They develop programs to meet
societal needs, interface with government and corporations,
aid in self-regulating and self-disciplining and serve the vital
function of the preservation of our profession.
role as a medical professional
role as a medical scientist
For centuries, physicians possessed little more medical knowledge than
did non-physicians claiming to be healers. In addition, physicians often served
only the elite or affluent members of society. With the
industrial revolution and the associated scientific revolution,
the body of medical knowledge grew and evolved. Medical
schools were established and improved and ultimately provided
a mechanism for learning and advancing the science of
medicine. The industrial revolution increased the available
wealth, and the scientific advances made the health care worth
purchasing, so the role of the physician as the medical scientist
and professional authority was established

Our professional authority is based on knowledge and
expertise. As physicians, we use our professional authority
to act as an intermediary between the patient and a body of
knowledge, which generally is not possessed by the patient
or society. Therefore, the physician possesses professional
authority based on expert knowledge in his/her role as medical
scientist, and patients benefit from this authority but are also
vulnerable to its potential abuse.

Medical professionalism establishes the trust that enables
the physician to exercise his/her expert or professional authority.
The use of this professional authority must be in the
best interest of the patient. Trust is at the heart of the healing
relationship and the core of the profession, and trust is
predicated on the integrity of both the individual physician
and the profession as a whole.
Our role as healer dates back to antiquity, and its authority
patient-physician relationship
The goal of the patient-physician relationship is healing, and
the basis for the relationship is trust.
The basic trust is that the physician will always act in the best interest of the patient (altruism).
A sick person is a vulnerable individual and must be reassured that the physician will act in his/her best interest and will not take advantage of the trusting relationship.
The sick person must be reassured that the physician will recognize
the basic worth of the patient, will preserve the patient’s
confidentiality, and will not take liberties with the patient’s
The oath that we take as physicians is a public profession
of these values and a public pledge to honor them. The
act of taking an oath as a physician demands ethical integrity,
which serves as the basis for trust in the patient-physician
relationship, and in the relationship of the physician to the
science of medicine.

We are physicians with the roles of healer, medical professional
and medical scientist. How we conduct ourselves and
our behavior in the performance of these roles, is our medical
professionalism. This behavior is the expression of our personal
values, the values and ethics expressed in our medical codes,
and the covenants we have with our patients and society.
Our medical science empowers us as physicians with the
professional authority to provide the best healing in the
patient-physician relationship. Our codes and covenants are
evolutionary and must always meet the needs of our patients
and the medical needs of society. The price of failure to meet
these needs would be the loss of our medical professionalism.
Medical professionalism is an ideal toward which we as
physicians must always be striving.
professionalism in medical education
Questions considered included:

What is meant by medical professionalism; how is it defined for academic purposes?
Where is professionalism currently being addressed in our curriculum?
How can we assess professionalism in our students?
What might we do, both from a curriculum and extra-curricular standpoint, to improve professional behavior among students, faculty, residents and other staff?
professionalism card
society’s expectations of medicine
medicine’s expectations of society

Services of the healer
Assured competence
Altruistic service
Morality and integrity
Source of objective advice
Promotion of the public good

Health care system
Adequately funded
Participation in public policy
Shared (patients and society) responsibility for health
Status and rewards

The term “ethics” simply refers to a system of moral principles or standards governing conduct.The difference between clinical ethics, bioethics, or any other form of ethics is the subject matter to which the ethical principles pertain.

Bioethics is essentially an umbrella term for moral conduct in the broad area of life sciences and medicine. As described by the World Health Organization, bioethics deals with issues related to health and health care management, animal welfare, and environmental issues. It also encompasses the following subject areas: philosophy of science, biotechnology, politics, law, medicine, and theology.

Clinical ethics tackles patient-based ethical decision making. A subset of bioethics, clinical ethics and medical ethics are often used interchangeably. This area of ethics considers different judgments as they apply to the clinical practice of medicine. Thus, clinical ethics is a system of principles governing medical conduct with respect to patients and their families.

