Medical Professionalism

18 Medical Professionalism Joseph Kwan and Julie Chen Introduction The profession of medicine is under siege. Our resistance must be professionalism.' —Edward D. Harris, Jr. Chair Emeritus of Medicine, Stanford University School of Medicine Medicine has changed. It has become a complex and challeng- ing endeavour to be a doctor: to master the relentlessly growing base of new knowledge, to navigate within a complex health care system, to function under the time pressure of a heavy patient load, all the while trying to innovate, administrate, and commu- nicate. Expectations of patients are growing, financial burdens are heavy, and personal time is lacking. The commercialization of health care is more prevalent than ever and cases of medical misconduct regularly make the headlines. In such an environment, it is natural then, for the instinct of self-preservation to take hold and “the temptations of self-interest, power, prestige, pride, profit, and privilege that beset all humans in all ages™ to prevail. Despite the siege from outside and inside forces, medicine has not devolved into just another business. Though the practice of medicine has evolved over the centuries and differed in scope and Style over time, across specialties, and from country to country, the core values at the heart of medicine—compassion, service, altruism, and trustworthiness—have remained steadfast. Medicine

260 Problem-Based Medical Case Management must withstand the siege not just by preventing the erosion of these core values, but by ensuring that they thrive, by being embodied in each and every doctor. This embodiment is the individual aspect of medical professionalism, the translation of the core values of the profession into action as demonstrated in the everyday interactions that comprise each doctor’s own medical practice. Professionalism also has a collective aspect; it is through professionalism, this “set of core values, behaviours and relationships,”3 that the social con- tract doctors have with society is fulfilled. Individual doctors work to diagnose, treat, and prevent disease; they also promote health, provide support, and offer advice. However, beyond the technical expertise is compassion, a deep awareness of the suffering of another and the accompanying desire to relieve it, and other humanistic attributes such as respect and empathy which are fundamental to the patient-doctor relationship. - Service means working responsibly for the benefit of another. To do so, doctors must be clinically competent to practice in their field, strive to maintain excellence through self-improvement and continuing education, perform the duties expected of them in their work.and be accountable for their actions both individually, and as a profession, through the privilege of self-regulation. Practising unselfishly, or altruism, is the highest commitment to service. When providing care to a patient, doctors must always put the patient first ahead of their own self-interest though this does not mean at the expense of their own personal health or other impor- tant aspects of their lives. Compassion, service, and altruism earn the doctor the trust of his/her patient and earn the medical profes- sion the trust of society. Trustworthiness is thus the cornerstone of good medical practice. There are numerous eloquent and comprehensive conceptu- alizations and definitions of professionalism which encompass the above values in various frameworks. They aim to guide the profession,*® inform scholarly understanding,® or provide novel approaches to teaching and learning,” but all convey the same sense that values are central to the practice of medicine and that medicine is necessarily a moral enterprise based on trust.

e Case 18.1 Medical Professionalism 261 Having a physician imbued with professionalism offers patients by far the best hope for experiencing a beneficial outcome . . . Nothing can substitute for having a trustworthy physician to safeguard a patient’s interest: not laws, not regulations, not a patient’s bill of rights, not watchdog federal agencies, not fine print in an insurance contract. Nothing.® —Jordan Cohen President Emeritus, Association of American Medical Colleges Only through professionalism can the trust between doctor- patient and doctor-society be cemented, and only through constant reminding, reflecting, and reconsidering can it be practised. The scenarios below are commonly encountered. They are simplistic and the issues highlighted seem obvious, but they are meant to serve as triggers for self-reflection on the many cultural, social, and medical factors that influence how these situations may arise, and why in reality they may not be so easy to resolve. Professionalism, like all aspects of medicine, takes diligence and practice. 18.1 Case study 1: Being open and honest when something goes wrong Clinical scenario A 65-year-old lady was admitted to the general medical ward for having a high international normalized ratio (INR) as a result of taking too much warfarin. Doctor A was instructed by his con- sultant to prescribe vitamin K to reverse the high INR. However, Doctor A prescribed vitamin K at 10 times the recommended dosage, and the medication was administered without question by the nursing staff. The patient did not come to any apparent harm the next day and the INR had reversed back to normal. This Mistake was noticed by the consultant at the ward round the next morning, The medical team discussed whether to inform the patient and family, especially when the patient was feeling well at the Ward round.

