Measuring Professionalism: Of Cabbages and Kings!

Association for Medical Education 2004 Spring Educational InstituteFairmont Royal York Hotel Toronto, Ontario10:00 AM – 11:30 AMSaturday, May 15th, 2004

Earl J. Reisdorff, MD, FACEP

Director of Medical Education Ingham Regional Medical CenterLansing, Michigan Associate Professor

College of Human MedicineMichigan State University residoe@irmcmail.irmc.org

ACGME Definitions of Professionalisma. Patient Care that is compassionate, appropriate, and effective for the treatment of health

problems and the promotion of health b. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g.

epidemiological and social-behavioral) sciences and the application of this knowledge to patient care

c. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

d. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals

e. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

f. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

Expanded Language

ACGME GENERAL COMPETENCIES Vers. 1.3 (9.28.99)

The residency program must require its residents to develop the competencies in the 6 areas below to the level expected of a new practitioner. Toward this end, programs must define the specific knowledge, skills, and attitudes required and provide educational experiences as needed in order for their residents to demonstrate the competencies.

PROFESSIONALISM

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:

demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development

demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices

demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities

Full text:

The Charter on Medical Professionalism

Physicians today are experiencing frustration as changes in the health care delivery systems in virtually all industrialized countries threaten the very nature and values of medical professionalism. Meetings among the European Federation of Internal Medicine, the American College of Physicians-American Society of Internal Medicine (ACP-ASIM), and the American Board of Internal Medicine (ABIM) have confirmed that physician views on professionalism are similar in quite diverse systems of health care delivery. We share the view that medicine's commitment to the patient is being challenged by external forces of change within our societies.

Recently, voices from many countries have begun calling for a renewed sense of professionalism, one that is activist in reforming health care systems. Responding to this challenge, the European Federation of Internal Medicine, the ACP-ASIM Foundation, and the ABIM Foundation combined efforts to launch the Medical Professionalism Project (www.professionalism.org) in late 1999. These three organizations designated members to develop a "charter" to encompass a set of principles to which all medical professionals can and should aspire. The charter supports physicians' efforts to ensure that the health care systems and the physicians working within them remain committed both to patient welfare and to the basic tenets of social justice. Moreover, the charter is intended to be applicable to different cultures and political systems.

Preamble

Professionalism is the basis of medicine's contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession.

At present, the medical profession is confronted by an explosion of technology, changing market forces, problems in health care delivery, bioterrorism, and globalization. As a result, physicians find it increasingly difficult to meet their responsibilities to patients and society. In these circumstances, reaffirming the fundamental and universal principles and values of medical professionalism, which remain ideals to be pursued by all physicians, becomes all the more important.

The medical profession everywhere is embedded in diverse cultures and national traditions, but its members share the role of healer, which has roots extending back to Hippocrates. Indeed, the medical profession must contend with complicated political, legal, and market forces. Moreover, there are wide variations in medical delivery and practice through which any general principles may be expressed in both complex and subtle ways. Despite these differences, common themes emerge and form the basis of this charter in the form of three fundamental principles and as a set of definitive professional responsibilities.

Fundamental Principles

Principle of primacy of patient welfare. This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.

Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients' decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.

Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

A Set of Professional Responsibilities

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 the provision of quality care. More broadly, the profession as a whole must strive to see that all of its members are competent and must ensure that appropriate mechanisms are available for physicians to accomplish this goal.

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. This expectation does not mean that patients should be involved in every minute decision about medical care; rather, they must be empowered to decide on the course of therapy. Physicians should also acknowledge that in health care, medical errors that injure patients do sometimes occur. Whenever patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously compromises patient and societal trust. Reporting and analyzing medical mistakes provide the basis for appropriate prevention and improvement strategies and for appropriate compensation to injured parties.

Commitment to patient confidentiality. Earning the trust and confidence of patients requires that appropriate confidentiality safeguards be applied to disclosure of patient information. This commitment extends to discussions with persons acting on a patient's behalf when obtaining the patient's own consent is not feasible. Fulfilling the commitment to confidentiality is more pressing now than ever before, given the widespread use of electronic information systems for compiling patient data and an increasing availability of genetic information. Physicians recognize, however, that their commitment to patient confidentiality must occasionally yield to overriding considerations in the public interest (for example, when patients endanger others).

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.

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.

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. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.

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.

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.

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. Such compromises are especially threatening in the pursuit of personal or organizational interactions with for-profit industries, including medical equipment manufacturers, insurance companies, and pharmaceutical firms. 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.

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.

Summary

The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges center on increasing disparities among the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform health care systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients' interests. To maintain the fidelity of medicine's social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an action agenda for the profession of medicine that is universal in scope and purpose.

Source: "Medical Professionalism in the New Millennium: A Physician Charter", Annals of Internal Medicine, 5 Feb 2002, 136:3, pp 243-246.

A Curmudgeon’s View For convenience, for the rest of this article I shall refer to these as the "Oath" (Hippocratic Oath) and the "Charter" (The Charter on Medical Professionalism) .

Small but amusing points1. Hippocrates comes across as rather humble. He appeals to the gods to help him live up to his

oath. A bit later he says that all medical students should adhere to "a stipulation and oath", but does not specify that all must follow his oath. While I presume he would not support an oath containing contradictory principles, he seems quite willing to accept the idea that his might not be the final word. On the other hand, the Annals of Internal Medicine article introduces the Charter with the assertion that "we will look back upon its publication as a watershed event in medicine" and "everyone who is involved with medical care should read the charter and ponder its meaning".

2. The Charter is very socially conscious, indeed quite "politically correct" at points. Shortly after making the rather pretentious statement about how all the doctors in the world should "ponder [the] meaning" of this Charter, the editors themselves ponder if doctors from non-Western cultures might not have different standards, and suggest a "dialogue" on the subject. The Charter attacks "market forces" as a threat to good medicine that must be overcome, and frets about the impact of "globalization". They have a lot to say about "social justice" and discrimination. The Oath, on the other hand, makes no reference to larger social or political issues: it speaks only of what the individual doctor should and should not do.

More substantive issues

Similarities1. Both say that a doctor should always put what is best for the patient above his own personal gain. 2. Both say that a doctor should not divulge private information about his patients. (The Charter

adds an exception in cases of "overriding ... public interest", such as when a patient endangers others.)

3. Both prohibit taking sexual advantage of patients.

Differences1. The Oath is very specific. For the most part, if someone claimed that a doctor had violated the

Oath, the only thing to debate would be the facts: did he really commit the claimed violation or not? For example, the Oath prohibits a doctor from participating in physician-assisted suicide or performing abortions. These are specific acts: the doctor did one of these things or he didn't.

The Charter is much more vague. It tells doctors to "promote justice in the health care system", to be "dedicated to continuous improvement in the quality of health care", and to "provide health care that is based on the wise and cost-effective management of limited clinical resources". Even if you knew exactly what a doctor did every minute of every day, it could still be quite difficult to say whether or not he had lived up to this Charter. Exactly what is an individual doctor supposed to do to improve the quality of health care ... "continuously"? How do we determine whether a given treatment plan is "wise" and "cost-effective"? There's lots of room for interpretation and judgment calls here.

As an editorial in World magazine put it (March 9, 2002), "Whereas the Hippocratic oath is a succinct 364 words (in the English translation), the Charter is 1,445 words that say much less".

2. The meaning and goals of the Oath are plain: Hippocrates opposed specific practices that other doctors engaged in or that he feared they might engage in, and he spells them out: euthanasia, abortion, sexual relations with patients, violating patient confidentiality, and failing to refer to a specialist. (That last one strikes me as being of a different character from the rest. I guess that he feared that a doctor, through arrogance and/or greed, might attempt procedures that he was not qualified to perform, with obvious potential harm to the patient.) (A tangential thought: I am, of course, referring back to the Oath as I write this to get the list right, and as I do so it suddenly occurs to me that the issues that concerned Hippocrates are almost all issues that are still in the news regularly today. Perhaps things haven't changed so much in 2,500 years after all.)

The Charter, on the other hand, plays word games that leave us guessing what they really mean. The example of this that I find the most puzzling, perhaps disturbing: There is a section on respecting a patient's right to make decisions about his own care that concludes, "Patients' decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care". What in the world is "inappropriate care"? If we just take the ordinary, literal English meaning of these words, I guess it would mean, "treatment that is not a good idea". But then what are we left with? Something like: Doctors should not try to make medical decisions for a patient, but should give the patient whatever treatment he asks for ... unless the doctor thinks that the patient's decision is wrong, in which case the doctor should ignore the patient's wishes and do what he thinks is best. But then, how is that different from the doctor just doing what he thinks is best all the time? I'd be happy to promise anyone that I would obey every order he gives me as ... long as I agree that it's a good idea and it's what I would have done anyway. Thus, I can't help but suspect that "inappropriate care" is a code word. I notice a couple of other similarly vague statements that I can't help but wonder might be related, namely: Another section talks about "wise and cost-effective" health care and a "just distribution of finite resources". And in two places they warn of the danger that "market forces" might pressure a doctor to "compromise" his "principles". Put this all together and -- and I freely admit that I am speculating here, but it seems to fit -- I think what they mean is this: If a patient asks for life-saving treatment and the doctor decides that this patient is not worth saving, that his quality-of-life is too poor, or that further care is too expensive, then the patient's wishes should be ignored and he should be left to die. That would be "wise and cost-effective". The fact that the patient has insurance or personal financial resources to pay for treatment is irrelevant, because that would be allowing "market forces" to pressure the doctor into "compromising his principles". I'm not making this up out of whole cloth: the idea of rationing medical care -- with decisions made either by government officials or hospital ethics committees -- has been floated a number of times in the last few decades, perhaps most dramatically in the "Clinton health care plan" proposed in the US in the early 90's that would have made it a federal crime for a doctor to give a patient treatment that was not approved by the government. (The proposal labeled this "graft and corruption in medical care".) If you have another idea what this might mean, I'm happy to hear it.

Medical Professionalism — Focusing on the Real Issues The New England Journal of Medicine

David J. Rothman, Ph.D.April 27, 2000, Number 17

There is considerable interest in reinvigorating medical professionalism.1,2,3,4,5,6 This interest reflects a profound unease with the seeming primacy of economic factors among those currently affecting medical practice in the United States. There is general agreement that

patients' interests must take precedence over physicians' financial self-interest and that professionalism also entails service to vulnerable populations and civic engagement. But as commentators focus on managed care and other issues of the moment, many considerations are entirely overlooked. These omissions may well subvert the effort to make professionalism relevant to contemporary medicine.

Because the focus on the threats from managed care is so intense, the thorny question of whether professionalism is more or less vibrant or effective today than it was under fee-for-service medicine has been slighted. Commentators do not consider whether professionalism has to be revived or, more dauntingly, created. Why is there such steadfast inattention to the past? Perhaps the reason is that an analysis of the historical record would severely complicate the agenda, forcing a shift of attention from managed care to the more fundamental problem of professionalism in American medicine.

Take the question of how well physicians met the demands of professionalism during the period from 1910 to 1980. Did they put their patients' interests first? That some physicians did is clear, but given the compelling evidence of over-treatment of patients and such practices as self-referral and fee splitting, it would be difficult to conclude that before managed care was introduced the profession as a whole unequivocally gave precedence to the interests of patients.7 At least since the inception of Medicare, which led to the extraordinary rise in physicians' incomes, some (perhaps many) physicians acted in ways that were designed to enhance their financial positions.

Thus, to the degree that managed care does not pose the initial or exclusive challenge to the precept of putting the interests of patients first, it is necessary to examine the internal, not the external, factors that have weakened professionalism. The problem involves medical norms and practices more than reimbursement formulas under managed care. The most pressing question is not how to redraft contracts between physicians and health maintenance organizations (HMOs) but how to reduce physicians' financial interests and better monitor their behavior. Concepts of professionalism are particularly relevant to this task, as a charge to physicians to make their financial compensation secondary to the welfare of their patients. In fact, professionalism may well require some financial sacrifices.

Discussions about professionalism before the introduction of managed care involved other issues, such as technical expertise and self-regulation of medical practice. These considerations, as formulated by Talcott Parsons in the 1920s and 1930s, were once understood as the foundation of professionalism. In fact, the goal of maintaining technical expertise among physicians has been exceptionally well met. Board certification has proved

so effective a mechanism that problems involving technical expertise have almost disappeared from discussions of professionalism.

However, the record on self-regulation, particularly with respect to incompetence and impairment, is replete with failures.8 Professional societies, with only a few exceptions, have not effectively disciplined their members. By-laws may provide for reprimand, probation, suspension, and expulsion of errant physicians. But most organizations do not publish records of their disciplinary actions. By all accounts, complaints against members are few

and rarely result in disciplinary action. The inadequacies of self-regulation make it clear that an examination of professionalism must go beyond questions of money and managed care. To the extent that self-regulation is the focus, professionalism today has to be invented, not restored.

This proposition is even more true of the current effort to make civic and social obligations central to medical professionalism. Over the past century, physicians have been extraordinarily reluctant to enter the public arena. A few exceptions aside, most physicians have not taken part in national politics (even when health care reform was debated), let alone in state or local politics (e.g., serving on school boards). If the historical record of civic engagement is so bleak, how can it be changed? Why expect doctors to engage in public service now if they have rarely done so in the past?

Just as the recent literature on professionalism ignores history, it slights the structural barriers, apart from managed care, to the accomplishment of the principles of professionalism. Most of the authors, for example, pay little attention to the interactions between pharmaceutical companies and physicians or the influence of such companies on undergraduate medical education and residency training. Despite the evidence that this influence is far-reaching, the few analysts who do remark on the issue fail to convey its importance. Pellegrino and Relman,1 for example, assert that contributions from pharmaceutical companies should not dominate the budgets of professional associations. But they do not cite the data showing how extensive these contributions are or discuss what the associations might have to do to survive without them.

To select one example from an organization that specifies in its budget reports the contributions of pharmaceutical companies, all 21 major donors to the American Academy of Family Physicians in 1995 were drug companies.9 If more professional societies divulged information about such contributions, this example might be multiplied many times over. There is also substantial evidence that gifts from pharmaceutical companies (such as subsidies for meetings and travel) influence the prescribing practices and formulary choices of physicians.10 A discussion of threats to professionalism that does not address the influence of pharmaceutical companies omits a critical consideration, one that, unlike managed care, is largely subject to the control of physicians.

Perhaps the most important omission from the recent discussions of professionalism is the question of how to implement and enforce professional standards. There are calls to expand the teaching of professionalism in medical schools and in residency programs and to have professional societies become more explicit about the norms they espouse. But the limitations of these two approaches are apparent. Ludmerer observes that lectures in the preclinical curriculum are no match for the rough-and-tumble lessons of clinical training.3 The rhetoric on respect for patients is too easily undercut by the reality of exhausted residents teaching medical students how to avoid a "hit." But Ludmerer does not suggest how to implement a change. He is eager "to make the internal culture of academic medical health centers less commercial and more service oriented," but he has no more specific strategy for accomplishing this goal than to appeal to the "courage" of medical leaders.

Nor is it completely satisfactory to depend on a public declaration of norms, whether through new oaths or ceremonies in which first-year medical students are given white coats. Take, for example, the call for greater social engagement through the provision of care to

underserved populations or greater civic participation. Professional resolutions favoring such practices might have some effect on individual behavior, but it is doubtful that they would have a substantial collective impact. Lofty phrases generally do not change customary ways of doing things. To put it another way, the burden is surely on those who would rely on such strategies to demonstrate that they would be successful.

In what other ways might professionalism be promoted and implemented? There are a range of possible strategies, many requiring fundamental departures from current procedures. First, professional and board-certifying societies could require rather than recommend

standards of behavior, including service. One could imagine that, like continuing medical education, service to vulnerable groups of people would be required to maintain certification. A number of community organizations already attempt to meet the medical needs of uninsured patients by coaxing physicians, more or less successfully, to provide care to such patients without charging fees. A minimal requirement to render free care might improve the health of poor patients and promote medical practice that exemplifies the precepts of professionalism. The controversy that would greet such a proposal cannot be underestimated, especially since physicians are under pressure to see larger numbers of insured patients. But controversy may be the price that has to be paid for taking professionalism seriously.

Second, professional associations could form alliances with consumer groups to accomplish goals that neither can realize separately.11 Sullivan suggests that medicine might wish to "go public" and become "much more of a partner to other fields and social interests."4 This approach informs at least one program, Medicare as a Profession (I chair the program's advisory board). Part of the Open Society Institute, it funds joint efforts by consumer groups and medical groups to improve the quality of care, implement professional standards, and provide care to underserved populations. Although physicians have traditionally refrained from joining forces with consumer groups, the need for such alliances may break the tradition.

Third, the medical school and residency curriculum should be altered, not only by including lectures on professionalism but also by inculcating the skills necessary to promote it. To the

degree that the profession accepts a commitment to social engagement, the curriculum should teach advocacy skills along with diagnostic skills. Once again, this would constitute a startling break with established patterns. Medical school faculty would have to include persons trained in advocacy and community organization. The clash of cultures would be great, but so would the benefits.

Fourth, medicine in its organized capacity must encourage and protect whistle-blowers, so that the profession is not so dependent on outsiders to identify and publicize problems. Whether the problem is specific instances of conflict of interest or abuses by managed-care companies, journalists and government officials have taken the lead in uncovering abuses and providing remedies. Thus, when HMOs imposed restrictions on the length of hospital

stays for new mothers and women recovering from mastectomy, the press — not organizations representing obstetricians or oncologists — spearheaded the protests and brought about corrective legislation.12 Journalists have been especially active in ferreting out instances of conflict of interest. To be sure, many medical journals have reported on the overall dimensions of the problem, and universities and medical schools have established useful oversight procedures. But it is the press that continues to highlight the failures of the existing system to control the behavior of physicians. A recent article in the New York Times on the development and testing of new cardiac devices is a telling case in point.13

Fifth, professional organizations must be persuaded to expand the agenda for which they lobby and advocate. Nearly all these organizations engage in extensive lobbying, with many

spending over $500,000 annually on such activities.14 Through lobbying firms or their own staff, they attempt to influence legislation on various matters, including health insurance, drug regulation, managed care, antitrust violations, and liability reform. But in most, if not all, cases, these efforts conform to the special interests of the organization's members.