The ethics of professionalism in medicine is more concerned with the characteristics and behaviours of physicians in the context of medicine as a profession. Specifically, it examines desirable and undesirable attributes of physicians. Desirable behaviours include altruism, accountability, excellence, duty, honor, integrity, respect for others, and a commitment to lifelong learning. Undesirable conduct, on the other hand, includes abuse of power, bias, sexual harassment, breach of confidentiality, arrogance, greed, misrepresentation, impairment, lack of conscientiousness, and conflicts of interest. The ethics pertaining to professionalism not only motivate patient-physician interaction, but also outline expected behaviour with other physicians, health care workers, medical students, and preceptors.
how do the ethics of professionalism differ from clinical ethics or bioethics?
the elements of professionalism as defined by the american board of internal medicine
Altruism The essence of professionalism, in which the best interest of the patients,
not self-interest, is the rule.
Accountability To patients—honoring the patient/physician relationship.
To society—addressing the health needs of the public.
To the profession—adhering to medicine's ethical precepts.
Excellence A commitment to life-long learning and to exceed “ordinary
Duty Free acceptance of a commitment to service (e.g., enduring unavoidable
risks in the care of patients and advocating best care regardless of ability
to pay).
Honor and integrity
Consistent regard for the highest standards of behavior and the
refusal to violate one's personal or professional codes.
Respect for others
Including patients, families, other physicians, and health care professionals
what is professionalism in medicine?
general considerations
physician roles
role as a healer
role as a medical professional
role as a medical scientist
society's expectations of medicine
medicine's expectations of society
patient-physician relationship
professionalism in medical education
how do the ethics of professionalism differ from clinical ethics or bioethics?
Increasing attention has been focused on developing professionalism in medical school graduates. Unfortunately, the culture of academic medical centers and the behaviors that faculty model are often incongruent with our image of professionalism. The need for improved role modeling, better assessment of student behavior, and focused faculty development is reviewed. We propose that the incentive structure be adjusted to reward professional behavior in both students and faculty.
Both formal teaching and role modeling are important to the development of professional values. In order for faculty to effectively model attitudes and attributes for students, they must hold these same characteristics and values for themselves.

Here we face a major obstacle in delivering change: our actions must be congruent with our rhetoric. Despite institutional efforts to improve professionalism, medical students often receive mixed messages. On the one hand, schools are increasingly teaching about the importance of professionalism. On the other hand, students regularly observe unprofessional behavior.

In a study of students at six medical schools, 98% of students reported hearing instructing physicians speak in a derogatory manner about their patients while on the wards and 61% of students reported seeing team members engage in behavior the students deemed unethical.
Hafferty has suggested that the informal and hidden curricula, which emphasize the importance of informal interpersonal interactions and the influence of organizational structure and culture on the education process, greatly influence student learning and often are counter to the formal curriculum.

Similarly, Stern found that medical students received a disproportionate amount of their training in professional values from the informal curriculum and that those values were often in direct conflict with those espoused by the formal curriculum.

Faculty development with an eye toward role modeling is a key component of the effort to promote professionalism.
Further, the community must find ways to provide faculty with information concerning their own performance relative to the standards. In his work on motivational effects, Bandura asserted that both knowledge of standards and knowledge of one's own performance are required to change behavior through self-evaluative mechanisms.

One alternative would be to emphasize student, peer, and self-evaluation of professionalism of faculty members. By expanding the evaluation pool, we may encourage more faculty awareness and concern for professional behavior. Recognizing the power of informal interactions, explicitly acknowledging professional values standards, and incorporating the evaluation of performance against these standards into self and peer review processes are ways of helping faculty further develop these values in themselves and model them to others.
Accurate student assessment with feedback is crucial to fostering professionalism in medical students.
Unfortunately, many current assessment practices are not optimal. The ABIM has opined that humanism can most realistically be assessed by direct observation.
But, with time-strapped clinicians evaluating students in clinical clerkships, direct observation of students in the clinical environment is a rarity.
When observation does occur, one study found that faculty were hesitant and, in most cases, unwilling to confront learners exhibiting what they perceived to be disrespectful, hostile, or uncaring behaviors toward patients.
Faculty admitted they were uncomfortable providing negative feedback, were not prepared to do so, and felt ill at ease imposing what they perceived to be their own standards and values on others.
If our goal is to foster professionalism in training physicians, faculty must have time to observe students in clinical scenarios and must receive training that allows them to accurately assess student behaviors and provide effective, evaluative feedback.
tools for assessing professionalism
A number of approaches to more accurate assessment of professionalism have been suggested.

The use of objective structured clinical exams (OSCEs) and simulated patient-based assessment has been shown to decrease some of the variability of ratings by providing a more stable and objective venue for assessment. Such methodologies are increasingly being utilized to assess qualities ranging from communication skills to cultural sensitivity. OSCEs have been shown to provide reliable and valid assessments of students’ humanism, communication, and empathy. In 2005, the United States Medical Licensing Examination will include a multistation OSCE designed to assess communication skills. Successful performance on the OSCE will be required to obtain medical licensure.