262 Problem-Based Medical Case Management Case 18.2 What are the main professional issues illustrated by this case? All clinical staff should be open and honest when things go wrong. When you realize that an error has occurred, after doing what you can to improve the situation, a person (preferably the most senior - clinician) from the medical team should speak to the patient and/ . or their family, and apologize for the error made. This principle applies not only to situations where the patient has suffered actual harm or distress as a result of the error, but also in situations where they might in the future suffer potential harm or distress. Therefore, the best time to inform the patient and their family is usually as soon as you realize that an error has occurred, and be open and honest about what happened, not when actual harm or distress has already been experienced or become apparent. ' When speaking with the patient and family, it is vital to share all you know and believe to be true about what happened and why, and what the outcome is likely to be. You should explain if any- thing is still uncertain and respond honestly to any questions. It is also important to document all the conversations in detail, using quotations whenever possible. You must always be completely honest and never falsify or alter the patient’s medical record. Some patients might choose not to know the finer details, but your default position should be to assume that they should know all the facts. 18.2 Case study 2: Improper disclosure on social media Clinical scenario Doctor B just started work as a new doctor after graduating from medical school. During his first week of work, he was so excited about his new profession that he wrote many accounts of his expe- rience on social media. On one occasion, he disclosed the name of a deceased patient as well as their diagnosis and treatment received. On another occasion, he “named and shamed” several of his colleagues and accused them of being incompetent and

Case 18.3 Medical Professionalism 263 under-performing. In his blogs, he also uploaded some pictures of the medical ward where he worked, which showed the faces of patients and clinical staff. Doctor B’s blogs and online com- ments were very popular with lots of “likes” and generated plenty of replies. What are the main professional issues illustrated by this case? Doctors need to be very careful when writing on social media sites including blogs, internet forums, and social networking sites, even when these sites are not accessible to the public. You must never use social media to talk about individual patients or their care and never share identifiable information about the patient, their family members, or staff. Although individual pieces of data may not breach confidentiality in their own right, the sum of the leaked information might be sufficient to identify individuals. You must maintain confidentiality at all times. Professionalism means treating your colleagues fairly and with respect. It is therefore improper to discuss the action, performance, or conduct of your colleagues or employer on social media. Very rapidly, a seemingly innocent comment or blog can become *“viral” and disseminated as malicious gossip, which can have devastating consequences. If you have specific concerns about a colleague, it is important that your concerns are voiced through the proper chan- nels, so that appropriate actions can be taken. Whether you are communicating through online media or face- to-face contact, you must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession. 18.3 Case study 3: Maintaining a professional boundary Clinical scenario Doctor C has been attending to a young female patient in hospi- tal for minor illness. Upon discharge, the female patient gave her

264 Problem-Based Medical Case Management Case 18.3 telephone number to Doctor C and asked him to contact her after work. There was mutual affection and Doctor C was tempted to contact her at home. Although there was no clear need for medical follow-up in the outpatient clinic, he has arranged for her to return to his own clinic every 2-4 weeks for further clinical assessments including physical examination. What are the main professional issues illustrated by this case? As a doctor, in whom the patient has put his/her trust, you must not use this highly privileged position to pursue a sexual or improper emotional relationship with a patient or someone who is close to them. As trust forms the basis of any doctor-patient relationship, patients must know beyond doubt that their doctor will conduct themselves professionally at all times, and not view them as poten- tial targets for personal relationships. If a patient or someone close to them attempts to pursue an improper emotional relationship with you, you must treat them sensitively and politely and re-establish a professional boundary. If this is not possible, it may be necessary to end the professional relationship, with a full explanation about the situation to the - person concerned. A detailed documentation of all contacts and conversations should be performed at all times. . Relationships with former patients are trickier, depending on many factors such as the length of time since the professional - relationship ended, and the nature of the previous relationship. | However, having a relationship with a former patient could be regarded as an abuse of power with your position as a trusted - doctor, especially when you are a psychiatrist or a paediatrician. The best practice is to stay well clear of them. . Potentially problematic relationships are not necessarily sexual or emotional, but also financial, social, and psychological. For example, providing “special” treatments for patients solely for the purpose of receiving financial rewards or social opportunities is unprofessional. '