Thus, the American Academy of Dermatology has fought to maintain direct access to specialists because it is the "most efficient and cost-effective method of providing quality dermatologic services."15 By the same token, the American Academy of Ophthalmology has strongly opposed the creation of "centers of excellence as they apply to cataract surgery," as well as "single surgery payment provisions,"16 apparently because they would reduce

earnings for ophthalmologists. And when Medicare benefits were being debated by Congress, the American College of Gastroenterology lobbied to include screening for colorectal cancer as a benefit.17

Imagine what could have happened if these societies had advocated for the well-being of patients without regard for their own special interests. Support by dermatologists and ophthalmologists for colorectal-cancer screening would carry great weight in the debate over whether to include it as a benefit. Again, the barriers to such activities are formidable. Members of professional organizations do not want their dues spent on advancing the other fellow's specialty, and they may believe that only subspecialists can determine what patients need. But think of how the public might respond to advocacy that was driven not by narrow self-interest but by a broader professional vision of patients' welfare.

Sixth, professional societies, medical schools, and teaching hospitals should adopt policies to minimize the influence of pharmaceutical companies and their representatives. If professional societies raised annual membership dues and registration fees for meetings, they would reduce their dependence on underwriting and advertising by drug companies. At the very least, these organizations should refrain from such practices as identifying drug-company donors in programs for meetings according to the level of support (platinum, gold, silver, and so forth); this suggests a degree of venality that is inconsistent with professionalism.18 Societies may not wish to ban drug-company booths from annual meetings on the grounds that such a restriction might hamper the spread of new information, but no educational purpose is served by allowing the booths to dispense such "brand reminders" as pens, note pads, briefcases, flashlights, and golf balls.19

In the same spirit, medical schools should adopt formal rules that prohibit all gifts from drug companies to students, whether books, stethoscopes, or meals. Medical training should not include acquiring a sense of entitlement to the largesse of drug companies. Finally, teaching hospitals should enforce these same restrictions, proscribing drug-company sponsorship of lunches, conferences, and travel for house staff, and should also make it clear that accepting birthday presents, Christmas gifts, or food and drink off the premises from drug-company representatives violates the ethical norms of the profession.

However fanciful, impractical, or misguided these suggestions may seem, they make it clear that physicians have avoided the admittedly tough question of how professionalism is to become more central to their thinking and behavior. A general call to embrace the ethic may be appealing and may even exert some influence in the long run, but it is not sufficient to bring about substantial change in the near future. Professionalism is too important for an exclusive reliance on such tactics. An infusion of strength and relevance is needed. By one means or another, professionalism must become a vital part of American medicine today.

David J. Rothman, Ph.D.

Columbia University College of Physicians and SurgeonsNew York, NY 10032

References

1. Pellegrino ED, Relman AS. Professional medical associations: ethical and practical guidelines. JAMA 1999;282:984-986.[Full Text]

2. Swick HM, Szenas P, Danoff D, Whitcomb ME. Teaching professionalism in undergraduate medical education. JAMA 1999;282:830-832.[Abstract/Full Text]

3. Ludmerer KM. Instilling professionalism in medical education. JAMA 1999;282:881-882.[Full Text]

4. Sullivan WM. What is left of professionalism after managed care? Hastings Cent Rep 1999;29:7-23.[Medline]

5. Wynia MK, Latham SR, Kao AC, Berg JW, Emanuel LL. Medical professionalism in society. N Engl J Med 1998;341:1612-1616.[Full Text]

6. Casalino LP. The unintended consequences of measuring quality on the quality of medical care. N Engl J Med 1999;341:1147-1150.[Full Text]

7. Rodwin MA. Medicine, money, and morals: physicians' conflicts of interest. New York: Oxford University Press, 1993.

8. Derbyshire RC. How effective is medical self-regulation? Law Hum Behav 1983;7:193-202.

9. AAFP Foundation corporate members. Bull Am Acad Fam Physicians 1995;10:4.

10. Chren MM, Landefeld CS. Physicians' behavior and their interactions with drug companies: a controlled study of physicians who requested additions to a hospital drug formulary. JAMA 1994;271:684-689.[Abstract]

11. Cleary PD, Edgman-Levitan S. Health care quality: incorporating consumer perspectives. JAMA 1997;278:1608-1612.[Abstract]

12. Kassirer JP. Our endangered integrity -- it can only get worse. N Engl J Med 1997;336:1666-1667.[Full Text]

13. Eichenwald K, Kolata G. Hidden interests — a special report: when physicians double as entrepreneurs. New York Times. November 30, 1999:A1.

14. Washington Representatives (a directory of lobbyists and organizations) 1996, pursuant to 1995 Lobbying Disclosure Act (Public Law 104-65). The Center for Responsive Politics maintains a file on each organization. (Or see: http://opensecrets.org/lobbyists/98lookup.htm.)

15. American Academy of Dermatology Web site. (See: http://www. aad.org.)

16. American Academy of Ophthalmology Web site. (See: http://www. eyenet.org.)

17. American Academy of Gastroenterology Web site. (See: http://www. acg.gi.org.)

18. Program and abstracts of the 32nd Annual Meeting of the American Society of Nephrology. Washington, D.C.: American Society of Nephrology, 1999.

19. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA 2000;283:373-380.[Abstract/Full Text]

Selected Professionalism References Anonymous. Medical professionalism in the new millennium: a physicians' charter*. Clin-Med. 2002 Mar-Apr; 2(2): 116-8.The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges centre on increasing disparities between the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform healthcare systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients' interests. To maintain the fidelity of medicine's social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the healthcare system for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an action agenda for the profession of medicine that is universal in scope and purpose.

Anonymous. Issues in medical ethics. Understanding professionalism and its implications for medical education. Proceedings of a conference. New York City, New York, USA. November 3, 2000. Mt-Sinai-J-Med. 2002 Nov; 69(6): 354-420.

Arnold,-L. Assessing professional behavior: yesterday, today, and tomorrow. Acad-Med. 2002 Jun; 77(6): 502-15.PURPOSE: The author interprets the state of the art of assessing professional behavior. She defines the concept of professionalism, reviews the psychometric properties of key approaches to assessing professionalism, conveys major findings that these approaches produced, and discusses recommendations to improve the assessment of professionalism. METHOD: The author reviewed professionalism literature from the last 30 years that had been identified through database searches; included in conference proceedings, bibliographies, and reference lists; and suggested by experts. The cited literature largely came from peer-reviewed journals, represented themes or novel approaches, reported qualitative or quantitative data about measurement instruments, or described pragmatic or theoretical approaches to assessing professionalism. RESULTS: A circumscribed concept of professionalism is available to serve as a foundation for next steps in assessing professional behavior. The current array of assessment tools is rich. However, their measurement properties should be strengthened. Accordingly, future research should explore rigorous qualitative techniques; refine quantitative assessments of competence, for example, through OSCEs; and evaluate separate elements of professionalism. It should test the hypothesis that assessment tools will be better if they define professionalism as behaviors expressive of value conflicts, investigate the resolution of these conflicts, and recognize the contextual nature of professional behaviors. Whether measurement tools should be tailored to the stage of a medical career and how the environment can support or sabotage the assessment of professional behavior are central issues. FINAL THOUGHT: Without solid assessment tools, questions about the efficacy of approaches to educating learners about professional behavior will not be effectively answered.

Ber,-R; Alroy,-G. Teaching professionalism with the aid of trigger films. Med-Teach. 2002 Sep; 24(5): 528-31.Medical professionalism includes expert knowledge, self-regulation and fiduciary responsibility to place the needs of patients ahead of the self-interest of physicians. In teaching medical professionalism to our medical students only the behavioural elements are dealt with. One of the challenges facing medical educators today is how medical professionalism can be taught. At the authors' faculty of medicine brief videotapes (trigger films) of amateur actor physician-patient encounters in various clinical settings (taken from genuine encounters) are used as a stimulus for discussion and instruction of medical

professionalism. A series of 16 trigger films has been produced that raise many medical professional issues. The films and the issues raised are described in brief. These trigger films are viewed by small groups of medical students together with a physician tutor facilitator at various stages of their studies. It is noteworthy how fast the transition occurs in students, from observing the trigger films in their pre-clinical stage as a client, to observing them in their clinical years from the angle of a provider; from identifying with the patient's concerns to identifying with the physicians' behaviour; from being a critical person to becoming a person who accepts the rules and regulations of the guild. Most probably the power of the teaching of ethical and professional rules is overruled by the power of everyday clinical experience during their clinical clerkships. It is planned to run a series of trigger film sessions with senior and junior physicians of the major clerkships, in an attempt to promote an institutional environment/atmosphere/culture of professional behaviour.

Bloom,-S-W. Professionalism in the practice of medicine. Mt-Sinai-J-Med. 2002 Nov; 69(6): 398-403.Although medicine is universally recognized as the archetype of the professions, it can only be understood as part of the modern medical center, a dynamic social system consisting of the university, the hospital, the medical center and, most recently, corporate managed care. Such a view results in a portrait of medicine as a profession transformed, driven by huge and growing health care markets, its fate tied not only to state bureaucracies, but also to the dynamics of both health and non-health care businesses. The question asked here is how does such a radical change in medical practice affect medical education?. Using methods of historical analysis, it appears that medical educators operate as though the educational process itself determines the values, and therefore the present and future behavior of their students. In other words, at the end of their formal education, doctors are fully formed professionals. However, from the analysis of this paper it can be concluded that the physician as an individual cannot function independently of the structure of the society and its general conception of the world. In the structure of medicine s present situation, the ethical standards of professionalism, as they are classically defined, cannot survive. Instead, modern medical graduates, much like their teachers and professional mentors, will be forced to adapt to a situation that is contradictory to the best traditions of medicine. How to stop this process is the urgent question. Three answers are presented.

Chervenak,-F-A; McCullough,-L-B. Professionalism and justice: ethical management guidelines for leaders of academic medical centers. Acad-Med. 2002;77(1): 45-7. Academic health centers (AHCs) exist for the sake of pursuit of excellence in their missions of patient care, teaching, and research. Survival should be a means to these goals and not an end unto itself. Because of the fiscal crisis in health care, leaders of AHCs face the possible diminution or even extinction of their centers. When preventing such a fate becomes the governing concern of these leaders, power concentrates in their hands and can be used to force cooperation among competing faculty members and groups for the sake of mutual survival. The ethical concepts of professionalism and justice can be used to create a vital, practical, alternative vision for the leadership of AHCs, in which their missions once again become central to their organizational culture. Creating a morally sustainable organizational culture of professionalism and justice should rely not on forced cooperation, but on voluntary cooperation of all stakeholders in the pursuit of a common goal-professional excellence in patient care, teaching, and research-with survival understood to be a means to this goal. To achieve this alternative vision, the authors propose five management guidelines. For example, all faculty should be made accountable not only for maximizing the good of the organization's professionalism but also for fostering financial viability.

Chisholm,-C-D; Whenmouth,-L-F; Daly,-E-A; Brizendine,-E-J; Cordell,-W-H. A comparison of faculty contact time with emergency medicine residents in different teaching venues. Acad-Emerg-Med. 2003 May; 10(5): 472.AB: OBJECTIVE: Emergency Medicine (EM) residencies must implement the 6 ACGME core competencies by 2006. EM educators recommend direct observation (DO) as the optimal evaluation tool for 4 of the 6 core competencies (Patient Care, Systems-Based Practice, Interpersonal and Communication Skills, and Professionalism). The 24/7 faculty presence in the Emergency Department (ED) is believed to facilitate DO as an assessment technique. METHODS: Observational study of faculty contact in 2 EDs, 2 trauma services, inpatient medicine, adult & pediatric ICUs, and a pediatric outpatient clinic (UVC). Faculty contact was categorized as DO of patient care, indirect patient care, or non-patient care activities using a priori definitions. EM residents were shadowed for 2-hour intervals. Subjects were blinded to the nature of the study and data gathering was encrypted. RESULTS: 270 observation periods of 2 hours each were conducted, sampling 32 EM R1, 33 EM R2-3, 41 EM and 38 non-EM faculty. Total faculty contact time ranged from a maximum of 30% (95% CI = 20, 41) in the pediatric ICU to a minimum of 10% (3, 16) on internal medicine wards. Overall ED faculty contact was 20% (18, 22). DO by faculty ranged from a high of 5% (3, 8) in the pediatric UVC to a low of 1% (0, 2) on internal medicine wards. Overall ED DO was 3.6% (2.6, 4.7). ED DO did not vary across EMR level or by site. DO varied by treatment area within the ED with the critical area being substantially higher (6%) when compared with the non-critical care areas (1%). CONCLUSIONS: Direct observation of EM residents was low in all training venues studied. Overall DO was the highest in ED critical care areas and lowest on medicine ward rotations. EM faculty who are already involved in routine teaching, supervision, and patient care rarely performed DO in spite of their immediate physical presence 24/7. This suggests that alternative strategies may be required to assess core competencies through direct observation in the Emergency Department.

Connelly,-J-E. The other side of professionalism: doctor-to-doctor. Camb-Q-Healthc-Ethics. 2003 Spring; 12(2): 178-83.

Cruess,-S-R; Johnston,-S; Cruess,-R-L. Professionalism for medicine: opportunities and obligations. Med-J-Aust. 2002 Aug 19; 177(4): 208-11.Physicians' dual roles - as healer and professional - are linked by codes of ethics governing behaviour and are empowered by science. Being part of a profession entails a societal contract. The profession is granted a monopoly over the use of a body of knowledge and the privilege of self-regulation and, in return, guarantees society professional competence, integrity and the provision of altruistic service. Societal attitudes to professionalism have changed from supportive to increasingly critical - with physicians being criticised for pursuing their own financial interests, and failing to self-regulate in a way that guarantees competence. Professional values are also threatened by many other factors. The most important are the changes in healthcare delivery in the developed world, with control shifting from the profession to the State and/or the corporate sector. For the ideal of professionalism to survive, physicians must understand it and its role in the social contract. They must meet the obligations necessary to sustain professionalism and ensure that healthcare systems support, rather than subvert, behaviour that is compatible with professionalism's values.

Davis,-M-H. OSCE: the Dundee experience. Med-Teach. 2003 May; 25(3): 255-61.The Dundee Medical School has bean running OSCEs since 1977. In 1995, an integrated systems-based spiral curriculum on the core and options model was introduced. In 1997, outcome-based education was introduced as the basis for instruction, with a task-based educational strategy employed for students in years 4 and 5. This blend of educational strategies was considered in the design of the student assessment process. Assessment instruments, appropriate for use at each of the four levels of Miller's pyramid, were identified and included in the assessment process. The OSCE was used for summative assessment of

students at the level of 'shows how' or simulation in years 2, 3 and 4. A year 2 OSCE is described here. Features of the Dundee OSCE are identified, relating to number and length of individual stations, practicalities or assessing a year group of students without student contamination with examination information and the blueprints used to design the examinations. Suggestions made for future development of the OSCE include the OSSE, the Objective Structured Selection Examination, and an exploration of the potential of the OSCE to assess attitudes, personal attributes and professionalism. The need is identified for a platform to debate issues such as should individual medical schools attempt to achieve national test centre standards with their examinations.

Epstein,-R-M; Hundert,-E-M. Defining and assessing professional competence. JAMA. 2002 Jan 9; 287(2): 226-35.CONTEXT: Current assessment formats for physicians and trainees reliably test core knowledge and basic skills. However, they may underemphasize some important domains of professional medical practice, including interpersonal skills, lifelong learning, professionalism, and integration of core knowledge into clinical practice. OBJECTIVES: To propose a definition of professional competence, to review current means for assessing it, and to suggest new approaches to assessment. DATA SOURCES: We searched the MEDLINE database from 1966 to 2001 and reference lists of relevant articles for English-language studies of reliability or validity of measures of competence of physicians, medical students, and residents. STUDY SELECTION: We excluded articles of a purely descriptive nature, duplicate reports, reviews, and opinions and position statements, which yielded 195 relevant citations. DATA EXTRACTION: Data were abstracted by 1 of us (R.M.E.). Quality criteria for inclusion were broad, given the heterogeneity of interventions, complexity of outcome measures, and paucity of randomized or longitudinal study designs. DATA SYNTHESIS: We generated an inclusive definition of competence: the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served. Aside from protecting the public and limiting access to advanced training, assessments should foster habits of learning and self-reflection and drive institutional change. Subjective, multiple-choice, and standardized patient assessments, although reliable, underemphasize important domains of professional competence: integration of knowledge and skills, context of care, information management, teamwork, health systems, and patient-physician relationships. Few assessments observe trainees in real-life situations, incorporate the perspectives of peers and patients, or use measures that predict clinical outcomes. CONCLUSIONS: In addition to assessments of basic skills, new formats that assess clinical reasoning, expert judgment, management of ambiguity, professionalism, time management, learning strategies, and teamwork promise a multidimensional assessment while maintaining adequate reliability and validity. Institutional support, reflection, and mentoring must accompany the development of assessment programs.

Fins,-J-J; Gentilesco,-B-J; Carver,-A; Lister,-P; Acres,-C-A; Payne,-R; Storey-Johnson,-C. Reflective practice and palliative care education: a clerkship responds to the informal and hidden curricula. Acad-Med. 2003 Mar; 78(3): 307-12.The authors discuss the damaging influence of informal and hidden curricula on medical students and describe a two-week clerkship in palliative care and clinical ethics at their school (Weill Medical College of Cornell University). This required clerkship, begun in 1999, uses reflective practice and a special pedagogic technique, participant observation, to counteract the influences of the informal and hidden curricula. This technique seeks to immerse the participant observer in the context of care. In their role as participant observers, students are relieved of any direct clinical responsibilities for two weeks so they have time for the careful observation and reflection required and also can consider the humanistic dimensions of practice, which are often displaced by the need to master diagnostic and therapeutic skills. Course objectives include identifying psychosocial and

contextual factors that influence care, principles of pain and symptom management, and ethical and legal issues at the end of life. Students are expected to learn how to apply ethical norms to patient care, describe methods of pain and symptom management, communicate in an effective and humanistic manner, and articulate models of patient-centered advocacy. The clerkship fosters professionalism in patient care, appreciation of cultural diversity, and the student's ability to assume responsibility for developing competency in these areas. Although it is too early to know whether this clerkship will ultimately affect the practice patterns of students who experience it, short-term evaluation has been very favorable.

Ginsburg,-S; Regehr,-G; Stern,-D; Lingard,-L. The anatomy of the professional lapse: bridging the gap between traditional frameworks and students' perceptions. Acad-Med. 2002 Jun; 77(6): 516-22.PURPOSE: To support students' developing professionalism, it is necessary to understand the professional challenges and dilemmas they perceive in the clinical setting. This study systematically documented and catalogued students' reports of professional lapses. METHOD: Six focus groups were conducted with senior medical students (n = 29) at three universities. Using a grounded-theory approach, three researchers analyzed the students' reports of specific lapses in professionalism for recurrent themes. The resulting coding structure was applied using NVivo qualitative data analysis software. RESULTS: A total of 120 pages of text yielded 48 specific incidents of professional lapses, which were analyzed by three researchers using grounded theory. Most incidents were witnessed (n = 34) or known about (n = 4), as opposed to self-reported (n = 10). Six critical "issues" emerged: communicative violations (to or about patients or other health care professionals); role resistance (individuals chafing against constraints or expectations of their perceived roles); objectification of patients (ignoring patients or treating patients as vehicles for learning); accountability (to colleagues or patients, including avoiding patients, failing to disclose information, or failing to treat appropriately); physical harm (to patients or others); and crossfire (being put in the middle of a struggle between superiors). CONCLUSIONS: This study explored how students experienced and operationalized professionalism in clinical settings at a variety of universities. Interestingly, the critical issues they reported as salient did not map easily onto standard, abstract definitions of professionalism. This incongruence suggested that the development of effective curricula in this domain must bridge the gap between traditional taxonomies and students' perceptions of professionalism.

