"...medicine's current crisis of pofessionalism is not connected to a loss of knowledge, skills, or overall technical competence, but to its loss of moral standing and authority."
Educating for professionalism: creating a culture of humanism in medical ...By Delese Wear,et al, ch. 2 ("In Search of a Lost Cord Profe..."), p. 14
... profession: social contract... 1.priority of other's interests over own; 2. autonomy (proportionate to specialized claim to knowledge) & self-regulation
Self-regulation requires freedom to self-disclose. Flexner and Codman demonstrated this effectively but we are, nearly 100 years on, still needing a reminder of that fact. If we take the punitive path, we prohibit process. In a dynamic environment, mistakes are openly studied and growth ensues.
"These standards may help him to discover how little he knows
and how much there is he does not know. They may help him to
grow in knowledge, and also to realise that he is growing. They
may help him to become aware of the fact that he owes his growth
to other people's criticism and that reasonableness is readiness
to listen to criticism."
KARL POPPER, 1978
"A standard critique of professional ethics in medicine has been that it is chiefly concerned with decorum and never rises above the level of etiquette to genuine ethical reflection." -Professional ethics and primary care medicine: beyond dilemmas and decorum
By Harmon L. Smith, LR Churchill - 1986, Duke University Press, p.3.
"Moreover, even among those who believe that the concept has some independent normative value worth preserving, the claim that "professionalism" can be taught remains deeply controversial.1" Wilkins 1996, p. 241
There is no absolute certainty in science. Scientific knowledge is
conjectural, hypothetical. As a consequence there can be no authorities.
What we might call the "old" professional ethics are based on the
search for objective truth and on the ideals of rationality and intellectual
responsibility. But the old ethics are built on the view that scientific
knowledge can be certain knowledge, that knowledge grows normally
by accumulation, and that it can be acquired and stored in a person's
mind. These ideas create an environment favourable to the emergence
of authorities. To be an authority became an ideal of the old professionalism.
These ideas have terrible consequences. Authority tends to become
important in its own right. An authority is not expected to err; if he
does, his errors tend to be covered up to uphold the idea of authority.
Thus the old ethics lead to intellectual dishonesty. They lead us to
hide our mistakes, and the consequences of this tendency may be worse
even than those of the mistake that is being hidden. They influence our
educational system, which encourages the accumulation of knowledge
and its regurgitation in exminations. Students are punished for mistakes.
Thus they hide their ignorance instead of revealing it; this makes
it difficult for them, and for their teachers, to correct their deficiencies...
...
(5) For all these reasons our attitude towards mistakes must change.
It is here that ethical reform must begin. For the old attitude leads to
the hiding of our mistakes and to forgetting them as fast as we can.
(6) Our new principle must be to learn from our mistakes so that we
avoid them in future; this should take precedence even over the acquisition
of new information. Hiding mistakes must be regarded as a deadly
sin. Some errors are inevitably exposed-for example, operating on
the wrong patient, or removing a healthy limb. Although the injury
may be irreversible the exposure of such errors can lead to the adoption
of practices designed to prevent them. Other errors, some of which
may be equally regrettable, are not so easily exposed. Obviously,
those who commit them may not wish to have them brought to light,
but equally obviously they should not be concealed since, after discussion
and analysis, change in practice may prevent their repetition.
(7) It is therefore our task to search for our mistakes and to investigate
them fully. We must train ourselves to be self critical.
(8) We must recognise that self criticism is best but that criticism
by others is necessary and especially valuable if they approach problems
from a different background. We must therefore learn to accept gracefully,
and even gratefully, criticism from those who draw our attention
to our errors.
(9) If it is we who draw the attention of others to their mistakes we
should remind ourselves of similar errors we have made. We should
remember that it is human to err and that even the greatest scientists
make mistakes.
(10) Rational criticism should be directed to definite, clearly
identified mistakes. It should contain reasons and should be expressed
in a form which allows its refutation. It should make clear which
assumptions are being challenged and why. It should never contain
insinuations, mere assertions, or just negative evaluations. It should be
inspired by the aim of getting nearer to the truth; and for this reason
it should be impersonal.
We submit these ten theses...
Popper et al, BMJ 287, 1983, p. 1920
In 1910 Flexner published a scathing attack on the standard of
American medical schools and hospitals.7 It led to drastic changes in
American medical schools and stimulated the Clinical Congress of
North America to announce plans for the reform of hospital care and
of surgical practice. The Congress was influenced by Codman, who
had resigned from the Massachusetts General Hospital because of his
dissatisfaction with the standards of surgical care.8 Codman set up his
own hospital; he published abstracts of all cases admitted to it between
1912 and 1916 and analysed unfavourable results. He advocated critical
appraisal of the care of individual cases, arguing that it would help to
unearth correctable deficiencies and to improve the overall quality of
medical care.
Codman's views...
...