Case 18.4 Medical Professionalism 265 18.4 Case study 4: Conflict of interest Clinical scenario Doctor D was approached by a pharmaceutical company manager to sponsor her latest medical conference, at the exclusivity of all other sponsors. The reward for Doctor D was a one-week “edu- cational trip” to the Caribbean island of St Lucia, which included first-class return airfare, top hotel accommodation, and a yachting trip. In return, Doctor D needed to attend an afternoon of medical lectures put on by the pharmaceutical company at the St Lucia Hotel. For her medical conference, the pharmaceutical company manager asked Doctor D whether the programme could include several targeted lectures to promote a particular drug which was manufactured by the company. Moreover, the manager also asked whether Doctor D could prescribe that drug in her clinic as a first line treatment when there was no good research data to do so. What are the main professional issues illustrated by this case? As a professional doctor, you must not allow any interests you have to affect the way you manage or prescribe for patients. If you are faced with a real or potential conflict of interest, you must be open and honest about the conflict, declaring your interest for- mally, and be prepared to exclude yourself from that professional (or research) relationship. Furthermore, it is improper to exploit your patients’ vulnerability or lack of medical knowledge when charging excessive fees for your clinical services. You must not ask for or accept any gift or hospitality from any individual or company that may affect your clinical practice. Reciprocally, you must not offer your colleagues or others any gift orhospitality that may in turn influence their practice such as clini- cal referrals to yourself. The best practice is to refuse all gifts or bequests where they could potentially be perceived as an abuse of trus,

266 Problem-Based Medical Case Management Case 18.5 Often it is impossible to avoid all potential conflicts of interest, so it is important to use your professional judgement at all times to try to identify and avoid any conflicts, and to declare any conflicts as early as possible. If in doubt, always seek professional advice and guidance about the best course of action. The term “probity” means being honest and trustworthy and acting with integrity. 18.5 Case study 5: Self-prescription Clinical scenario Doctor E self-prescribed a 6-month supply of a strong opioid drug for his own personal use to “help him sleep”. The drug was only available on prescription and not over the counter. The prescription was written in forged handwriting on a Hospital Authority (gov- ernment health care system) prescription pad which he was not entitled to use. He deliberately completed it in a manner that con- cealed his identity as the doctor who had written the prescription (as if it was written by a doctor for the patient). He admitted that he had an opioid addiction problem but did not think this affected his clinical work. What are the main professional issues illustrated by this case? You must be honest and trustworthy when writing reports, and when completing or signing forms, reports, and other documents including prescription. Gaining access to strong and addictive medications such as opioid drugs using forged means is dishonest and improper. Taking opioid drugs or any other substances (e.g., alcohol) whilst at work could seriously impair a doctor’s fitness to practice. Your professional duty is to maintain and develop your compe- tence and performance so that the safety of the patient is protected at all times. Unfortunately, substance abuse and drug depend- ence are frequent amongst doctors, hence it is important to seek -

Medical Professionalism 267 professional help whenever there is any concern about yourself, or to alert the appropriate people if there is any concern about your colleague. It is the professional responsibility of a doctor to raise a concern and act upon a concern whenever patient care might potentially be compromised. Conclusion Everyone needs a good, professional doctor. What sets good, pro- fessional doctors apart is their ability to make the care of their patients their primary concern—they are competent; they keep up with their clinical knowledge and skills; they form good rela- tionships with patients and colleagues; they are open, honest, and trustworthy; and they conduct themselves with the highest integ- rity and within the law. Good, professional doctors respect the patients’ rights to privacy and dignity. They treat each patient as an individual, with sensitivity, empathy, and compassion. They always try to do their best to ensure that their patients receive the highest quality of care, whatever their personal background, finan- cial status, or level of disability.” It is impossible to be a perfect doctor, but being aware of the pitfalls and pressures to which we are all susceptible and being able to manoeuver around them and to take responsibility when we fall victim are sure steps in assuring professionalism. References 1. Byyrny, RL, Papadakis MA, and Paauw DS, eds. (2015). Medical Professionalism: Best Practices. Menlo Park: Alpha Omega Alpha Honor Medical Society. 2. Pellegrino E (2000). Medical professionalism: Can it, should it survive? Journal of the American Board of Family Medicine 13(2):147-49. 3. Rcp (2005). Doctors in Society: Medical Professionalism in a Changing World. Report of a Working Party of the Royal College of Physicians. London: Royal College of Physicians.

268 Problem-Based Medical Case Management 4. ABIM (2002). Medical professionalism in the new millenium: A phy- sician charter. Annals of Internal Medicine 136: 243-46. 5. GMC (2013). Good Medical Practice. London: General Medical Council. 6. Stern DT (2006). Measuring Medical Professionalism. New York: Oxford University Press. 7. Shapiro J, Nixon LL, Wear SE, and Doukas DJ (2015). Medical pro- fessionalism: What the study of literature can contribute to the con- versation. Philosophy, Ethics, and Humanities in Medicine: PEHM 10(1):10.