Another method that has been gathering support is student peer review. Peer evaluations have the potential to add value to the importance of teamwork and help train students in evaluation and feedback skills. Early studies have demonstrated evidence of reliability and validity in peer assessment in medical students. Peer evaluations have been shown to offer useful insight into learners’ interpersonal skills and professional behavior. While students in one study expressed concern about their ability to be objective when evaluating peers and about how such a process could impact personal relationships, the study also reported that students generally found both sides of the process useful and that students were enthusiastic about participating.

Another approach to evaluating professionalism requires an expansion of the evaluator pool. The 360-degree evaluation has been suggested by the ACGME as a way of providing feedback from multiple sources in a student's sphere of influence in the clinical setting. Evaluators may include patients, nursing staff, and peers, as well as faculty and house staff, who provide feedback on the learner's performance. While this assessment method may be cumbersome to administer, it is likely that students would benefit by becoming more aware of, and taking more pride in, the quality of interactions with all participants involved in the care of a patient. Three hundred sixty-degree assessments have been shown to be effective in a number of organizational environments outside of medicine. A recent study of this approach in physical medicine and rehabilitation residents indicated instrument reliability and reproducibility, and concluded that the approach was useful in providing formative feedback to residents regarding professionalism.
Unfortunately, as yet, there are no proven best practices for assessing professionalism.
In a recent, exhaustive review of the assessment of professionalism, Arnold concluded that, while there is a rich array of assessment tools available, no single tool is adequate and multiple sources ought to be used to assess professionalism.
The ACGME and the ABIM both agree that multiple methods and evaluators should be used to increase the reliability and validity of assessments.
As the field of evaluating professionalism matures, there is little question that more direct observation and a more concerted effort toward honest assessment and feedback will move our profession closer to the ultimate goal of reliably evaluating students' professional qualities.
More study is needed to test the validity and reliability of measures to assess professionalism.
real incentives to behave professionally
If we want professional behavior to increase—on the part of either students or faculty—we need to provide real incentives for such change. Currently, medical education is predominantly geared to reward academic achievement. Students find that their acceptance into a desirable residency program is dependent, in large part, on their medical school grades and rankings.
Students’ perceptions of the association between their professional behavior and their overall grade in a clerkship are not always clear.
Some schools are beginning to develop policies and mechanisms for formally identifying and working with students who display unprofessional behavior.
The University of California, San Francisco, School of Medicine has developed such a system. By including interpersonal skills as a specific area in which clerkship students are evaluated and, if found lacking, are remediated and counseled, the system designers have begun to change the reward structure and, hence, the value system.
Another example is Brown University School of Medicine, which has implemented a competency-based curriculum that defines nine abilities, including effective communication, in which a student must be certified in order to graduate. By making competency in this area a program requirement, the curriculum designers have indicated to students the degree to which they value communication skills, an important component of professionalism. The impact of such programs on student attitudes and behavior remains to be seen, but recognition of the need and implementation of programs designed to meet the need are important first steps.
There are at least two tangible ways to reward faculty who model exemplary professional and humanistic behavior. One is through awards.
On the local level, some medical schools use awards to recognize faculty members who demonstrate outstanding professional or humanistic behavior.
Another, more universally accessible reward would be the provision of some type of educational relative value units (RVUs) that count toward promotion and are given for excellent role-modeling behavior. Development of educational RVUs would require medical schools to make a significant financial investment in fostering professionalism.
A national panel on medical education appointed by the AAMC recently developed a “metrics system for measuring medical school faculty effort and contributions to a school's education mission,” including a four-step process to create RVUs for education activities.
Additional study is necessary to develop systems of measuring and rewarding high-quality professionalism role modeling among educators.
By creating a clear link between professional behavior and rewards, we can encourage students and faculty to take more pride in the art of communication, empathy, and caring
System-wide success requires the medical education community to engage in dialogue about how to adjust the formal as well as the informal curricula and to be aware of the connectedness of both. If we are serious about the goal, we must move beyond rhetoric.
We must find accurate ways to assess professionalism in both students and faculty.
We must also change the incentive system so that rewards adequately reflect the characteristics and behaviors that are deemed important.
At the same time, we must increasingly hold ourselves accountable for modeling the attitudes and behaviors we desire to instill in our students. Only then can we move forward intentionally, designing processes and systems that will create and support the future we envision.
Patient care
Medical knowledge
Practice-based learning and improvement
Inter-personal and communication skills
demonstrate respect, compassion and integrity,
demonstrate responsiveness to patient needs that supercedes self-interest,
demonstrate accountability to patients, society and the profession,
demonstrate excellence and on-going professional development,d
demonstrate adherence to ethical principles,
demonstrate sensitivity and responsiveness to diverse patient population, and
demonstrate respect for patient privacy and automony.
Systems-based practice
ACGME general competency domains and constituent components
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