Glannon,-W; Ross,-L-F. Are doctors altruistic? J-Med-Ethics. 2002 Apr; 28(2): 68-9; discussion 74-6.There is a growing belief in the US that medicine is an altruistic profession, and that physicians display altruism in their daily work. We argue that one of the most fundamental features of medical professionalism is a fiduciary responsibility to patients, which implies a duty or obligation to act in patients' best medical interests. The term that best captures this sense of obligation is "beneficence", which contrasts with "altruism" because the latter act is supererogatory and is beyond obligation. On the other hand, we offer several examples in which patients act altruistically. If it is patients and not the doctors who are altruistic, then the patients are the gift-bearers and to that extent doctors owe them gratitude and respect for their many contributions to medicine. Recognizing this might help us better understand the moral significance of the doctor-patient relationship in modern medicine.

Gordon,-J. Assessing students' personal and professional development using portfolios and interviews. Med-Educ. 2003 Apr; 37(4): 335-40.BACKGROUND AND PURPOSE: Medical schools are placing more emphasis on students' personal and professional development (PPD) and are seeking ways of assessing student progress towards meeting outcome goals in relation to professionalism. The Faculty of Medicine at the University of Sydney sought an assessment method that would demonstrate

the value of reflection in attaining PPD, provide feedback and encourage students to take responsibility for setting and achieving high standards of performance. METHODS: The instruments used to assess Year 1 students in PPD are a portfolio and interview. This assessment format encourages students to explore ideas and values that are important to them and relevant to the PPD theme. A confidential interview, based on the PPD goals, is held with a faculty member who has read the student's portfolio. RESULTS: In 1997/98, 96% of students agreed that they had engaged in useful reflection on their approach to the course and 91% agreed that the experience was worthwhile. A further 76% of students agreed that they could see opportunities to modify their approach in some ways as result of this exercise. CONCLUSION: Sustained PPD is essential in equipping doctors for the varied stresses of careers in medicine. Despite, or perhaps because of, the latitude in the Year 1 assessment, both students and faculty members found the process of value. This form of assessment acknowledges that the most valid assessment formats cannot always be made reliable and that in some parts of the curriculum it is more important to demonstrate trust in students' own motivation to become competent and mindful practitioners. The fact that the portfolio and interview are the only summative assessments in the first year emphasises the importance that the Faculty places on PPD.

Hatem,-C-J Teaching approaches that reflect and promote professionalism. Acad-Med. 2003 Jul; 78(7): 709-13.The teaching and cultivation of professionalism have long been part of medical education and have had recent special emphasis because professionalism has been identified as a core competency by the Accreditation Council for Graduate Medical Education. The author focuses on two complementary teaching initiatives that contribute to the development of professionalism in the academic environment: a resident-as-teacher program and an approach to faculty bedside teaching that mirrors and extends the lessons of the resident-as-teacher effort. These have been implemented and refined over the previous 15 years by the author and his colleagues at Mount Auburn Hospital in Cambridge, Massachusetts. The commitment to the development and refinement of residents' teaching skills serves to promulgate the fundamental elements of professionalism, with emphasis on caring and the educational well-being of the team. The author describes the elements and benefits of these approaches and shows how they can foster the development of professionalism in graduate medical education.

Heard,-J-K; Allen,-R-M; Clardy,-J. Assessing the needs of residency program directors to meet the ACGME general competencies. Acad-Med. 2002 Jul; 77(7): 750.OBJECTIVE: New accreditation requirements for residency training programs require residents to have educational experiences that allow them to demonstrate competency in the following areas: (1) patient care, (2) medical knowledge, (3) practice-based learning and improvement, (4) interpersonal and communication skills, (5) professionalism, and (6) systems-based practice. Residents' competence must be assessed with dependable measures. Residency training program directors (PDs) need assistance in complying with these new requirements. DESCRIPTION: Using a survey modified from Michigan State University, we asked PDs to rate their current understanding of and preparation for the general competencies and to provide written comments. PDs of the 47 ACGME-accredited programs received e-mailed instructions to complete the Web-based survey. Twenty-four PDs (51%) complied by the deadline. The mean ratings were calculated from a five-point scale (1 = strongly disagree, major impediment or least useful, 5 = strongly agree, not an impediment, or most useful). PDs felt they were informed (3.45) and understood (3.67) the requirements, but they were not well prepared to meet them (2.95). The perceived impediments to implementation included amount of PD time (2.27), amount of residents' protected time for the curriculum (2.30), amount of residency support staff (2.73), lack of expertise in curriculum development (2.73) and evaluation (2.41), and lack of funding for resources other than personnel (2.91). PDs rated types of assistance that would be helpful:

developing workshops or presentations on curriculum development and evaluation techniques (3.82), developing curricula (4.14), providing one-on-one consultation (4.23), receiving examples of materials, methods, and ideas from other programs (4.41), and describing evaluation methods/instruments (4.50). Written comments stated that time to concentrate on the topic, release time from clinical responsibilities, and technical computer support would be helpful. Of the six competency areas, PDs were most interested in receiving assistance in developing curricular materials for the competencies of systems-based practice (4.50), professionalism (4.36), and practice-based learning and improvement (4.27). PDs were most interested in receiving assistance in developing evaluations for practice-based learning and improvement (4.59), professionalism (4.59), interpersonal and communication skills (4.45), and systems-based practice (4.36). PDs responded that they currently use written faculty evaluations to assess all six general competency areas. DISCUSSION: Results of the survey indicate that PDs require assistance to comply with the new ACGME requirements. Curricular materials and valid and reliable evaluation methods need to be developed. In order to assist PDs, the following activities are under way: (1) PDs are members of a listserve for sharing ideas and examples of curricular and evaluation materials; (2) PDs attend a monthly seminar series that provides practical information for curricular material development and specific evaluation methods, including indications for use and feasibility; (3) educators from our Office of Educational Development provide individual consultations with each PD; (4) PDs participate in an eight hour workshop with practical sessions for developing curricular materials and evaluations; and (5) two institution-wide assessments are being developed: a patient-satisfaction survey and a 360-degree evaluation to assess communication skills and professionalism.

Heru,-A-M. Using role playing to increase residents' awareness of medical student mistreatment. Acad-Med. 2003 Jan; 78(1): 35-8.The teacher-learner relationship is subject to both internal and external influences that may lead to mistreatment and harassment of the student. The student who is mistreated may mistreat students when he or she becomes a teacher. The author describes an experiential program for residents at Brown Medical School from 1999 to 2002 in which residents, through role playing, helped produce teaching videotapes on medical student mistreatment. Fourteen residents had participated in the program to date. They reported that they had benefited from an increased awareness of the effects of student mistreatment and had learned how to handle mistreatment more effectively. They also reported increased sensitivity to others and improved self-awareness, qualities that they planned to incorporate into their professional identities and that should help them avoid mistreatment of students and residents later in their careers. Because preventing mistreatment from being transmitted to the next generation is an important way to increase medical professionalism, the author recommends that role-playing exercises dealing with mistreatment be a part of all residency education.

Klein,-E-J; Jackson,-J-C; Kratz,-L; Marcuse,-E-K; McPhillips,-H-A; Shugerman,-R-P; Watkins,-S; Stapleton,-F-B. Teaching professionalism to residents. Acad-Med. 2003 Jan; 78(1): 26-34.The need to teach professionalism during residency has been affirmed by the Accreditation Council for Graduate Medical Education, which will require documentation of education and evaluation of professionalism by 2007. Recently the American Academy of Pediatrics has proposed the following components of professionalism be taught and measured: honesty/integrity, reliability/responsibility, respect for others, compassion/empathy, self-improvement, self-awareness/knowledge of limits, communication/collaboration, and altruism/advocacy. The authors describe a curriculum for introducing the above principles of professionalism into a pediatrics residency that could serve as a model for other programs. The curriculum is taught at an annual five-day retreat for interns, with 11 mandatory sessions devoted to addressing key professionalism issues. The authors also explain how the

retreat is evaluated and how the retreat's topics are revisited during the residency, and discuss general issues of teaching and evaluating professionalism.

Larkin,-G-L; Binder,-L; Houry,-D; Adams,-J. Defining and evaluating professionalism: a core competency for graduate emergency medicine education. Acad-Emerg-Med. 2002 Nov; 9(11): 1249-56.Professionalism, long a consideration for physicians and their patients, is coming to the forefront as an essential element of graduate medical education as one of the six new core competency requirements of the Accreditation Council for Graduate Medical Education (ACGME). Professionalism is also integral to the widely endorsed Model of the Clinical Practice of Emergency Medicine (Model). Program directors have now been charged with implementing the new core competencies in training programs and to assess the acquisition of these competencies in their trainees. To assist emergency medicine (EM) program directors in this endeavor, the Council of Emergency Medicine Residency Directors (CORD-EM) held a consensus conference in March 2002. A focused Consensus Group addressed the specific core competency of professionalism during the course of this conference, and the results are highlighted in this article. The definition and curricular requirements relating to professionalism are highlighted, specific techniques for evaluating this core competency in EM are reviewed, and recommendations are provided regarding the most appropriate assessment method for EM programs.

Larkin,-G-L; Marco,-C-A; Abbott,-J-T. Emergency determination of decision-making capacity: balancing autonomy and beneficence in the emergency department. Acad-Emerg-Med. 2001 Mar; 8(3): 282-4.AB: The determination of decision-making capacity (DMC) is an essential component of securing voluntary informed consent, for either treatment or refusal of care. Decision-making capacity should be determined on some level during each patient encounter. Decision-making capacity includes the ability to receive, process, and understand information, the ability to deliberate, the ability to make choices, and the ability to communicate those preferences. For patients in whom DMC may be uncertain, a more explicit approach to determination of DMC is recommended. However, DMC determination must neither compromise patient safety nor delay needed care. When DMC determination is challenging, or when the ramifications of a decision are serious, the assistance of a third party (such as a surrogate, a consultant, or another clinician) may be valuable in discerning the most appropriate action. In addition to the obvious clinical utility of DMC assessment, the steps taken in the very establishment of DMC may promote patient trust, professionalism, and humanistic clinical practice. While DMC may be conditional, the compassion and respect we have for our patients must be unconditional.

Li,-S-F; Haber,-M; Birnbaum,-A. Patient satisfaction and physician dress in the emergency department. Acad-Emerg-Med. 2003 May; 10(5): 550.BACKGROUND: To determine if patients' evaluations of EM physicians are influenced by their manner of dress. Past studies concerning patient responses to physicians' style of dress have been limited to clinic/in-patient settings, or were limited to preference by photographs. There is one study of patients' attitude toward ED physician attire, done in the UK, where patients did not show any preference of dress. We wish to determine if patient preferences are influenced by physicians' dress in our clinical setting, a U.S. urban hospital. METHODS: A cross-section, convenience sample of patients. Physician dress was recorded. Patients were asked to determine on a 100 mm VAS their evaluation of physician appearance, satisfaction, and professionalism. Dress styles were recorded as scrubs, dress shirt/pants, or mixed. We estimated 56 patients were needed to detect a 10% difference between groups based on an estimated mean of 75, sd of 10, 2-tailed alpha of.05, beta of.2. Comparison of scores between groups was done using one-way ANOVA, or Kruskal-Wallis when variances were unequal. Comparison of variances was done using the F test. Correlation between physician

appearance and satisfaction or professionalism was done using Pearson's rho. RESULTS: 117 patients were surveyed. Physician dress style was 56% scrubs, 26% mixed, and 17% dress. There were no differences between patients' evaluation of appearance, satisfaction, or professionalism between the three groups (Table 1). There was poor correlation between ratings on dress and physician satisfaction (r(2) =.42) or professionalism (r(2) =.32). CONCLUSIONS: Physicians' dress style in the ED does not affect patients' evaluations of their performance.

Lie,-D; Rucker,-L; Cohn,-F. Using literature as the framework for a new course. Acad-Med. 2002 Nov; 77(11): 1170.OBJECTIVE: The award-winning book The Spirit Catches You and You Fall Down,(1) a true story of the collision between two cultures (American and Hmong) with heartrending consequences for the patient, the patient's family, and the medical professionals who care for them, has been favorably reviewed(2) and used to stimulate teaching of cultural diversity, ethics, and professionalism to students and residents. We used it as a required text for a new Patient Doctor Society (PDS) course for 184 first- and second-year medical students. This report describes the scope and contexts in which the book was used to meet specific course goals. DESCRIPTION: PDS is a required 90-hour introduction to medical interviewing, which integrates ethics, communication, clinical reasoning, cultural diversity, humanities, spirituality, integrative medicine, nutrition, and behavioral science. To provide a common experience among these diverse topics, faculty members were asked to use examples from the book to achieve their learning objectives. A required faculty development session illustrated strategies for effectively using the text. Focusing on chapter 13 ("Code X"), dramatic portrayals of differences in beliefs about end-of-life care and clinician-family communication, facilitated the introduction of methods including point-of-view writing, role-plays, and faculty-facilitated discussions as techniques for meeting course objectives. At PDS orientation, we used the same chapter, and had faculty members lead small groups of students using the teaching techniques they acquired. About 90% of students read the book prior to orientation. Students favorably reviewed this three-hour session. For the ethics session, unfacilitated small groups of students were asked to identify and discuss the ethical issues in chapter 11 ("The Big One"), which describes a major turning point in the health care provided to the text's central character, Lia. Each group presented its "moral diagnosis" and ethical arguments for resolution. Class discussion then focused on the diverse views presented, to emphasize the importance of justifying decisions and to practice using tools of ethical analysis. In the communication skills workshop, we excerpted dramatic readings from the book. Faculty members played the roles of the author, the patient's mother, and one of Lia's physicians. The interaction became a dialogue to illustrate the points of view of the participants. The dialogue was used to stimulate discussion about potential pitfalls in physician-patient communication and understanding. In a medical humanities session, excerpts from the book were compared with poetry explicating themes of physician arrogance and humility. DISCUSSION: The Spirit Catches You and You Fall Down provides a context appropriate to teaching students how to listen to, and learn from patient stories. The story will be reintroduced in the pediatrics clerkship. Caution will be exercised to (1) avoid overexposure to the text, (2) counteract the potential to interpret the story too narrowly, and (3) assure that faculty become familiar with the text and its uses. We intend to track outcomes in knowledge, skills and attitudes for each content area, and observe the degree that the book facilitates achievement of objectives. We will follow several cohorts of students to verify longitudinally the learning effects observed.

Lockyer,-J. Multisource feedback in the assessment of physician competencies. J-Contin-Educ-Health-Prof. 2003 Winter; 23(1): 4-12.Multisource feedback (MSF), or 360-degree employee evaluation, is a questionnaire-based assessment method in which rates are evaluated by peers, patients, and coworkers on key performance behaviors. Although widely used in industrial settings to assess performance, the method is gaining acceptance as a quality improvement method in health systems. This

article describes MSF, identifies the key aspects of MSF program design, summarizes some of the salient empirical research in medicine, and discusses possible limitations for MSF as an assessment tool in health care. In industry and in health care, experience suggests that MSF is most likely to succeed andb2 result in changes in performance when attention is paid to structural and psychometric aspects of program design and implementation. A carefully selected steering committee ensures that the behaviors examined are appropriate, the communication package is clear, and the threats posed to individuals are minimized. The instruments that are developed must be tested to ensure that they are reliable, achieve a generalizability coefficient of Ep2 = .70, have face and content validity, and examine variance in performance ratings to understand whether ratings are attributable to how the physician performs and not to factors beyond the physician's control (e.g., gender, age, or setting). Research shows that reliable data can be generated with a reasonable number of respondents, and physicians will use the feedback to contemplate and initiate changes in practice. Performance may be affected by familiarity between rater and ratee and sociodemographic and continuing medical education characteristics; however, little of the variance in performance is explained by factors outside the physician's control. MSF is not a replacement for audit when clinical outcomes need to be assessed. However, when interpersonal, communication, professionalism, or teamwork behaviors need to be assessed and guidance given, it is one of the better tools that may be adopted and implemented to provide feedback and guide performance.

Lynch,-D-C; Pugno,-P; Beebe,-D-K; Cullison,-S-W; Lin,-J-J. Family practice graduate preparedness in the six ACGME competency areas: prequel. Fam-Med. 2003 May; 35(5): 324-9.BACKGROUND AND OBJECTIVES: Since July 2002, family practice residency program accreditation requires evidence of teaching and assessing residents in six competency areas. This study was conducted to obtain baseline information about family practice graduates' perceptions of the importance of specific competencies and the extent to which residency training prepared them to perform skills representative of the six competency areas. METHODS: A national, cross-sectional survey was conducted of family physicians who had graduated from residency programs from 1998 to 2000. RESULTS: The response rate was 54% (n=1,228). Graduates reported the most preparation in patient care skills, followed by interpersonal and communication skills and then professionalism. The least preparation was reported for skills pertinent to practice-based learning and improvement, systems-based practice, and some areas of professionalism. CONCLUSIONS: Areas of residency education that appear to warrant improvement include education about system aspects of care, practice-based learning and improvement, and selected professionalism issues.