There were sporadic but unsuccessful attempts to promote audit
of patient care during the '20s and '30s. After the second world war
interest revived; surgical studies provided the impetus.410 1 They
showed wide variation in the performance of different hospitals,
and of individual surgeons in the same hospitals, but, more importantly,
it was found that when surgeons were told of the findings the number of
"unjustified" operations fell dramatically. Subsequent studies of medical
problems, such as diabetes and pneumonia, showed similar variations
in the performance of physicians." Since then many similar
studies have been reported,4 12 and in most instances there was evidence
indicating corrigible deficiencies in medical care.
Only a few of these studies tried to assess whether performance
improved as a result of the study. So it has been questioned whether
audit has any practical consequences. It has been argued that effort to
identify deficiencies would be wasted if they could not be corrected.
When such an assessment was made, however, there was usually evidence
that performance did improve.'I11 13 -23 Almost all of these
studies emphasised the importance of critical evaluation, of the feeding
back of information. The value of "feedback" in the modification of
behaviour cannot be doubted. It is a fundamental biological process:
it is the basis of all learning, of "profiting from experience," of "learning
from mistakes...
...
The reluctance of people to have their work evaluated is closely
linked with their reluctance to comment on, or to complain about,
the behaviour of others. Most people "live and let live." This attitude,
we admit, is not only understandable: it is invaluable. Social life
depends on it. Who should throw the first stone ? Who indeed can
really distinguish between an honest mistake and culpable negligence ?
This is why we believe that efforts to improve performance must come
from a desire for self improvement, a desire based on an essentially
ethical insight. Audit must not be part of a disciplinary instrument;
it must be a tool for learning by feedback."
Ibid, p. 1921
A new ethos
In monitoring medical care tolerance is essential and in the
search for mistakes there should be no denigration of others nor
any condemnation associated with the process of peer review.
It would be morally wrong and would deter doctors from taking
part. The goal must be educational and practical: it must be
linked to the improvement of all doctors and not to the punishment
of those who err. Only with such an ethos can we establish
a new type of confidence: that mutual criticism is not personal
and perjorative but that it springs from a mutual respect and a
desire to improve the lot of patients.
If this view is accepted certain consequences follow naturally.
It then becomes important not only to acknowledge mistakes but
to search for them, in order to correct them as quickly as possible.
Not only would we learn from our errors but others would learn
from them as well. When errors are due to lack of skill we will,
we hope, try to improve our skill; and when, as is sometimes the
case in medicine, our errors are due to carelessness, or our failure
to do what we know we ought to do, then we will look for ways of
improving our behaviour.
Our ideas are not as revolutionary as they seem. A tradition
similar to the one the medical profession should emulate still
exists among great artists and scientists and among musiciains.
Around 1513 Durer wrote: "But I shall let the little I have learnt
go forth into the day in order that someone better than I may
guess the truth, and in his work may prove and rebuke my error.
At this I shall rejoice that I was yet a means whereby this truth
has come to light."2 8 This spirit is still alive, and needs encouragement,
not only in artists and scientists, but in doctors
and those in other walks of life.
-Ibid, p. 1922
Refelective Practice Schon
5 pgs
"The intellectual skills and education of doctors have seldom been doubted, and medicine has usually managed to evade close external regulation. This independence has excited criticism from some outside observers. George Bernard Shaw famously pilloried the seemingly conspiratorial conformity of the profession, suggesting that the medical profession made decisions only guided by “the sort of conscience that makes it possible to keep order in a pirate ship or a troop of brigands”.3 The authority of professionals could also be construed as wielding power, ultimately the power to create and preserve a monopoly of practice.4 In the eyes of some, such a monoculture has allowed medical practitioners to work impervious to criticism, unaware or unaffected by the impact of their decisions on other aspects of their patients' lives or on public welfare." Stephenson, 2001.
"Medical students should, therefore, be forewarned about the tensions associated with joining a profession that has always faced threats to its independence—but threats that can usually be countered by a clear commitment to advancing the interests of patients. Such a commitment could be embodied in the compassionate care of both individual patients and populations, thereby completing the triad of professionalism." Stephenson, 2001.
"The care of populations" - call and mission. Rahab and the spies, the Jews in the cupboard, etc. Single acts of evil which bring about a greater good.
"In the absence of an explicit moral base, critics could readily claim that self-regulation by physicians was nothing but a cover for the monopolization of trade." NEJM 1999
"The core of professionalism constitutes “. . . those attitudes
and behaviors that serve to maintain patient interest
above physician self-interest. Accordingly, professionalism
. . . aspires to altruism, accountability, excellence,
duty, service, honor, integrity, and respect for others” (1).
Ethics is an endeavor. It refers to ways of understanding" Roberts 2004, p. 1
-Fox, 1995, p.762
-Ibid
Ibid, p. 3
"As in the US longitudinal study,13 we did not observe the increase in the development of moral reasoning that was expected with maturation and involvement in university studies. We found a significant decrease in weighted average scores after 3 years of medical education. Our findings do not, however, establish a direct causal relation between the observed decrease in moral development and medical education."