Lypson,-M-L; Hauser,-J-M. Talking medicine: a course in medical humanism--what do third-year medical students think? Acad-Med. 2002 Nov; 77(11): 1169-70.OBJECTIVE: The early 1990s sparked an interest in organized medicine to reclaim and re-evaluate how it promotes professionalism among physicians. The American Board of Internal Medicine (ABIM) launched Project Professionalism as a means to define and evaluate professionalism as a component of clinical competence. The course "Talking Medicine" was developed to create a series of small-group discussions on humanism and professionalism where students can reflect on the process of becoming a physician and share personally or ethically difficult and rewarding cases with each other. We asked students to define these concepts and use these definitions to spark small-group discussion. DESCRIPTION: "Talking Medicine" is predicated on the belief that humanism and professionalism come to students and others through understanding a number of core concepts and relationships complemented by self-reflection. "Talking Medicine" offers a consistent (every other week for ten weeks) opportunity to share experiences in small groups (six to eight students), facilitated by two preceptors, in a format driven by students' experiences. Although the focus is on students' experiences, readings are provided on basic topics and contexts in humanism and professionalism (e.g., end-of-life care, mistakes, spirituality in medicine, and

boundaries between patients and doctors). Also, at the beginning of each internal medicine clerkship we asked students to define humanism and professionalism anonymously on sheets of paper to be handed to the preceptors. DISCUSSION: "Talking Medicine" began in summer 2000. We hope to expand it to other institutions. We surveyed students and found 94% felt "very" or "somewhat" comfortable in the course. Seventy-three percent of students reported that the course increased their "connectedness" to classmates, and 61% favored its occurring during all rotations. Fifty-nine percent reported that their interest in caring for patients improved, and 53% reported their interest in internal medicine as a field improved. Answers to open-ended questions highlighted the importance of "Talking Medicine" as a forum to connect with others-both students and faculty. Despite this course's focus during an internal medicine clerkship, students see a broader definition of professionalism than the ABIM; the student's definitions were similar in many ways to the Group of Educational Affairs definition of professionalism. Third-year medical students focus more on tolerance of difference (e.g., race, socioeconomic status, and varying health beliefs), and the importance of collegiality and collaboration in the new environment of patient care. Their vantage point early in training allows them to look critically at the profession they are joining and view its shortcomings and strengths. Future work is needed that focuses on how these definitions change as students' progress through fourth year, into residency, and finally continuing medical education. Nevertheless, we suggest that "Talking Medicine" may be most effective in helping classmates connect to and learn from each other, thereby setting a foundation for changes in how they interact with patients.

McLaughlin,-S-A; Doezema,-D; Sklar,-D-P. Human simulation in emergency medicine training: a model curriculum. Acad-Emerg-Med. 2002 Nov; 9(11): 1310-8.The authors propose a three-year curriculum for emergency medicine residents using human simulation both to teach and to assess the Accreditation Council for Graduate Medical Education (ACGME) core competencies. Human simulation refers to a variety of technologies that allow residents to work through realistic patient problems so as to allow them to make mistakes, learn, and be evaluated without exposing a real patient to risk. This curriculum incorporates 15 simulated patient encounters with gradually increasing difficulty, complexity, and realism into a three-year emergency medicine residency. The core competencies are incorporated into each case, focusing on the areas of patient care, interpersonal skills and communication, professionalism, and practice based learning and improvement. Because of the limitations of current assessment tools, the demonstration of resident competence is used only for formative evaluations. Limitations of this proposal and difficulties in implementation are discussed, along with a description of the organization and initiation of the simulation program.

Miles,-S-H. On a new charter to defend medical professionalism: whose profession is it anyway? Hastings-Cent-Rep. 2002 May-Jun; 32(3): 46-8.

Norcini,-J-J; Blank,-L-L; Duffy,-F-D; Fortna,-G-S. The mini-CEX: a method for assessing clinical skills. Ann-Intern-Med. 2003 Mar 18; 138(6): 476-81.OBJECTIVE: To evaluate the mini-clinical evaluation exercise (mini-CEX), which assesses the clinical skills of residents. DESIGN: Observational study and psychometric assessment of the mini-CEX. SETTING: 21 internal medicine training programs. PARTICIPANTS: Data from 1228 mini-CEX encounters involving 421 residents and 316 evaluators. INTERVENTION: The encounters were assessed for the type of visit, sex and complexity of the patient, when the encounter occurred, length of the encounter, ratings provided, and the satisfaction of the examiners. Using this information, we determined the overall average ratings for residents in all categories, the reliability of the mini-CEX scores, and the effects of the characteristics of the patients and encounters. MEASUREMENTS: Interviewing skills, physical examination, professionalism, clinical judgment, counseling, organization and efficiency, and overall competence were evaluated. RESULTS: Residents were assessed in various clinical settings

with a diverse set of patient problems. Residents received the lowest ratings in the physical examination and the highest ratings in professionalism. Comparisons over the first year of training showed statistically significant improvement in all aspects of competence, and the method generated reliable ratings. CONCLUSIONS: The measurement characteristics of the mini-CEX are similar to those of other performance assessments, such as standardized patients. Unlike these assessments, the difficulty of the examination will vary with the patients that a resident encounters. This effect is mitigated to a degree by the examiners, who slightly overcompensate for patient difficulty, and by the fact that each resident interacts with several patients. Furthermore, the mini-CEX has higher fidelity than these formats, permits evaluation based on a much broader set of clinical settings and patient problems, and is administered on site.

Patenaude,-J; Niyonsenga,-T; Fafard,-D. Changes in students' moral development during medical school: a cohort study. CMAJ. 2003 Apr 1; 168(7): 840-4.INTRODUCTION: The requirements of professionalism and the expected qualities of medical staff, including high moral character, motivate institutions to care about the ethical development of students during their medical education. We assessed progress in moral reasoning in a cohort of medical students over the first 3 years of their education. METHODS: We invited all 92 medical students enrolled at the University of Sherbrooke, Que., to complete a questionnaire on moral reasoning at the start of their first year of medical school and at the end of their third year. We used the French version of Kohlberg's Moral Judgment Interview. Responses to the questionnaire were coded by stage of moral development, and weighted average scores were assigned according to frequency of use of each stage. RESULTS: Of the 92 medical students, 54 completed the questionnaire in the fall of the first year and again at the end of their third year. The average age of the students at the end of the third year was 21 years, and 79% of the students included in the study were women. Over the 3-year period, the stage of moral development did not change substantially (i.e., by more than half a stage) for 39 (72%) of the students, shifted to a lower stage for 7 (13%) and shifted to a higher stage for 8 (15%). The overall mean change in stage was not significant (from mean 3.46 in year 1 to 3.48 in year 3, p = 0.86); however, the overall mean change in weighted average scores showed a significant decline in moral development (p = 0.028). INTERPRETATION: Temporal variations in students' scores show a levelling process of their moral reasoning. This finding prompts us to ask whether a hidden curriculum exists in the structure of medical education that inhibits rather than facilitates the development of moral reasoning.

Robins,-L-S; Braddock,-C-H 3rd; Fryer-Edwards,-K-A. Using the American Board of Internal Medicine's "Elements of Professionalism" for undergraduate ethics education. Acad-Med. 2002 Jun; 77(6): 523-31.PURPOSE: To examine the feasibility of using the taxonomy of professional and unprofessional behaviors presented in the American Board of Internal Medicine's (ABIM's) Project Professionalism to categorize ethical issues that undergraduate medical students perceive to be salient. METHOD: Beginning second-year medical students at the University of Washington School of Medicine (n = 120) were asked to respond to three open-ended questions about professional standards of conduct and peer evaluation. Two of the authors read and coded the students' responses according to the ABIM's elements of professionalism (altruism, accountability, excellence, duty, honor and integrity, and respect for others) and the challenges to those elements (abuse of power, arrogance, greed, misrepresentation, impairment, lack of conscientiousness, and conflict of interest). Coding disagreements were solved using review and revision of the category definitions. New categories were created for students' responses that described behaviors or issues that were not captured in the ABIM's categories. RESULTS: A total of 114 students responded. The ABIM's professional code was adapted for students and teachers, making it context- and learning-stage-specific. One new category of challenges, conflicts of conscience, was added, and one category (abuse of power) was expanded to include abuse of power/negotiating power asymmetries.

CONCLUSIONS: Using the ABIM's taxonomy to name professional and unprofessional behaviors was particularly useful for examining undergraduate medical students' perceptions of the ethical climate for learning during the first year of medical school, and it holds promise for research into changes in students' perceptions as they move into clinical experiences. Using the framework, students can build a unified professional knowledge-and-skills base.

Siegler,-M. Training doctors for professionalism: some lessons from teaching clinical medical ethics. Mt-Sinai-J-Med. 2002 Nov; 69(6): 404-9.Medical professionalism encourages physicians to place their patients’ interests above self-interest. In recent years, many medical organizations, including the American Board of Internal Medicine (ABIM), Association of American Medical Colleges (AAMC), and the American Medical Association (AMA), have developed initiatives to strengthen medical professionalism. By emphasizing professionalism, supporters of these initiatives hope that medicine and physicians may recapture professional autonomy, decrease public criticism of medicine and physicians, and help physicians regain the moral high ground in the unending struggle with payers, both public and private. One crucial question facing medical educators is whether the concepts of professionalism can be taught to medical students and residents. This paper draws upon the author s thirty years of experience in teaching clinical medical ethics to provide guidance on how to teach the concepts of professionalism to students and residents.

Sklar,-D-P; Doezema,-D; McLaughlin,-S; Helitzer,-D. Teaching communications and professionalism through writing and humanities: reflections of ten years of experience. Acad-Emerg-Med. 2002 Nov; 9(11): 1360-4.Both professionalism and interpersonal communication are core competencies for emergency medicine residents as well as residents from other specialties. The authors describe a weekly, small-group seminar lasting one year for emergency medicine residents that incorporates didactic materials, case studies, narrative expression (stories and poems), and small-group discussion. Examples of cases and narrative expressions are provided and a rationale for utilizing the format is explained. A theoretical model for evaluation measures is also included.

Stephenson,-A; Higgs,-R; Sugarman,-J. Teaching professional development in medical schools. Lancet. 2001 Mar 17; 357(9259): 867-70.AB: Doctors must increasingly be aware of what they should be, as well as what they should know. Professionalism, including a value system that supports the compassionate care of patients, is a means of encapsulating and prioritising these competing responsibilities. Accordingly, in this article, we assume that professionalism is an essential aspect of medical practice that needs to be taught to those entering medicine. We first describe critiques of professionalism and current challenges to it, in practice and in medical education. We then assess the current efforts of curriculum reform to incorporate professionalism and the methods used to teach it. Adopting and assessing such approaches to ensure that they are effective is of central importance in the education of future clinicians.

Surdyk,-P-M. Educating for professionalism: what counts? Who's counting? Camb-Q-Healthc-Ethics. 2003 Spring; 12(2): 155-60.

Wallach,-P-M; Roscoe,-L; Bowden,-R. The profession of medicine: an integrated approach to basic principles. Acad-Med. 2002 Nov; 77(11): 1168-9.OBJECTIVE: The University of South Florida College of Medicine developed and implemented an innovative three-week course entitled, "The Profession of Medicine: An Integrated Approach to Basic Principles" to introduce new medical students to topics and skills that are important to their successful study of medicine. Demonstrating the clinical relevance of the

basic sciences, the importance of lifelong learning, and ethics and professionalism in medicine were emphasized. Basic physical examination techniques, searching the medical literature and evidence-based medicine, and study and computer skills were introduced in addition to traditional orientation topics. DESCRIPTION: Four interdisciplinary "state of the art" presentations demonstrated the importance of lifelong learning and the clinical relevance of basic science concepts. Lectures on acute myocardial infarction, breast cancer, duodenal ulcer, and pulmonary prematurity were presented as if the lectures were being given in 1980. Students attended lectures on basic science principles relevant to these topics, and then met in small groups with librarians, content experts, and small-group facilitators to begin investigating an assigned topic. For example, student groups researched the development of EMS and chest pain centers, thrombolysis and percutaneous coronary intervention, and the psychological implications of acute myocardial infarction for patients and families. Students were introduced to effective literature-searching techniques, the tenets of evidence-based medicine, and effective computer skills in the context of studying their assigned topics. Each group then selected a student presenter to deliver an eight-minute PowerPoint presentation of its 2001 "state of the art" findings, making particular note of scientific advances and new therapeutic protocols developed since 1980, such as the use of artificial surfactant in premature babies, the role of H. pylori in duodenal ulcers, and the discovery of the genetics of breast cancer. These projects as well as a series of small-group educational programs enabled students and faculty to develop a strong sense of team-work and cohesiveness. Students had opportunities to practice components of the history and physical examination on standardized patients relevant to the four clinical topic areas, such as cardiac and abdominal examinations with emphasis on anatomic principles. Basic ethical principles and their application to cases that pertained to the four clinical topics were introduced, and students participated in a small-group ethics case conference. Throughout the course, students and faculty were required to wear specially designed nametags. By the time the course concluded with the White Coat ceremony, the 75 participating faculty and 104 students knew one another, making the ceremony particularly meaningful. DISCUSSION: The pace at which scientific findings revolutionize the practice of medicine continues to accelerate. While it is important for undergraduate medical students to master the basic and clinical science foundations of medical practice, it may be even more important to teach students how to find and interpret medical information, form professional relationships with mentors and peers, and make a commitment to lifelong learning and professionalism. It is critical that students understand that the curricular program at any college of medicine is only the beginning of a life of study.

Welling,-R-E; Boberg,-J-T. Professionalism: lifelong commitment for surgeons. Arch-Surg. 2003 Mar; 138(3): 262-4; discussion 264.Presently, there is a major initiative to rekindle the humanistic qualities in the practice of medicine. Although there have been many suggestions on ways to rejuvenate this initiative, it has not been a primary focus of graduate medical education until recently. Surgery residents are expected to maintain a high standard of ethical behavior; demonstrate a commitment to continuity of patient care; and demonstrate sensitivity to the age, gender, and culture of patients and fellow health care professionals. We in surgical education must accept the responsibility for the renewal in teaching and evaluating the professional and ethical principles of surgery residents. This change will not happen quickly, but it should be done skillfully because future generations will look back on this time of renewal in medicine and critique us on our ability or inability to achieve this goal.

Yates,-S. Finding your funny bone. Incorporating humour into medical practice. Aust-Fam-Physician. 2001 Jan; 30(1): 22-4.BACKGROUND: Many people confuse seriousness with professionalism. Humour enables you to separate who you are from the difficult work you do. OBJECTIVE: To illustrate ways humour and fun can be incorporated into day to day working life. DISCUSSION: People are more productive, cooperative and flexible when they have fun at work. Becoming a humour

consumer of tapes, jokes, TV shows, movies or funny books, strengthens your sense of humour, relieves stress and improves relationships.

Professionalism

Curriculum Committee Working Group for General Competency Curriculum Development

Committee Members: Earl J. ReisdorffGregory L. Walker, Program Director Jane Sbalchiero, Director of Education

Submitted to Faculty Training Committee Date: _________

Approved by Faculty Training Committee Date: _________

Approved by Sponsoring Institution GMEC Date: _________

Section 2Introduction to Professionalism

Professionalism in Emergency Medicine Training

The Context:

No one comes to the emergency department because they’re having a good day.-- Anonymous

Healthcare workers at all levels of the medical system often quickly forget that the system exists to serve the individual patient.

Dr. Greg Henry in Emergency Medicine Risk Management 1991 pg 5.

They [the public] expect that the healing professionals will treat patient with dignity and will regard patients’ welfare as their principal concern.

JM Merrill South Med J 1987;80:1211.

Our character is what we are doing when no one is looking.-- H. Jackson Browne

General Principles

Emergency medicine already embraces and teaches Professionalism.[Reisdorff EJ, et. al. Acad Emerg Med 2003;10:1049] A multi-center trial involving 5 programs and 150 residents confirmed the intrinsic inclusion of Professionalism as a competency in emergency medicine residencies. Specifically, acquisition of skills, expertise, and knowledge in Professionalism occurs in EM programs. EM1 scores where lowest and EM3 scores were the highest (p >.001).

Given the aforementioned results, one must be somewhat cautious in significantly modifying the curricula of residency training programs. On could errantly force EM to stray from a current process that seems to assure the acquisition of the GCs.

Section 3ACGME Definitions Professionalism

ACGME Definitions

PROFESSIONALISM

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:

demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development

demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices

demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities

http://www.acgme.org/outcome/comp/compFull. asp. Accessed October 31, 2003

Section 4Core Content (E.g., items from the Clinical Model of Emergency Medicine, Code of Conduct for Academic Emergency Medicine, American College of Emergency Physicians Code of Ethics, Academic Emergency Medicine Series, Ethics Curriculum for Emergency Medicine Residencies, SAEM Ethics Committee 1994)

Professional Dimensions of Emergency Medicine (Modified from Larkin GL, et. al. Acad Emerg Med 2002;9:1249-56)

Ethics

Professional Codes of Ethics

Fundamentals of Medical Ethics

Legal Ethical IssuesSigning out against Medical Advice Informed consent

Documentation / Billing Requirements

ConfidentialityIncluding HIPPA

Sensitivity to Diverse Populations Age, Race, Sex, Religion, Socio-economically disadvantaged, developmentally delayed, chemically dependant, etc.

Business Conflicts Relationships with pharmaceutical companies and medical supply companies

Executes clinical responsibilities Administrative expectationsTreating colleagues fairly

Section 5Goals and Objectives for Professionalism

General Goals and Objectives

Ethics

The emergency medicine resident will:

Understand the following terms/concepts: beneficence, maleficence, non-maleficence, justice and autonomy.

Read and understand the Ethics Curriculum for Emergency Medicine Residencies, (SAEM Ethics Committee 1994)

Read and understand the Code of Conduct for Academic Emergency Medicine (Acad Emerg Med 1999;6:45)

Read and understand the American College of Emergency Physicians Code of Ethics

Legal Ethical Issues

The emergency medicine resident will:

Understand the concept of competency for medical decision making

Understand the process of- and criteria for signing out against medical advice

Understand the concept of informed consent (including explaining invasive procedures for families)

Documentation / Billing Requirements

The emergency medicine resident will:

Understand the ethical implications of accurate documentation, especially as it pertains to billing

Confidentiality

The emergency medicine resident will:

Understand the importance of patient confidentiality, including adherence to HIPPA

Sensitivity to Diverse Populations

The emergency medicine resident will:

Understand the patient differences regarding age, race, sexual orientation, religious affiliations, socioeconomic circumstances, developmental delays, and chemical addiction.

Display sensitivity to patients, including issues regarding age, race, sexual orientation, religious affiliations, socioeconomic circumstances, developmental delays, and chemical addiction.

Business Conflicts

The emergency medicine will:

Understand the ethical and socially appropriate relationship with pharmaceutical companies and medical supply companies

Executes Clinical Responsibilities

The emergency medicine will:

Follow general practices of clinical responsibilities including, coming to work on time, working throughout the entire shift, maintains a medical (professional) decorum

Treat colleagues fairly

Section 6Matrix Strategy for Implementation

Core Content Area

Experiential Didactic Reading Special Methods

Ethics

Understand beneficence, maleficence, non-maleficence, justice and autonomy.

Read and understand the Ethics Curriculum for Emergency Medicine Residencies, (SAEM Ethics Committee 1994)

Read and understand the Code of Conduct for Academic Emergency Medicine

Read and understand the American College of Emergency Physicians Code of Ethics

Introduction to ethics lecture (1-2 hours each year)

Journal club (“Medical Error During Residency: To Tell or Not to Tell” Ann Emerg Med 2003;42:565)

Tintinalli (ch. 17) Rosens (ch. 198,199)

Ethics Curriculum for Emergency Medicine Residencies (SAEM Ethics Committee 1994)

Code of Conduct for Academic Emergency Medicine (Acad Emerg Med 1999;6:45)

American College of Emergency Physicians Code of Ethics

Discussion of ethical behavior and program expectations during orientation, including sexual harassment

Legal Ethical Issues

Understand competency for medical decision making

Understand process of- and criteria for signing out AMA

Understand concept of informed consent (including explaining procedures)

Medico-legal issues (competency, AMA, and informed consent)

Ethics Curriculum for Emergency Medicine Residencies (SAEM Ethics Committee 1994)

American College of Emergency Physicians Code of Ethics

Documentation / Billing Requirements

Understand ethical implications of accurate documentation, especially as it

Lecture on billing and coding

American College of Emergency Physicians Code of Ethics

pertains to billing

Confidentiality

Understand importance of patient confidentiality, including adherence to HIPPA

HIPPA training during orientation

Ethics Curriculum for Emergency Medicine Residencies (SAEM Ethics Committee 1994

American College of Emergency Physicians Code of Ethics

Attend HIPPA training during orientation

Sensitivity to Diverse Populations

Understand pt. differences, i.e., age, race, sexual orientation, religious affiliations, socioeconomic circumstances, developmental delay, and chemical addiction.

Display sensitivity to pts., issues regarding age, race, sexual orientation, religious affiliations, socioeconomic circumstances, developmental delays, and chemical addiction.

Tintinalli (chs. 306-311)

Rosen’s (chs. 160, 181, 195, 197)

Sensitivity Training During Orientation

Business Conflicts

Understand the ethical and socially appropriate relationship with pharmaceutical companies and medical supply companies

American College of Emergency Physicians Code of Ethics

Review FDA Guidelines during orientation

Executes Clinical Responsibilities

Follow general practices of clinical responsibilities including, coming to work on time, working throughout the entire shift, maintains a medical (professional) decorum

Tintinalli (chs. 296)

Rosens (chs. 201)

Review clinical responsibilities and intra-residency relationships during orientations

Treat colleagues fairly

Curriculum Elements for Professionalism

Experiential

Resident will rotate on several different non-EM/ED rotations. In these arenas, the resident will be exposed a diverse population of patients (requiring a demonstration of sensitivity) as well as a number of clinical situations posing ethical concerns.

Expectations and guidelines for the execution of clinical responsibilities are out-lined for every rotation.

Resident will rotate extensively in the ED while on the EM rotation. In these arenas, the resident will be exposed a diverse population of patients (requiring a demonstration of sensitivity) as well as a number of clinical situations posing ethical concerns.

A host of professionalism issue will be reviewed during residency orientation during the annual orientation for the individual sessions for the sponsoring hospital, participating institution hospital, and EM residency.

Didactic

Key lectures to consider would involved the following areas:o Ethics (basic principles, applicable codes of conduct for emergency physicians) o Medical – Legal concerns (especially regarding informed consent, capacity for

medical decision making, and leaving against medical advice) o Patient confidentiality, including adherence to HIPPA regulationso Demonstrating sensitivity to patient differences, especially as they relate to age,

race, sexual orientation, religious affiliations, socioeconomic circumstances, developmental delay, and chemical addiction.

Reading

Selected chapters, monographs (e.g., Emergency Medicine Clinics of North America, EM Reports), and review articles should be selected for required reading during residency. The core text will be Tintinalli JE, Kelen G, Stapczynski JS. Emergency Medicine: A Comprehensive Study Guide in Emergency (6th ed.). New York, McGraw-Hill, 2004. Also the residents must read the attached documents including but nit limited to Ethics Curriculum for Emergency Medicine Residencies (SAEM Ethics Committee 1994), Code of Conduct for Academic Emergency Medicine (Acad Emerg Med 1999;6:45), and the American College of Emergency Physicians Code of Ethics (see www.acep.org).

Topics consider for reading may include the following: o General principles of ethics (including ethics of resuscitation)o End-of-life care o Medical concerns of- and interactions with diverse populations (including patients

with substance abuse problems, elderly patients, pediatric patients, patients with physical disabilities, patients with developmental delay, the homeless patient, the morbidity obese patient,

o Physician wellness and well-being (including physician stress and the impaired physician)

o The social role of emergency medicine o Multiculturalism and care delivery

Primary readings are from Tintinalli JE, Kelen GD, Stapczynski JS (eds). Emergency Medicine. A Comprehensive Study Guide (6th ed.). New York, McGraw-Hill 2004.Ethical issues of resuscitation Ch. 17 (p. 99) Marco CA Physician well-being Ch. 296 (p. 1841) Koltonow SHInjection drug users Ch. 306 (p. 1891) Baumann BM, Shepard SM The elder patient Ch. 307 (p. 1896) Saunders ABAdults with physical disabilities Ch. 308 (p. 1900) Tawney PJW, Oh JNThe mentally retarded patient Ch. 309 (p. 1903) Sikich L The homeless patient Ch. 310 (p. 1906) Rao RB, Goldfrank LRThe Morbidly Obese Patient Ch. 311 (p. 1908) Vissers RJ, Raftery KA

Secondary readings are from Marx JA, Hockberger RS, Walls RM (eds). Rosen’s Emergency Medicine. Concepts and Clinical Practice (5th ed.) St. Louis, Mosby, 2002.

General approach to the pediatric patient Ch. 160 (p. 2218) Austin PE

Evaluation of the developmentally and physically disabled patient Ch. 181 (p. 2546) Cydulka RK, Stephan M.

The social role of emergency medicine Ch. 195 (p. 2705) Gordon JAMulticulturalism and care delivery Ch. 197 (p. 2715) Bernstein E, Bernstein J, James T Bioethics Ch. 198 (p. 2725) Iserson KV End of life Ch. 199 (p. 2734) Honigman B, Armstrong JD IIIWellness, stress, and the impaired

physician Ch. 201 (p. 2761) Goldberg R

Code of Ethics for Emergency Physicians (Approved by the ACEP Board of Directors June 1997; Reaffirmed October 2001 by ACEP Board of Directors) Attached

A Concise Curriculum in Medical Ethics *(* Developed from the Ethics Curriculum for Emergency Medicine Residencies; SAEM Ethics Committee 1994) Attached

A Code of Conduct for Academic Emergency Medicine (Larkin GL for the SAEM Ethics Committee. Acad Emerg Med 1999;6:45) Attached

Section 7Evaluation Processes

Evaluation Considerations Monthly evaluations should reflect the general tenets of the GCs, including Professionalism.

Twice yearly, Professionalism items should be assessed in a more detailed fashion.

Certain lectures (e.g., Ethics) can have a pre- or post-test administered.

Several issues regarding Professionalism are addressed during orientation. The discussion of these items should be recorded. This most likely would take the form of a signed letter of understanding. Another alternative would be a binary scoring strategy (e.g., of Yes/No).

When able, validated evaluation items should be considered for assessing Professionalism.

Section 8Potential Evaluation Items TABLE 1.

Evaluation Items for Professionalism (Italics designate validated items)

Professionalism

Ethics Adheres to ethical principles in emergency medicine Reviewed the ethics curriculum (CORD) Avoids negative, nonproductive remarks about hospital staff Avoids nonproductive, condescending remarks about other

medical fields Avoids the use of profanity Demonstrates caring and empathy Treat all patients with dignity Uses the words beneficence, non-maleficence, medical futility, and autonomy in discussions about ethical issues The resident understands the ethics terms/concepts of beneficence, maleficence, non-

maleficence, justice, and autonomy. The resident has read the Ethics Curriculum for Emergency Medicine Residencies,

(SAEM Ethics Committee 1994) The resident has read the Code of Conduct for Academic Emergency Medicine The resident has read the American College of Emergency Physicians Code of Ethics Understand beneficence, malifecence, non-maleficience, justice and autonomy Read and understand the Ethics Curriculum for Emergency Medicine Residencies,

(SAEM Ethics Committee 1994)Read and understand the Code of Conduct for Academic Emergency Medicine

Read and understand the American College of Emergency Physicians Code of Ethics

Legal Ethical Issues Fairly assesses patients on issues of competency regarding medical decision making

capacity The resident understands the concept of competency for medical decision making The resident understands the process of- and criteria for signing out against medical

advice The resident understands the concept of informed consent (including explaining invasive

procedures for families) Understand competency for medical decision making Understand process of- and criteria for signing out AMA Understand concept of informed consent (including explaining procedures)

Documentation / Billing Requirements

Medical records are finished promptly Medical records are legible Medical records complete The resident understands the ethical implications of accurate documentation,

especially as it pertains to billing Understand ethical implications of accurate documentation, especially as it pertains to

billing

Confidentiality Maintains patient confidentiality The resident understand the importance of patient confidentiality, including adherence to

HIPPA Understand importance of patient confidentiality, including adherence to HIPPA

Sensitivity to Diverse Populations Demonstrates sensitivity to a diverse population Avoids the use of language and humor that mocks or demeans others Introduces her/himself to all family members in the room Introduces her/himself to patient The resident understands patient differences regarding age, race, sexual orientation,

religious affiliations, socioeconomic circumstances, developmental delays, and chemical addiction.

The resident displays sensitivity to patients, including issues regarding age, race, sexual orientation, religious affiliations, socioeconomic circumstances, developmental delays, and chemical addiction.

Business Conflicts Places patient interests above financial self-interests The resident understands the ethical and socially appropriate relationship with

pharmaceutical companies and medical supply companies

Executes Clinical Responsibilities Administrative paperwork done correctly and efficiently Arrives to work on time Dress is neat, clean, and appropriate Works throughout entire shift Maintains a professional decorum at all times Participates in education meetings / residency conferences Participates in administrative aspects of residency Demonstrates behaviors conducive to resident wellness

Demonstrates positive and professional interactions with faculty and staff Treats colleagues fairly

Evaluation Matrix – Professionalism

Core Content Objective Item Evaluation Process

Frequency

Ethics

Understand beneficence, maleficence, non-maleficence, justice and autonomy.

Read and understand the Ethics Curriculum for Emergency Medicine Residencies, (SAEM Ethics Committee 1994)

Read and understand A Code of Conduct for Academic Emergency Medicine

Read and understand the American College of Emergency Physicians Code of Ethics

Not applicable

Read the curriculum

Read the Code of Conduct

Read the Code of Ethics

Competes Professionalism Workbook

Signed a letter of attestation that he/she read it

Signed a letter of attestation that he/she read it

Signed a letter of attestation that he/she read it

Once during EM1 or EM2 year

Once during EM1 or EM2 year

Once during EM1 or EM2 year

Once during EM1 or EM2 year

Legal Ethical Issues

Understand competency for medical decision making

Understand process of- and criteria for signing out AMA

Understand concept of informed consent (including explaining procedures)

Read and understand the Ethics Curriculum for Emergency Medicine Residencies, (SAEM Ethics Committee 1994)

Read and understand the American College of Emergency Physicians Code of Ethics

Competes Professionalism Workbook

Signed a letter of attestation that he/she read the required ethics materials

Once during EM1 or EM2 year

Once during EM1 or EM2 year

Documentation / Billing Requirements

Understand ethical implications of accurate documentation, especially as it pertains to billing

Read and understand the Ethics Curriculum for Emergency Medicine Residencies, (SAEM Ethics Committee 1994)

Read and understand the American College of Emergency Physicians Code of Ethics

Medical records are finished promptly

Competes Professionalism Workbook

Signed a letter of attestation that he/she read the required ethics materials

Global composite evaluation form (see Acad Med 2001;76:753-57)

Once during EM1 or EM2 year

Once during EM1 or EM2 year

Every Six Months

Confidentiality

Understand importance of patient confidentiality, including adherence to HIPPA

Medical records complete

Medical records finished promptly

Medical records are legible (including prescriptions, etc.)

Global composite evaluation form (see Acad Med 2001;76:753-57)

Every Six Months

Sensitivity to Diverse Populations

Understand pt. differences, i.e., age, race, sexual orientation, religious affiliations, socioeconomic circumstances, developmental delay, and chemical addiction.

Display sensitivity to pts., issues regarding age, race, sexual orientation, religious affiliations,

Demonstrates sensitivity to a diverse population

Global composite evaluation form (see Acad Med 2001;76:753-57)

Every Six Months

socioeconomic circumstances, developmental delays, and chemical addiction.

Business Conflicts Places patient

interests above financial self-interests.

The resident understands the ethical and socially appropriate relationship with pharmaceutical companies and medical supply companies.

Read and understand the Ethics Curriculum for Emergency Medicine Residencies, (SAEM Ethics Committee 1994)

Read and understand the American College of Emergency Physicians Code of Ethics

Competes Professionalism Workbook

Signed a letter of attestation that he/she read the required ethics materials

Once during EM1 or EM2 year

Once during EM1 or EM2 year

Executes Clinical Responsibilities

Follow general practices of clinical responsibilities including, coming to work on time, working throughout the entire shift, maintains a medical (professional) decorum

Treat colleagues fairly

Administrative paperwork done correctly and efficiently.

Arrives to work on time.

Dress is neat, clean, and appropriate.

Works throughout entire shift.

Participates in administrative aspects of residency.

Maintains a professional decorum at all times.

Demonstrates behaviors conducive to resident wellness.

Demonstrates positive and professional interactions with

Global composite evaluation form (see Acad Med 2001;76:753-57)

Every Six Months

faculty and staff.

The resident will treat colleagues fairly.

Section 9Articles for Consideration Selected Abstracts with Application to Professionalism

Anonymous. Medical professionalism in the new millennium: a physicians' charter*. Clin-Med. 2002 Mar-Apr; 2(2): 116-8.The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges centre on increasing disparities between the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform healthcare systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients' interests. To maintain the fidelity of medicine's social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the healthcare system for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an action agenda for the profession of medicine that is universal in scope and purpose.

Anonymous. Issues in medical ethics. Understanding professionalism and its implications for medical education. Proceedings of a conference. New York City, New York, USA. November 3, 2000. Mt-Sinai-J-Med. 2002 Nov; 69(6): 354-420.

Arnold,-L. Assessing professional behavior: yesterday, today, and tomorrow. Acad-Med. 2002 Jun; 77(6): 502-15.PURPOSE: The author interprets the state of the art of assessing professional behavior. She defines the concept of professionalism, reviews the psychometric properties of key approaches to assessing professionalism, conveys major findings that these approaches produced, and discusses recommendations to improve the assessment of professionalism. METHOD: The author reviewed professionalism literature from the last 30 years that had been identified through database searches; included in conference proceedings, bibliographies, and reference lists; and suggested by experts. The cited literature largely came from peer-reviewed journals, represented themes or novel approaches, reported qualitative or quantitative data about measurement instruments, or described pragmatic or theoretical approaches to assessing professionalism. RESULTS: A circumscribed concept of professionalism is available to serve as a foundation for next steps in assessing professional behavior. The current array of assessment tools is rich. However, their measurement properties should be strengthened. Accordingly, future research should explore rigorous qualitative techniques; refine quantitative assessments of competence, for example, through OSCEs; and evaluate separate elements of professionalism. It should test the hypothesis that assessment tools will be better if they define professionalism as behaviors expressive of value conflicts, investigate the resolution of these conflicts, and recognize the contextual nature of professional behaviors. Whether measurement tools should be tailored to the stage of a medical career and how the environment can support or sabotage the assessment of professional behavior are central issues. FINAL THOUGHT: Without solid assessment tools, questions about the efficacy of approaches to educating learners about professional behavior will not be effectively answered.

Ber,-R; Alroy,-G. Teaching professionalism with the aid of trigger films. Med-Teach. 2002 Sep; 24(5): 528-31.Medical professionalism includes expert knowledge, self-regulation and fiduciary responsibility to place the needs of patients ahead of the self-interest of physicians. In

teaching medical professionalism to our medical students only the behavioural elements are dealt with. One of the challenges facing medical educators today is how medical professionalism can be taught. At the authors' faculty of medicine brief videotapes (trigger films) of amateur actor physician-patient encounters in various clinical settings (taken from genuine encounters) are used as a stimulus for discussion and instruction of medical professionalism. A series of 16 trigger films has been produced that raise many medical professional issues. The films and the issues raised are described in brief. These trigger films are viewed by small groups of medical students together with a physician tutor facilitator at various stages of their studies. It is noteworthy how fast the transition occurs in students, from observing the trigger films in their pre-clinical stage as a client, to observing them in their clinical years from the angle of a provider; from identifying with the patient's concerns to identifying with the physicians' behaviour; from being a critical person to becoming a person who accepts the rules and regulations of the guild. Most probably the power of the teaching of ethical and professional rules is overruled by the power of everyday clinical experience during their clinical clerkships. It is planned to run a series of trigger film sessions with senior and junior physicians of the major clerkships, in an attempt to promote an institutional environment/atmosphere/culture of professional behaviour.

Bloom,-S-W. Professionalism in the practice of medicine. Mt-Sinai-J-Med. 2002 Nov; 69(6): 398-403.Although medicine is universally recognized as the archetype of the professions, it can only be understood as part of the modern medical center, a dynamic social system consisting of the university, the hospital, the medical center and, most recently, corporate managed care. Such a view results in a portrait of medicine as a profession transformed, driven by huge and growing health care markets, its fate tied not only to state bureaucracies, but also to the dynamics of both health and non-health care businesses. The question asked here is how does such a radical change in medical practice affect medical education?. Using methods of historical analysis, it appears that medical educators operate as though the educational process itself determines the values, and therefore the present and future behavior of their students. In other words, at the end of their formal education, doctors are fully formed professionals. However, from the analysis of this paper it can be concluded that the physician as an individual cannot function independently of the structure of the society and its general conception of the world. In the structure of medicine s present situation, the ethical standards of professionalism, as they are classically defined, cannot survive. Instead, modern medical graduates, much like their teachers and professional mentors, will be forced to adapt to a situation that is contradictory to the best traditions of medicine. How to stop this process is the urgent question. Three answers are presented.

Chervenak,-F-A; McCullough,-L-B. Professionalism and justice: ethical management guidelines for leaders of academic medical centers. Acad-Med. 2002;77(1): 45-7. Academic health centers (AHCs) exist for the sake of pursuit of excellence in their missions of patient care, teaching, and research. Survival should be a means to these goals and not an end unto itself. Because of the fiscal crisis in health care, leaders of AHCs face the possible diminution or even extinction of their centers. When preventing such a fate becomes the governing concern of these leaders, power concentrates in their hands and can be used to force cooperation among competing faculty members and groups for the sake of mutual survival. The ethical concepts of professionalism and justice can be used to create a vital, practical, alternative vision for the leadership of AHCs, in which their missions once again become central to their organizational culture. Creating a morally sustainable organizational culture of professionalism and justice should rely not on forced cooperation, but on voluntary cooperation of all stakeholders in the pursuit of a common goal-professional excellence in patient care, teaching, and research-with survival understood to be a means to this goal. To achieve this alternative vision, the authors propose five management guidelines. For example, all faculty should be made accountable

not only for maximizing the good of the organization's professionalism but also for fostering financial viability.