+Patenaude, 2003
"The results of studies performed in the United States
and elsewhere suggest a negative trend in the progress of
ethical skills during medical training.7–10 These studies,
which used 3 different instruments, yielded divergent results,
showing sometimes decreased ethical sensitivity11 and
sometimes inhibited development in moral reasoning.12–15
Some of the results demonstrated a strong correlation between
low levels of moral reasoning and the number of legal
proceedings for malpractice (unpublished data)."
-Patenaude, 2003, p. 840
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Part B - {Predicting Behaviour from Medical School Patterns}
Stern 2004:
+The outcome measures of clerkship professionalism scores were found to be highly reliable (alpha 0.88–0.96). No data from the admissions material was found to be predictive of professional behaviour in the clinical years...
+One might expect that with hundreds of excellent tests for knowledge and skills used in medical schools around the country, we must have developed some assessment of professional behaviour. Regrettably, there is not a single reliable and valid method available to predict the behaviours of our medical graduates in this domain.7,8
+The most certain method of maintaining professional behaviour in doctors would be to ensure that only those students who are likely to behave professionally are admitted to medical school. When studied, the admissions process has been found to lack predictive power in areas outside academic performance.16 Although we can predict future performance in communication and moral reasoning skills as components of professionalism,17–20 these measurements have not been shown to correlate prospectively with global measures of professional behaviour.
+(Conclusion) This study identifies a set of reliable, context-bound outcome measures in professionalism. Although we searched for predictors of behaviour in the admissions application and other domains commonly felt to be predictive of professionalism, we found significant predictors only in domains where students had had opportunities to demonstrate conscientious behaviour or humility in self-assessment.
...This might suggest a primacy in the formation process itself -
->Educating for professionalism: creating a culture of humanism in medical... {afterword: Growing the Physicians we Need}:
"the most urgent challenges and opportunities at the intersection of professional development and social consciousness" (p. 184)
which may lead one to address residual issues surrounding the hidden curriculum. Clearly there are better institutions and what defines one as such bears investigating...
Sulmasy's "Rebirth of a Clinic".
Papadakis 2004:
+Problematic behavior in medical school is associated with subsequent disciplinary action by a state medical board. Professionalism is an essential competency that must be demonstrated for a student to graduate from medical school.
Acad Med. 2004;79:244 –249.
+Another limitation of our study is that physicians disciplined by a medical board comprise an unknown percentage of the total group of physicians engaging in unprofessional behavior. Furthermore, various social biases may well influence which physicians behaving unprofessionally are ultimately disciplined. Thus, we caution against generalizing the identified associations to all types of unprofessional behavior in physicians.
Greenburg 2004:
PROFESSIONALISM
Variables associated with poor professionalism ratings included
(Table 2): poor performance in any academic marker during
medical school (annual grades, cumulative grades, annual
class rank, USMLE exam scores), nonwhite race (RR=1.5, 95%
CI=1.04–2.2), earning a masters degree before USU matriculation
(RR=1.9, 95%CI=1.1–3.2), and having an academic
difficulty noted in the student’s academic record (RR=1.8,
95%CI=1.2–2.8).
Again, despite numerous strong univariate associations
between potential predictors of poor professionalism in multivariable
models, only the third year GPA was an independent
predictor (OR=7.29, 95%CI=4.1–13.0). This model (Fig. 2) was
also well fitting (Hosmer–Lemeshow test, p=.72) and
...
CONCLUSION
Despite our limitations, a number of important conclusions
emerged from this large, comprehensive longitudinal database
of our graduates. First, competency during internship is hard
to predict with commonly used data collected before and
during medical school. Despite the broad range of potential
predictive variables available, our predictive ability was only
modest. Secondly, the USMLE and clinical year GPA are the
best predictors that program directors currently have to
identify interns who may perform poorly in professionalism
and cognitive domains. Third, our paper has implications for
medical educators and program directors. As our multivariable
analyses suggest that the many candidate variables evaluated
in our study do not predict performance after controlling for
the third year grades and USMLE exam scores, we feel that
applicants for internship should be evaluated most heavily on
their performance during their clinical clerkships and on the
USMLE exams.
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C: Boundaries
Post (2000), Physicians and Patient Spirituality: Professional Boundaries,
Competency, and Ethics
"Spirituality as manifested by faith in a higher
being is remarkably resurgent in the contemporary
United States (4). But why address this form of
spirituality now as a matter of serious medical and
ethical concern? First, when patients feel that their
spiritual needs are neglected in standard clinical
environments, many of them may be driven away
from effective medical treatment. This tendency is
exemplified by a review of the medical records of
172 children who died after their parents relied on
faith healing instead of standard medicine. The researchers
found that most of the children would
have survived if they had received medical care (5).
More attention to patient spirituality in the clinical
context of standard medical care could attract more
patients to proven interventions."
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