Chisholm,-C-D; Whenmouth,-L-F; Daly,-E-A; Brizendine,-E-J; Cordell,-W-H. A comparison of faculty contact time with emergency medicine residents in different teaching venues. Acad-Emerg-Med. 2003 May; 10(5): 472.AB: OBJECTIVE: Emergency Medicine (EM) residencies must implement the 6 ACGME core competencies by 2006. EM educators recommend direct observation (DO) as the optimal evaluation tool for 4 of the 6 core competencies (Patient Care, Systems-Based Practice, Interpersonal and Communication Skills, and Professionalism). The 24/7 faculty presence in the Emergency Department (ED) is believed to facilitate DO as an assessment technique. METHODS: Observational study of faculty contact in 2 EDs, 2 trauma services, inpatient medicine, adult & pediatric ICUs, and a pediatric outpatient clinic (UVC). Faculty contact was categorized as DO of patient care, indirect patient care, or non-patient care activities using a priori definitions. EM residents were shadowed for 2-hour intervals. Subjects were blinded to the nature of the study and data gathering was encrypted. RESULTS: 270 observation periods of 2 hours each were conducted, sampling 32 EM R1, 33 EM R2-3, 41 EM and 38 non-EM faculty. Total faculty contact time ranged from a maximum of 30% (95% CI = 20, 41) in the pediatric ICU to a minimum of 10% (3, 16) on internal medicine wards. Overall ED faculty contact was 20% (18, 22). DO by faculty ranged from a high of 5% (3, 8) in the pediatric UVC to a low of 1% (0, 2) on internal medicine wards. Overall ED DO was 3.6% (2.6, 4.7). ED DO did not vary across EMR level or by site. DO varied by treatment area within the ED with the critical area being substantially higher (6%) when compared with the non-critical care areas (1%). CONCLUSIONS: Direct observation of EM residents was low in all training venues studied. Overall DO was the highest in ED critical care areas and lowest on medicine ward rotations. EM faculty who are already involved in routine teaching, supervision, and patient care rarely performed DO in spite of their immediate physical presence 24/7. This suggests that alternative strategies may be required to assess core competencies through direct observation in the Emergency Department.

Epstein,-R-M; Hundert,-E-M. Defining and assessing professional competence. JAMA. 2002 Jan 9; 287(2): 226-35.CONTEXT: Current assessment formats for physicians and trainees reliably test core knowledge and basic skills. However, they may underemphasize some important domains of professional medical practice, including interpersonal skills, lifelong learning, professionalism, and integration of core knowledge into clinical practice. OBJECTIVES: To propose a definition of professional competence, to review current means for assessing it, and to suggest new approaches to assessment. DATA SOURCES: We searched the MEDLINE database from 1966 to 2001 and reference lists of relevant articles for English-language studies of reliability or validity of measures of competence of physicians, medical students, and residents. STUDY SELECTION: We excluded articles of a purely descriptive nature, duplicate reports, reviews, and opinions and position statements, which yielded 195 relevant citations. DATA EXTRACTION: Data were abstracted by 1 of us (R.M.E.). Quality criteria for inclusion were broad, given the heterogeneity of interventions, complexity of outcome measures, and paucity of randomized or longitudinal study designs. DATA SYNTHESIS: We generated an inclusive definition of competence: the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served. Aside from protecting the public and limiting access to advanced training, assessments should foster habits of learning and self-reflection and drive institutional change. Subjective, multiple-choice, and standardized patient assessments, although reliable, underemphasize

important domains of professional competence: integration of knowledge and skills, context of care, information management, teamwork, health systems, and patient-physician relationships. Few assessments observe trainees in real-life situations, incorporate the perspectives of peers and patients, or use measures that predict clinical outcomes. CONCLUSIONS: In addition to assessments of basic skills, new formats that assess clinical reasoning, expert judgment, management of ambiguity, professionalism, time management, learning strategies, and teamwork promise a multidimensional assessment while maintaining adequate reliability and validity. Institutional support, reflection, and mentoring must accompany the development of assessment programs.

Ginsburg,-S; Regehr,-G; Stern,-D; Lingard,-L. The anatomy of the professional lapse: bridging the gap between traditional frameworks and students' perceptions. Acad-Med. 2002 Jun; 77(6): 516-22.PURPOSE: To support students' developing professionalism, it is necessary to understand the professional challenges and dilemmas they perceive in the clinical setting. This study systematically documented and catalogued students' reports of professional lapses. METHOD: Six focus groups were conducted with senior medical students (n = 29) at three universities. Using a grounded-theory approach, three researchers analyzed the students' reports of specific lapses in professionalism for recurrent themes. The resulting coding structure was applied using NVivo qualitative data analysis software. RESULTS: A total of 120 pages of text yielded 48 specific incidents of professional lapses, which were analyzed by three researchers using grounded theory. Most incidents were witnessed (n = 34) or known about (n = 4), as opposed to self-reported (n = 10). Six critical "issues" emerged: communicative violations (to or about patients or other health care professionals); role resistance (individuals chafing against constraints or expectations of their perceived roles); objectification of patients (ignoring patients or treating patients as vehicles for learning); accountability (to colleagues or patients, including avoiding patients, failing to disclose information, or failing to treat appropriately); physical harm (to patients or others); and crossfire (being put in the middle of a struggle between superiors). CONCLUSIONS: This study explored how students experienced and operationalized professionalism in clinical settings at a variety of universities. Interestingly, the critical issues they reported as salient did not map easily onto standard, abstract definitions of professionalism. This incongruence suggested that the development of effective curricula in this domain must bridge the gap between traditional taxonomies and students' perceptions of professionalism.

Gordon,-J. Assessing students' personal and professional development using portfolios and interviews. Med-Educ. 2003 Apr; 37(4): 335-40.BACKGROUND AND PURPOSE: Medical schools are placing more emphasis on students' personal and professional development (PPD) and are seeking ways of assessing student progress towards meeting outcome goals in relation to professionalism. The Faculty of Medicine at the University of Sydney sought an assessment method that would demonstrate the value of reflection in attaining PPD, provide feedback and encourage students to take responsibility for setting and achieving high standards of performance. METHODS: The instruments used to assess Year 1 students in PPD are a portfolio and interview. This assessment format encourages students to explore ideas and values that are important to them and relevant to the PPD theme. A confidential interview, based on the PPD goals, is held with a faculty member who has read the student's portfolio. RESULTS: In 1997/98, 96% of students agreed that they had engaged in useful reflection on their approach to the course and 91% agreed that the experience was worthwhile. A further 76% of students agreed that they could see opportunities to modify their approach in some ways as result of this exercise. CONCLUSION: Sustained PPD is essential in equipping doctors for the varied stresses of careers in medicine. Despite, or perhaps because of, the latitude in the Year 1 assessment, both students and faculty members found the process of value. This form of assessment acknowledges that the most valid assessment formats cannot always be made reliable and that in some parts of the curriculum it is more important to demonstrate trust in

students' own motivation to become competent and mindful practitioners. The fact that the portfolio and interview are the only summative assessments in the first year emphasises the importance that the Faculty places on PPD.

Hatem,-C-J Teaching approaches that reflect and promote professionalism. Acad-Med. 2003 Jul; 78(7): 709-13.The teaching and cultivation of professionalism have long been part of medical education and have had recent special emphasis because professionalism has been identified as a core competency by the Accreditation Council for Graduate Medical Education. The author focuses on two complementary teaching initiatives that contribute to the development of professionalism in the academic environment: a resident-as-teacher program and an approach to faculty bedside teaching that mirrors and extends the lessons of the resident-as-teacher effort. These have been implemented and refined over the previous 15 years by the author and his colleagues at Mount Auburn Hospital in Cambridge, Massachusetts. The commitment to the development and refinement of residents' teaching skills serves to promulgate the fundamental elements of professionalism, with emphasis on caring and the educational well-being of the team. The author describes the elements and benefits of these approaches and shows how they can foster the development of professionalism in graduate medical education.

Hockberger RS, Binder LS, Graber MA, et. al. The model of the clinical practice of emergency medicine. Ann Emerg Med 2001;37:745-70.

Klein,-E-J; Jackson,-J-C; Kratz,-L; Marcuse,-E-K; McPhillips,-H-A; Shugerman,-R-P; Watkins,-S; Stapleton,-F-B. Teaching professionalism to residents. Acad-Med. 2003 Jan; 78(1): 26-34.The need to teach professionalism during residency has been affirmed by the Accreditation Council for Graduate Medical Education, which will require documentation of education and evaluation of professionalism by 2007. Recently the American Academy of Pediatrics has proposed the following components of professionalism be taught and measured: honesty/integrity, reliability/responsibility, respect for others, compassion/empathy, self-improvement, self-awareness/knowledge of limits, communication/collaboration, and altruism/advocacy. The authors describe a curriculum for introducing the above principles of professionalism into a pediatrics residency that could serve as a model for other programs. The curriculum is taught at an annual five-day retreat for interns, with 11 mandatory sessions devoted to addressing key professionalism issues. The authors also explain how the retreat is evaluated and how the retreat's topics are revisited during the residency, and discuss general issues of teaching and evaluating professionalism.

Larkin,-G-L; Binder,-L; Houry,-D; Adams,-J. Defining and evaluating professionalism: a core competency for graduate emergency medicine education. Acad-Emerg-Med. 2002 Nov; 9(11): 1249-56.Professionalism, long a consideration for physicians and their patients, is coming to the forefront as an essential element of graduate medical education as one of the six new core competency requirements of the Accreditation Council for Graduate Medical Education (ACGME). Professionalism is also integral to the widely endorsed Model of the Clinical Practice of Emergency Medicine (Model). Program directors have now been charged with implementing the new core competencies in training programs and to assess the acquisition of these competencies in their trainees. To assist emergency medicine (EM) program directors in this endeavor, the Council of Emergency Medicine Residency Directors (CORD-EM) held a consensus conference in March 2002. A focused Consensus Group addressed the specific core competency of professionalism during the course of this conference, and the results are highlighted in this article. The definition and curricular requirements relating to professionalism are highlighted, specific techniques for evaluating this core competency in

EM are reviewed, and recommendations are provided regarding the most appropriate assessment method for EM programs.

Larkin,-G-L; Marco,-C-A; Abbott,-J-T. Emergency determination of decision-making capacity: balancing autonomy and beneficence in the emergency department. Acad-Emerg-Med. 2001 Mar; 8(3): 282-4.AB: The determination of decision-making capacity (DMC) is an essential component of securing voluntary informed consent, for either treatment or refusal of care. Decision-making capacity should be determined on some level during each patient encounter. Decision-making capacity includes the ability to receive, process, and understand information, the ability to deliberate, the ability to make choices, and the ability to communicate those preferences. For patients in whom DMC may be uncertain, a more explicit approach to determination of DMC is recommended. However, DMC determination must neither compromise patient safety nor delay needed care. When DMC determination is challenging, or when the ramifications of a decision are serious, the assistance of a third party (such as a surrogate, a consultant, or another clinician) may be valuable in discerning the most appropriate action. In addition to the obvious clinical utility of DMC assessment, the steps taken in the very establishment of DMC may promote patient trust, professionalism, and humanistic clinical practice. While DMC may be conditional, the compassion and respect we have for our patients must be unconditional.

Li,-S-F; Haber,-M; Birnbaum,-A. Patient satisfaction and physician dress in the emergency department. Acad-Emerg-Med. 2003 May; 10(5): 550.BACKGROUND: To determine if patients' evaluations of EM physicians are influenced by their manner of dress. Past studies concerning patient responses to physicians' style of dress have been limited to clinic/in-patient settings, or were limited to preference by photographs. There is one study of patients' attitude toward ED physician attire, done in the UK, where patients did not show any preference of dress. We wish to determine if patient preferences are influenced by physicians' dress in our clinical setting, a U.S. urban hospital. METHODS: A cross-section, convenience sample of patients. Physician dress was recorded. Patients were asked to determine on a 100 mm VAS their evaluation of physician appearance, satisfaction, and professionalism. Dress styles were recorded as scrubs, dress shirt/pants, or mixed. We estimated 56 patients were needed to detect a 10% difference between groups based on an estimated mean of 75, sd of 10, 2-tailed alpha of.05, beta of.2. Comparison of scores between groups was done using one-way ANOVA, or Kruskal-Wallis when variances were unequal. Comparison of variances was done using the F test. Correlation between physician appearance and satisfaction or professionalism was done using Pearson's rho. RESULTS: 117 patients were surveyed. Physician dress style was 56% scrubs, 26% mixed, and 17% dress. There were no differences between patients' evaluation of appearance, satisfaction, or professionalism between the three groups (Table 1). There was poor correlation between ratings on dress and physician satisfaction (r(2) =.42) or professionalism (r(2) =.32). CONCLUSIONS: Physicians' dress style in the ED does not affect patients' evaluations of their performance.

Miles,-S-H. On a new charter to defend medical professionalism: whose profession is it anyway? Hastings-Cent-Rep. 2002 May-Jun; 32(3): 46-8.

Norcini,-J-J; Blank,-L-L; Duffy,-F-D; Fortna,-G-S. The mini-CEX: a method for assessing clinical skills. Ann-Intern-Med. 2003 Mar 18; 138(6): 476-81.OBJECTIVE: To evaluate the mini-clinical evaluation exercise (mini-CEX), which assesses the clinical skills of residents. DESIGN: Observational study and psychometric assessment of the mini-CEX. SETTING: 21 internal medicine training programs. PARTICIPANTS: Data from 1228 mini-CEX encounters involving 421 residents and 316 evaluators. INTERVENTION: The encounters were assessed for the type of visit, sex and complexity of the patient, when the encounter occurred, length of the encounter, ratings provided, and the satisfaction of the

examiners. Using this information, we determined the overall average ratings for residents in all categories, the reliability of the mini-CEX scores, and the effects of the characteristics of the patients and encounters. MEASUREMENTS: Interviewing skills, physical examination, professionalism, clinical judgment, counseling, organization and efficiency, and overall competence were evaluated. RESULTS: Residents were assessed in various clinical settings with a diverse set of patient problems. Residents received the lowest ratings in the physical examination and the highest ratings in professionalism. Comparisons over the first year of training showed statistically significant improvement in all aspects of competence, and the method generated reliable ratings. CONCLUSIONS: The measurement characteristics of the mini-CEX are similar to those of other performance assessments, such as standardized patients. Unlike these assessments, the difficulty of the examination will vary with the patients that a resident encounters. This effect is mitigated to a degree by the examiners, who slightly overcompensate for patient difficulty, and by the fact that each resident interacts with several patients. Furthermore, the mini-CEX has higher fidelity than these formats, permits evaluation based on a much broader set of clinical settings and patient problems, and is administered on site.

Reisdorff EJ, Hayes OW, Carlson DJ, Walker GL. Assessing the new ACGME general competencies for resident education: a model from an emergency medicine program. Acad Med 2001;76:753-57.

Reisdorff EJ, Hayes OW, Reeves M, Reynolds B, Carlson DJ, Walker G, Wilkinson KC, Overton DT, Wagner MJ, Kowalenko T, Portelli D. Determining distinct measures for the ACGME general competencies for emergency medicine (abstract). Acad Emerg Med 2003;10:457.

Reisdorff EJ, Reynolds B, Hayes OW, Wilkinson KC, Overton D, et. al. The ACGME general competencies are an intrinsic part of emergency medicine residency training – a multicenter experience. Acad Emerg Med 2003;10:049-53.

Robins,-L-S; Braddock,-C-H 3rd; Fryer-Edwards,-K-A. Using the American Board of Internal Medicine's "Elements of Professionalism" for undergraduate ethics education. Acad-Med. 2002 Jun; 77(6): 523-31.PURPOSE: To examine the feasibility of using the taxonomy of professional and unprofessional behaviors presented in the American Board of Internal Medicine's (ABIM's) Project Professionalism to categorize ethical issues that undergraduate medical students perceive to be salient. METHOD: Beginning second-year medical students at the University of Washington School of Medicine (n = 120) were asked to respond to three open-ended questions about professional standards of conduct and peer evaluation. Two of the authors read and coded the students' responses according to the ABIM's elements of professionalism (altruism, accountability, excellence, duty, honor and integrity, and respect for others) and the challenges to those elements (abuse of power, arrogance, greed, misrepresentation, impairment, lack of conscientiousness, and conflict of interest). Coding disagreements were solved using review and revision of the category definitions. New categories were created for students' responses that described behaviors or issues that were not captured in the ABIM's categories. RESULTS: A total of 114 students responded. The ABIM's professional code was adapted for students and teachers, making it context- and learning-stage-specific. One new category of challenges, conflicts of conscience, was added, and one category (abuse of power) was expanded to include abuse of power/negotiating power asymmetries. CONCLUSIONS: Using the ABIM's taxonomy to name professional and unprofessional behaviors was particularly useful for examining undergraduate medical students' perceptions of the ethical climate for learning during the first year of medical school, and it holds promise for research into changes in students' perceptions as they move into clinical experiences. Using the framework, students can build a unified professional knowledge-and-skills base.

Siegler,-M. Training doctors for professionalism: some lessons from teaching clinical medical ethics. Mt-Sinai-J-Med. 2002 Nov; 69(6): 404-9.Medical professionalism encourages physicians to place their patients’ interests above self-interest. In recent years, many medical organizations, including the American Board of Internal Medicine (ABIM), Association of American Medical Colleges (AAMC), and the American Medical Association (AMA), have developed initiatives to strengthen medical professionalism. By emphasizing professionalism, supporters of these initiatives hope that medicine and physicians may recapture professional autonomy, decrease public criticism of medicine and physicians, and help physicians regain the moral high ground in the unending struggle with payers, both public and private. One crucial question facing medical educators is whether the concepts of professionalism can be taught to medical students and residents. This paper draws upon the author s thirty years of experience in teaching clinical medical ethics to provide guidance on how to teach the concepts of professionalism to students and residents.

Sklar,-D-P; Doezema,-D; McLaughlin,-S; Helitzer,-D. Teaching communications and professionalism through writing and humanities: reflections of ten years of experience. Acad-Emerg-Med. 2002 Nov; 9(11): 1360-4.Both professionalism and interpersonal communication are core competencies for emergency medicine residents as well as residents from other specialties. The authors describe a weekly, small-group seminar lasting one year for emergency medicine residents that incorporates didactic materials, case studies, narrative expression (stories and poems), and small-group discussion. Examples of cases and narrative expressions are provided and a rationale for utilizing the format is explained. A theoretical model for evaluation measures is also included.

Surdyk,-P-M. Educating for professionalism: what counts? Who's counting? Camb-Q-Healthc-Ethics. 2003 Spring; 12(2): 155-60.

Wallach,-P-M; Roscoe,-L; Bowden,-R. The profession of medicine: an integrated approach to basic principles. Acad-Med. 2002 Nov; 77(11): 1168-9.OBJECTIVE: The University of South Florida College of Medicine developed and implemented an innovative three-week course entitled, "The Profession of Medicine: An Integrated Approach to Basic Principles" to introduce new medical students to topics and skills that are important to their successful study of medicine. Demonstrating the clinical relevance of the basic sciences, the importance of lifelong learning, and ethics and professionalism in medicine were emphasized. Basic physical examination techniques, searching the medical literature and evidence-based medicine, and study and computer skills were introduced in addition to traditional orientation topics. DESCRIPTION: Four interdisciplinary "state of the art" presentations demonstrated the importance of lifelong learning and the clinical relevance of basic science concepts. Lectures on acute myocardial infarction, breast cancer, duodenal ulcer, and pulmonary prematurity were presented as if the lectures were being given in 1980. Students attended lectures on basic science principles relevant to these topics, and then met in small groups with librarians, content experts, and small-group facilitators to begin investigating an assigned topic. For example, student groups researched the development of EMS and chest pain centers, thrombolysis and percutaneous coronary intervention, and the psychological implications of acute myocardial infarction for patients and families. Students were introduced to effective literature-searching techniques, the tenets of evidence-based medicine, and effective computer skills in the context of studying their assigned topics. Each group then selected a student presenter to deliver an eight-minute PowerPoint presentation of its 2001 "state of the art" findings, making particular note of scientific advances and new therapeutic protocols developed since 1980, such as the use of artificial surfactant in premature babies, the role of H. pylori in duodenal ulcers, and the discovery of the genetics of breast cancer. These projects as well as a series of small-

group educational programs enabled students and faculty to develop a strong sense of team-work and cohesiveness. Students had opportunities to practice components of the history and physical examination on standardized patients relevant to the four clinical topic areas, such as cardiac and abdominal examinations with emphasis on anatomic principles. Basic ethical principles and their application to cases that pertained to the four clinical topics were introduced, and students participated in a small-group ethics case conference. Throughout the course, students and faculty were required to wear specially designed nametags. By the time the course concluded with the White Coat ceremony, the 75 participating faculty and 104 students knew one another, making the ceremony particularly meaningful. DISCUSSION: The pace at which scientific findings revolutionize the practice of medicine continues to accelerate. While it is important for undergraduate medical students to master the basic and clinical science foundations of medical practice, it may be even more important to teach students how to find and interpret medical information, form professional relationships with mentors and peers, and make a commitment to lifelong learning and professionalism. It is critical that students understand that the curricular program at any college of medicine is only the beginning of a life of study.

A Concise Curriculum in Medical Ethics *

* Developed from the Ethics Curriculum for Emergency Medicine Residencies SAEM Ethics Committee 1994

Contributors: James G. Adams, Terri A. Schmidt (Chair), Arthur R. Derse, Glenn C. Freas, Lewis R. Goldfrank, Kenneth V. Iserson, Norm D. Kalbfleisch, Samuel M. Keim, Robert K. Knopp, Gregory L. Larkin, Marc L. Pollack, and David P. Sklar.

This document has been amended from the Ethics Curriculum for Emergency Medicine Residents as produced by the SAEM Ethics Committee. Earl Reisdorff has made changes from the original monograph. All citations, acknowledgements, and credits should be given to the SAEM Ethics Committee.

A Concise Curriculum in Medical Ethics

TABLE OF CONTENTS

I. Introduction: Basic ethical foundations of clinical medicine

II. Applying Ethics to Emergency Medicine

III. Issues Related to Patient Autonomya. Informed Consent and Refusalb. Patient Decision Making Capacityc. Patient Seeking Treatment of Minorsd. Advance Directives

IV. End of Life Decisionsa. Limiting Resuscitationb. Futilityc. Comfort Measures and Physician-Directed Euthanasia

V. The Physician-Patient Relationshipa. Confidentialityb. Truth Telling and Communicationc. Compassion and Empathy

VI. Issues Related to Justicea. Health Care Rationingb. Dutiesc. Moral Issues and Disaster Medicined. Research

VII. Teaching

VIII. Physician Relationship with the Biomedical Industry

A Concise Curriculum in Medical Ethics

INTRODUCTION

This curriculum has been developed to assist in the teaching of medical ethics to residents. It has been amended from a curriculum developed by the Society of Academic Emergency Medicine for emergency physicians. Most of the content has been generalized to meet the needs of all residents in graduate medical education training programs.

Following this introductory section, this curriculum is divided into topic-oriented teaching modules. Each module includes objectives, an illustrative case, a discussion, study questions, and a brief bibliography. Additional cases are provided at the end of the curriculum to prompt further discussion. Like all of medicine, biomedical ethics is continually evolving. It is not the intention of this curriculum to be all-inclusive. To the contrary, this is a short introduction -- not a complete text on medical ethics.

Before specific ethical issues are discussed, the relationship between ethics and the law must be clarified. The law does not provide the answer to many ethical problems. In addition, statutes can vary substantially between states. Ideally, ethical theory guides physicians towards a universally applicable standard. While the law is limited in its ability to provide universal guidance and direction, ethical analysis can often provide a framework for determining moral duty, obligation, and conduct.

Similarly, ethical analysis is no substitute for legal guidance. When dealing with dilemmas, when initiating policies and protocols, or when updating existing procedures, informed legal advice is encouraged.

Additional Reading

Moskop JC, Mitchell JM, Ray VG. An ethics curriculum for teaching emergency medicine residents. Ann Emerg Med 1990;19:187-192.

Windenwerder W. Ethical dilemmas for housestaff physicians. JAMA 1985;254:3454-3457.

I. Basic Ethical Foundation and Clinical Medicine

Objectives: 1. Discuss the moral principles that underlie the practice of medicine. 2. Define ethics. 3. Define respect for autonomy. 4. Define paternalism. 5. Define beneficence. 6. Define non-maleficence. 7. Define justice.

DiscussionEthics studies values and moral reasoning. Non-normative ethics describes and analyzes

moral beliefs without making a value judgment about right or wrong. Normative ethics attempts to define actions that are right and wrong. In medicine, the ethical challenge may require deciding between the lesser or two evils or the greater of two goods. Public policy, formal codes, guidelines, regulations, and clinical decision making should be based on an ethical foundation.

Four principles are commonly thought to define western healthcare ethics: respect for autonomy; beneficence; non-maleficence; and justice.

Beneficence and non-maleficence are ancient ethical tenants embodied in the Latin phrase -- primum non nocere, “above all do no harm”. Beneficence can be viewed as a positive action and non-maleficence is an avoidance of a negative action. Either way, at a minimum, physicians must act in a way that is not detrimental to patients.

Beneficence requires that physicians act in the best interests of their patients. This is accomplished by balancing the potential goods and potential harms in a way that best serves the patient. Beneficence is embodied in the Hippocratic Physician’s Oath to act “for the good of the patient”. There is a significant obligation of beneficence based on the health provider-patient relationship. Though the contemporary doctor-patient relationship is a contractual, fiduciary obligation, a professional’s obligation to benefit a patient is not based on the professional’s expectation of receiving benefits from the patient. The obligation is to act in the best interest of the patient and is a fundamental part of the role of the physician. Present day ethics codes strongly embody the principle of beneficence. The Declaration of Geneva, sworn by many medical students at graduation, states, “the health of my patients will be my first consideration” (World Medical Organization, 1983).

Autonomy is derived from two Greek root words, autos and nomos meaning, self-rule. Respect for autonomy has become increasingly prominent in the last half of the 20th century. Our society has encouraged the rise of respect for autonomy include the expansion of political democracy, improvement in the education of American citizens, and an increase in the diversity of values that encourages individuals to protect their own personal values. Failures to respect autonomy are characterized by the abuses of medical research committed by Nazi Germany on concentration camp victims, the United States Tuskeegee syphilis study (which continued into the 1970’s), and the U.S. government sponsored radiation studies.

Respect for autonomy is supported by law. New York State Supreme Court Justice Cardoza said in 1914 that “any individual of sound mind has a right to determine what shall be done to his body ....” Interestingly, informed consent does not appear as part of the American

case law until 1957. Since then, the concept of patient autonomy has proved to be enduring, and now is fundamental.

The final principle of healthcare ethics is justice. Justice is the principle we consider when attempting to make decisions about competing interests or allocating resources. Justice is often equated with fairness. Aristotel defined justice as treating equals equally, and unequals unequally. Theories of justice have been described as deontological and utilitarian. Utilitarian theories are based on the assumption that the right action is the action that creates the greatest possible balance of good over harm. Utilitarianism is often described as “the end justifies the means”. Deontological theories are based on the belief that some actions are right or wrong based on a higher rule or rules, not just based on the consequence of the action.

Bibliography1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 3rd ed. Oxford University Press, New York, 1989.2. Iserson KV, Sanders SAB, Mathieu DR, Buchanan AE (eds). Ethics in Emergency Medicine, Baltimore, Williams & Wilkins, 1986.3. Jonsen AR, Siegler M, Winslade WJ (eds). Clinical Ethics. 3rd ed. McGraw-Hill, Inc., New York, 1992.4. Luce JM. Ethical principles in critical care. JAMA 1990;263:696-700.

II. Applying Ethics to Emergency Medicine

Objectives: 1. Lists special problems associated with ethical decision-making in emergency medicine. 2. Describe two (2) models for ethical decision-making in emergency medicine. 3. List advantages and disadvantages of the two (2) models in emergency medicine.

Example case:A 92-year-old man in acute respiratory distress is brought in to the Emergency

Department from a nursing home. He had been at the nursing home for six months and is described as normally alert and oriented, but bedridden due to his end-stage congestive heart failure. He has no family in the area. He appears frail and debilitated, and cannot answer any questions. His systolic blood pressure is 90 mmHg, heart rate is 120 bpm, and the respiratory rate is 40. He has rales in all lung fields. Records from the nursing home do not provide any information about patient preferences regarding resuscitation or “code status”. Shortly after his arrival, his daughter from out of state calls and states her father would not want “aggressive treatment”.

DiscussionThe ED is a complex medical environment, presenting complex ethical challenges. Our

unfamiliarity with our patients and their wishes, the minimal time to establish a relationship, and complex medical situations all contribute to ethical conflict. Moreover, decisions must often be made quickly, sometimes before sufficient information is available.

It is useful to have a model for making ethical decisions. Jonsen, Siegler, and Winslade developed one such model. They propose that considering four factors can make any ethical decision: medical indications; patient preference; quality of life; and contextual features. The concept of medical indications includes the diagnosis and treatment of the patient’s condition and a consideration of what is needed to evaluate and treat the problem. The concept of patient preferences is based on the belief that healthcare providers should respect the wishes of patients, and whenever possible provide treatment which meets the patient’s goals. Quality of life considerations assume the goal of medical intervention is to improve the quality of the patient’s life. It is important to remember that quality of life must be defined from the patient’s point of view, not the healthcare providers. Finally, contextual features include all the other factors that can be involved in a specific situation such as the wishes of the family, the rules of law, the effect a decision will have on others, including healthcare workers, and socioeconomic considerations. This model assists in the organization of the healthcare provider’s thought, and helps avoid overlooking any pertinent aspect of the situation. Ethical decisions are then made based on the principles of respect for autonomy, beneficence, non-maleficence, and justice. This model, while thorough, may sometimes be too time consuming to help in emergency settings.

Iserson has developed another model specifically designed to help in the emergency setting. The first step is to ask the question, “Is this a type of ethics problem for which you have already worked out a rule or is this at least similar enough so that a rule could reasonably be extended to cover it?” If so, then follow the rule. The second step is to ask the question, “Is there an option that will buy time for deliberation without excessive risk to the patient?” If yes, buy time. Finally, if the first two steps do not yield a solution, then there are three rules to apply to any ethical decision. The three rules are:

1) Impartiality -- the decision maker is placed in the position of the patient by saying, “Would you be willing to have this action performed if you were in the patient’s place?”2) Universalizability -- Would you be willing to use the same solution in all similar

cases?3) Interpersonal justifiability -- consider whether you will be willing to defend the decision to others, to share the decision public. Emergency physicians are bound by the same obligations and are subject to the same

pitfalls as any other physician. Just as residents must develop expertise in sensitivity for clinical decision making, expertise must be concurrently developed to address ethical questions.

Study Questions:1. In the above case, what do you know about medical indications, quality of life, patient preferences, and contextual features? 2. How does that knowledge help you make a decision? 3. Use the Iserson model to help formulate a decision in this situation.

References 1. Iserson KV, Sanders AB, Mathieu DR, Buchanan AE (eds). Ethics in Emergency Medicine, Baltimore, Williams & Wilkins, 1986.2. Jonsen AR, Siegler M, Winslade WJ (eds). Clinical Ethics. 3rd ed. McGraw-Hill, Inc., New York, 1992.3. Adams JG, Arnold R, Siminoff L, Wolf AB. Ethical conflicts in the pre-hospital setting. Ann Emerg Med 1992;21:1259-1265.

III. Issues Related to Patient AutonomyA. Informed Consent

Objectives: 1. Explain why informed consent is obtained for treatment. 2. List the critical elements in the consent process. 3. Define the emergency rule. 4. Define expressed consent. 5. Define implied consent. 6. Describe the circumstances in which a physician may treat a patient against his/her will.

Case Example:A 39-year-old patient presents with a severe headache. The patient has a history of

headaches, but this episode is worse than usual. There is no fever. The patient has a nonfocal neurological examination; the patient’s sensorium is clear. The head CT scan is normal. The physician feels that a lumbar puncture is indicated.

DiscussionRespect for autonomy requires that the physician recognize the patient’s right to make

independent choices, and take actions based on personal values and beliefs. A person cannot make independent choices without the necessary information to make these decisions. Thus, informed consent involves two duties: 1) the duty to disclose information to patients; and 2) the duty to obtain the patient’s consent. Understand that the patient grants permission for medical treatment is fundamental to effective, rational, and medicolegally acceptable care.

Informed consent promotes patient self-determination and well being. Although patient self-determination implies a unilateral decision, the process of decision making is somewhat shared: the physician offers information and expert advice for the patient to consider. It is the healthcare provider’s responsibility to assure that the patient can meaningfully participate in the decisions. Shared decision making requires that the patient possess correct and complete information, and that the decision promotes the patient’s goals and life values. In the consent process, the three elements that must be met are information, comprehension, and voluntariness.

Legal Support for Informed ConsentWhile informed consent is fundamentally and ethically imperative, U.S. law requires that

a patient provide informed consent for medical treatment, except under unusual circumstances. This legal principle was recognized in 1914 when the New York State Supreme Court held that:

“every person of adult years of sound mind has a right to determine what shall be done with his own body and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages.” This landmark case cites the fundamental premise that any time physician touches a

patient, the patient must authorize such action. In the absence of such authorization, the intervention could be construed to be a battery. The imminent threat of such a violation constitutes an assault. This principle gives a patient with decision making capacity the legal right to refuse medical care.

In addition, lack of informed consent may result in an action for negligence against the healthcare provider. A failure to disclose potential complications or alternative treatments may constitute negligence if such information would influence the patient to alter his or her decision. This distinction was made clear in 1972, when the courts affirmed that performing an unauthorized procedure is battery, but performing an authorization procedure without appropriately disclosing the risks constitutes negligence.

The Emergency RuleThe Courts have ruled that an emergency exception to informed consent exists when the

patient is unconscious or otherwise incapable of consenting, and harm will occur from the failure with the benefit outweighing any threatened harm by the proposed treatment. When time does not permit informed consent, the emergency physician operates under the moral imperative of beneficence, acting in the best interests of the patient.

The Courts also have held that in the time of a life-threatening crisis, it is the physician's duty to do that which the occasion demands, even without the consent of the patient. To satisfy this situation, the condition of the patient must be so severe that definitive care could not be delayed until consent is obtained. The emergency rule depends upon the patient's inability to offer consent during urgent circumstances. How urgent a situation is depends primarily upon the consequences to the patient of a delay in rendering treatment, or upon the consequences of the failure to render any treatment at all.

Substituted ConsentWhen the patient is unable to consent due to physical or psychological distress, the

nearest relative or a designated surrogate is turned to for consent (see patient decision-making capacity). It is assumed that surrogate decision makers will make decisions based either on the patient's best interests or the patient's previously expressed wishes.

Implied Consent"Implied consent" is defined as a logical inference from the conduct of the patient. With

implied consent, the individual patient's actions indicate to the physician that treatment is requested. This is described in the case of O'Brien v. Cunard Steamship Co.. A passenger sued the steamship company for administering an immunization without his consent. The court ruled that the plaintiff's actions of standing in the line where injections were being administered, rolling up his sleeve and submitting to the injection, served as consent. The typical prehospital or ED encounter parallels this situation. When the patient or a designee requests help, care is administered. The patient implies consent by participating in the care, and actively submitting to treatment. Expressed consent is sought for any intervention with more than remote risks. Information must be freely shared with patients.

Refusal of CareInformed consent requires decision making capacity. It follows that patients with

decision making capacity also have a right not to consent to care. The elements of a valid, informed refusal are the same as consent:

1) The patient must have decision making capacity.2) Information including significant risks and magnitude of harm must be provided.3) The patient must comprehend the information.

4) Refusal must be voluntary without coercion or duress. Because refusal of care may conflict with the judgement and recommendation of the

physician, it is prudent for the physician to emphasize the risks presented by refusing care and outline any specific consequences to be expected. The physician must be careful because both consent and refusal must be made without coercion or duress.

The physicians should provide treatment despite a verbal refusal in patients who do not have decision making capacity, or when the life threat is so acute that the physician does not have time to assess their refusal. When patients do not have decision making capacity, the expected benefit of the intervention must outweigh the potential risk of harm to the patient.

Study Questions1. In this case, what must be discussed with the patient in order to obtain her consent?2. Do you need to obtain written consent from this patient?3. Why does a physician obtain informed consent for treatment?4. How do the principles of beneficence and autonomy relate to consent issues?

Bibliography1. Applelaum PS, Lidz CW, Meisel JD: Informed Consent: Legal Theory and Clinical Practice Oxford University Press, New York, 1987.2. Boisaubin EV, Dresser R: Informed consent in emergency care: Illusion and reform. Ann Emerg Med 1987; 16:62-67.3. Sprung CL, Winick BJ: Informed consent in theory and practice: legal and medical perspectives on the informed consent doctrine and a proposed reconceptualization Crit Care Med 1989; 17:1346-1354.

III. Issues Related to Patient AutonomyB. Patient Decision Making Capacity

Objectives1. Define decision-making capacity2. Contrast the medical interpretation of decision-making capacity with the legal definition of

competence.3. Define surrogate decision maker and health care proxy4. List the ways decisions can be made when a patient lacks decision-making capacity.

Example CaseA 55-year-old male patient comes to the ED complaining of nausea and chest pain over

the past two hours. An EKG reveals 3 mm ST depression in leads V2-V4. The patient's chest pain is relieved after three sublingual nitroglycerin tablets are given. A subsequent EKG reveals 1-2mm ST depression. He has no physician, takes no medication, and smokes 1 pack of cigarettes per day. He refuses to be admitted to the hospital, demanding to be immediately released. Despite your efforts to convince him to stay, he demands that he be allowed to go home.

DiscussionWhen a patient arrives in an emergency department and an evaluation by a physician is

begun, a physician-patient relationship is established. This relationship carries certain legal and ethical obligations for both parties. The physician ultimately advises on a plan of evaluation or a course of care. Patients have the ultimate authority to accept or refuse this advice.

The patient's authority is founded on: 1) the ethical principle of respect for autonomy2) the legal right of self-determination3) And, is based on the pivotal assumption that the patient is acting in his or her own

best interests. The obligation of the physician to protect patients from harm can conflict with the

obligation to respect patient autonomy, especially when the patient makes decisions that seem unwise or harmful. When this conflict occurs, physicians must assess the patient's ability to make a reasoned decision. Competence and decision-making capacity are two descriptors commonly used to characterize this ability. Competence is a legal term, decision-making capacity applies the concept of competence to the medical setting.

The Medical Concept of Decision Making CapacityAll adult patients are assumed to have appropriate decision making capacity to accept or

refuse medical advice unless there is clinical evidence that leads the physician to believe that the patient's decision-making capacity is significantly compromised. The determination of decision-making capacity requires that:1. The patient appreciates he or she has the power to make decisions on his or her behalf2. The patient understands the medical situation and prognosis, the nature of the

recommended evaluation or care, the alternatives, the risks and benefits of each, and the likely consequences

3. The patient's decision is stable over time, and is consistent with his or her life values or goals.The degree or level of decision-making capacity a patient must show varies with the

degree and probability of risk, the degree and probability of benefit, and the patient's decision to consent or refuse. The greater the risk posed by the patient's decision, the more exacting the standard of decision making capacity needs to be. Thus, a patient only needs a low level of decision-making capacity to consent to a procedure with substantial, highly probable benefits and minimal, low probable risks, but a high level of decision-making capacity to refuse the same treatment.

The Concept of Legal Competence In the law, competence requires the mental capacities sufficient to appreciate the nature

and consequences of such legal rights or responsibilities as making a will or contract as well as standing trial. The degree of understanding required by the law varies in relation to the task to be performed. The law assumes that adults are competent until proven otherwise in a formal legal decree (In Michigan, this often through a formal hearing conducted by a probate judge). Once the person is formally judged incompetent, a guardian or conservator is appointed by the court to make decisions. Depending on the Court’s determination of the degree of incompetence, a person can be judged incompetent relative to business or financial affairs, yet competent to consent to or refuse medical evaluation or treatment.

If a conservator is appointed to make medical decisions on behalf of the patient, then the conservator is ultimately the individual who must give consent, not the patient or members of his or her family. Each state has slightly different criteria for the determination of competence. It bears repeating that a person is technically determined to be incompetent only after a formal legal proceeding.

When a Patient Lacks Decision-Making CapacityIf the physician knows that a patient does not have medical decision-making capacity to

give an informed consent, how are medical decisions be made? The answer to this question depends on the speed with which the decision must be made, and what information about patient preferences is available.

If an immediate decision is required to save a person's life or limb, then legally and ethically, the emergency physician is obligated to provide appropriate care without the need for consent (See the Emergency Rule). If time permits and there is a legal decree that the patient is incompetent, then the emergency physician contacts the conservator of the patient who has the legal responsibility for medical decision-making. In addition, patients may have a durable power of attorney for health care, a living will, or previously expressed wishes to family or others that should be honored (see section on advance directives). When patients previously expressed wishes are known, based on the principle of respect for autonomy, those wishes are generally be honored.

Historically, there was substantial ethical and legal consensus supporting surrogate decision-making by family members. However, recent legal cases suggest that the Courts are less reliant on family members to act as surrogate decision-makers. Still, each State has laws describing the hierarchy of authority for family surrogate decision making. Surrogate decision-makers can be acceptable in the emergency setting, but the time required to confirm surrogate identity, explain the medical circumstances and prognosis, and assure sound reasoning, are

potentially prohibitive when there is a medical imperative to intervene. When doubt exists, a conservative course (resuscitation-stabilization) is warranted (the principle of beneficence).

Study Questions1. In the case presented, what must be discussed with the patient while counseling him

regarding his refusal?2. What must you know so that you can adequately counsel him?3. How would you assess whether the patient possessed adequate decision-making capacity?

Bibliography1. Applebaum PS, Grisso T: Assessing patients' capacities to consent to treatment. N Engl J Med 1988; 319:1635-1638.2. Brock, D and Wartman, SA: When competent patients make irrational choices. N Eng J Med 322:1595-1599. 3. Emanuel, EJ and Emanuel, LL: Proxy decision making for incompetent patients: An ethical and empirical analysis. JAMA 1992; 267:2067-2071. 4. Lo, B: Assessing decision making capacity. Law, Medicine, and Health Care 1990 18:3(Fall) 193-201. 5. Lo B, Rouse F, Dornbrand L: Family decision making on trial: Who decides for incompetent patients? N Engl J Med 1990;322:1228-1232.

III. Issues Related to Patient AutonomyC. Treatment of Minors

Objectives:1. Explain how consent for minors is obtained.2. Explain how the "emergency rule" applies to minors.3. Explain how state laws regarding minors and pregnancy, sexually transmitted diseases, substance abuse, and child abuse relate to consent and confidentiality.4. Explain the concepts of emancipated minors and mature minors.5. Describe situations when a minor can refuse care. Example Case

His parents bring a 16-year-old boy to the ED, insisting on a drug screen to confirm their suspicions that the teenager is using marijuana. The boy refuses to submit to an exam or produce a urine sample.

Discussion Respect for autonomy presumes that a person with decision-making capacity has the

right to make choices about health care. However, minors are generally presumed to not have decision-making capacity. In general, consent for the treatment of minors is obtained from a parent or legal guardian. We assume that parents make decisions based on the best interests of their child. Thus, with minors we are more likely to base our actions on the principle of beneficence rather than on the principle of respect for autonomy. However, as children become old enough to express their wishes and reason for themselves, they are entitled to respect for their preferences. The ethical task is to weigh the preferences of parents and children and solve those conflicts that arise.

In addition, ethical issues surrounding the care of minors in the ED are intertwined with state laws that address consent, substance abuse, pregnancy, abortion, and child abuse and neglect. Physicians must know the requirements of the law in the state in which they practice.

Although ethics and the law, generally presume that a minor lacks decision making capacity, there are many important exceptions to this rule. The emergency rule (see section on informed consent) presumes consent for anyone, including minors, with a true emergency. An “emergency” has been construed by Courts to go beyond just life threatening or disabling conditions. They allow treatment to alleviate pain or suffering from serious but nonemergent conditions.

Many states have laws allowing minors to consent when they seek care for pregnancy, sexually transmitted diseases, substance abuse, or child abuse. In addition, many states by statute or common law allow emancipated minors or mature minors to consent for their own medical care.

Emancipated minors are usually defined as minors who live independently of their parents and are self-supporting, minors who are married, have been pregnant, or who are in the armed forces. The mature minor is a young person (usually 15 years or older) who the physician believes possesses the requisite decision making capacity and demonstrates an understanding of the nature of the proposed treatment. Under most circumstances the mature minor can consent to or refuse treatment that is of low risk and to the minor's benefit.

Like adult patients, minors have a right to privacy and respect for confidentiality. Ethical dilemmas arise when a minor is accompanied by a parent who demands to know the nature of the condition or treatment which involves one of the exceptions for which a minor can give consent (pregnancy, child abuse, etc.) and the minor refuses to provide that information to the parent. The physician may feel conflict when she or he believes that involving the parent is in the child's best interests. However, in general, the wishes of the minor patient are respected when law or ethics allows the minor to consent. In addition, older minors have a right to privacy and sensitive information should generally not be shared with parents or others without first discussing disclosure with the minor.

Study Questions:1. How should you resolve the above case? Can you treat this teenager against his will?2. Describe treatments for which a mature minor may give consent, and treatments for which the mature minor may not give consent.3. Can an emancipated minor refuse a life saving blood transfusion on religious grounds?

Bibliography1. Holder AR: Parents, courts and refusal of treatment J Pediatr 1983; 103:515-521.2. Legal Correspondent: Teenage confidence and consent. Brit Med J 1985;290:144-145.3. Morrissey J, Hoffman A, Thorpe J: Consent and Confidentiality in the Health Care of Children and Adolescents: Legal Guide Macmillan: The Free Press, New York, 1986.4. Tsai AK, Schafermeyer RW, Kalifon D, et al: Evaluation and treatment of minors: Reference on consent. Ann Emerg Med 1993;22:1211-1217.

III. Issues Related to Patient AutonomyD. Advance Directives

Objectives1. Define advance directives: durable power of attorney for health care and living wills2. State the purpose of an advance directive and describe the requirements for a valid advance directive.3. Explain your state laws regarding advance directives.4. Explain the conditions that make an advance directive applicable.

Example CaseA 45-year-old man is brought to the ED with an altered level of consciousness. He has

AIDS, but until yesterday was alert and interactive, although confused at times. He has AIDS dementia. His companion brings along the patient's durable power of attorney for health care that names the companion as the surrogate decision-maker.

DiscussionAn advance directive is a written document that expresses the future wishes of a patient.

It gives patients control over the treatment decisions that will be made when they are unable to participate directly. The two main types of advance directive are living wills and durable powers of attorney for health care.

It is likely that the use of advance directives will increase with implementation of the Patient Self Determination Act, which became effective December 1, 1991. This federal act requires that hospitals that accept Medicare and Medicaid funds provide information about advance directives and develop policies for implementation of advance directives. Information about advance directives has also been mailed to all social security recipients.

Living wills express the wishes of patients regarding life-sustaining procedures in the event of terminal illness. They are legally recognized by over 45 states. Living wills have specific restrictions stating that the person would not want resuscitation if he or she is terminally ill, death is imminent, and resuscitation would only prolong the dying process. Because of these restrictive phrases, living wills are often of limited value in the ED and prehospital settings. The patient’s physician or a proxy decision-maker can provide clarification. When the applicability and circumstances are clear, the emergency physician has an obligation to respect the living will. If the physician cannot in good conscious do so, he or she should provide for another physician to care for the patient. Finally, the patient can revoke a living will at any time, even during a time of crisis in the ED.

All states have statutes governing durable powers of attorney. In some states, additional statutes explicitly identify durable powers of attorney for health care decisions. A durable power of attorney gives to another person the authority to make decisions for a patient if he or she becomes incapacitated. The person then becomes a legally recognized proxy decision-maker for the patient. When a durable power of attorney exists, the emergency physician should allow the designated person to participate in decisions regarding the patient's medical care. The proxy decision-maker should not base decisions upon his or her own values, but must make decisions according to the known wishes of the patient. Immunity is generally granted to the physician who carries out the proxy's decision in good faith. Physicians should be aware of state law,

federal guidelines and ethical responsibilities that outline policies regarding health care proxies and living wills. Emergency departments should have guidelines regarding advance directives.

Study questions1. What are your state’s laws as they relate to advance directives? Which forms of advance directives are allowed?2. In this case, who has decision making power for this person? 3. Who would you consult for decisions if the parents also came to the emergency department and requested to make decisions for their son?

Bibliography1. Annas GJ: The health care proxy and the living will. N Engl J Med 1991;324:1210-1213.2. Emanuel EJ, Emanuel LL: Proxy decision making for incompetent patients. JAMA 1992;267:2067-2071.3. Iserson KV: Federal advance directives legislation: potential effects on emergency medicine. J Emerg Med 1991;9:67-70.4. Orentlicher D: Advance medical directives. JAMA 1990;263:2365-2367.5. Siner DA: Advance directives in emergency medicine: Medical, legal and ethical implications. Ann Emerg Med 1989;18:1364-1369.

IV. End of Life DecisionsA. Limiting Resuscitation

Objectives1. Define "Do Not Resuscitate Order" (DNR order).2. Explain the conditions that must be present to withhold resuscitation in the ED and in the out of hospital environment.3. Explain the role of family and significant others in decisions about resuscitation.

Example CaseAn 83-year-old woman was found in asystole. The family showed the paramedics a

paper, signed by a physician, noting that the patient was not to be resuscitated in the event of cardiac arrest. State EMS policy, however, does not recognize prehospital do not resuscitate orders. In this patient, no resuscitation was undertaken. The police were notified that the patient was "dead on arrival".

DiscussionIt is legally and ethically acceptable to withhold resuscitative efforts on patients who

have expressed clear wishes not to undergo resuscitation. The challenge arises in the communication of such desires. The means of communication must be legally, ethically, and medically sound. The ED presents difficulties since the patient's wishes, medical condition, and prognosis are usually unknown. Effective communication must occur that relays the patient's desire that resuscitation be withheld. This can be through standardized mechanisms that many regions have developed

If there is doubt regarding the patient's wishes or the validity of a document, resuscitative efforts are be initiated. The decision to resuscitate is a complete and immediate yes or no decision. "Slow codes," suboptimal efforts, or delayed intervention are medically or ethically unacceptable.

Prehospital emergency medical services should honor "do not resuscitate" orders. Recognizable, standard DNR orders identify those patients who wish to avoid resuscitation attempts. Living wills are not used to limit prehospital resuscitation if the applicability of the document is unclear.

While it is ethically appropriate to honor DNR orders in the prehospital setting, a number of operational, legal, medical and ethical challenges must be overcome. The emergency medical service must rely on the personal physician to provide appropriate, written DNR orders that are consistent with patient preferences and medical indications. The form used for DNR orders must be acceptable to the emergency medical service and the legal jurisdiction. It must be clear regarding those interventions that are to be implemented and those that are to be withheld. One must ensure that the document reflects the current status of the patient. This is accomplished by requiring periodic renewal of the order.

Prehospital DNR orders should be portable, so the directive can be honored equally in the hospital, nursing home, private home, or public setting. An ideal system possesses DNR orders with standard communication and authorization procedures that are easily recognizable and do not demand interpretation or cause confusion. The document should be familiar to the prehospital provider, the family, the ED, the private physician, and nursing homes.

Study Questions1. Should the paramedics have followed state policy and attempted resuscitation?2. What evidence of patient wishes does a physician need withhold resuscitation attempts?

Is a relative's verbal request enough?3. Does the age, appearance, or physical condition of the patient matter?

Bibliography1. Adams JG, Derse AR, Gotthold WE, Mitchell JM, Moskop JC, Sanders AB: Ethical Aspects of Resuscitation Ann Emerg Med 1992;21:1273-1276.2. Ayres RJ: Current controversies in prehospital resuscitation of the terminally ill patient. Prehospital and Disaster Medicine 1990;5:49-57.3. American College of Emergency Physicians: Guidelines for "do not resuscitate orders" in the prehospital setting. Ann Emerg Med 1988;17:1106-1108.4. Miles SH, Crimmins TJ: Orders to limit emergency treatment for an ambulance service in a large metropolitan area. JAMA 1985;254:525-527.

IV. End of Life Decisions

B. Futility

Objectives1. Define futility.2. Describe situations in which futility can be used to withhold treatment in the emergency department and out of hospital setting.

Example CaseParamedics bring a 25-year-old man to the ED after sustaining a gunshot wound to his

head. He arrives with agonal respirations, and a systolic blood pressure of 60 mmHg. The bullet entered at the left temple and there is a large exit would with extruding brain from the right temple. His Glasgow Coma Scale is 3.

DiscussionAlthough not explicitly stated, we tend to assume that physicians do not offer treatments

to their patients that are not medically indicated. For many clinical conditions, the medical indications and prognosis for resuscitative measures still need to be defined. If a medical intervention is of no benefit, then it should not be applied. Nonetheless, relying on poorly defined notions of futility can diminish patient autonomy. The American Heart Association suggests the following criteria for medical futility in ACLS:

1. Appropriate BLS and ALS have already been attempted without restoration of circulation.

2. No physiologic benefit can be expected from ALS and BLS because the patient's physiologic functions are deteriorating despite maximum therapy (examples, overwhelming sepsis, cardiogenic shock).

3. No survivors have been reported under the given circumstances in well-designed studies.

Another definition states that if in the last 100 cases a medical treatment has been useless, that treatment is futile. This probability analysis allows for the possibility that 3 successes would occur in the next 100 similar cases.

Determining the goals is important when defining futility. One example is the patient for which living for a few days would be a benefit because it would allow her to say goodbye to family and see other relatives. Thus, while some authors suggest that patients and families need not be consulted in determining futility, it makes more sense to communicate with patients and families in order to define their goals for treatment. While the decision not to provide a futile therapy may rest with the physician, only through dialogue can the physician understand the patient’s goals of treatment. This approach allows for definition of the desired outcome, the acceptability of burdens, and the patient's or family's willingness to gamble with the outcome.

There is a presumption in favor of resuscitation in doubtful cases. Thus, the scope of medical futility in resuscitation decisions is narrow; it does not include estimates of future quality of life. Ongoing research into outcomes of resuscitation should better determine when intervention is futile.

Study Questions1. Discuss situations in which you might use futility to stop treatment in the ED.2. Discuss the difference between strict medical futility as no possibility of long-term

survival, and futility as lack of benefit.3. Does this case fit the definition of medical futility? What efforts toward resuscitation

should be attempted?

Bibliography1. Jecker NS, Schneiderman LJ: Ceasing futile resuscitation in the field: ethical considerations. Arch Int Med 1992;2392-2397. 2. Loewy EH, Carlson RA: Futility and its wider implications Arch Intern Med 1993; 153:429-431.3. Schneiderman LJ, Jecker NS, Jonsen AR: Medical futility: Its meaning and ethical implications. Ann Intern Med 1990; 112:949-954.4. Tomlinson T, Brody H: Futility and the ethics of resuscitation JAMA 1990; 264:1276-1280.5. Truog RD, Frader J: The problem with futility. N Eng J Med 1992;326:1560-1564

IV. End of Life DecisionsC. Comfort Measures and Physician-Directed Euthanasia

Objectives1. Describe “comfort measures”2. Define euthanasia3. Describe the double effect.

Example CaseA 37-year-old woman is dying from metastatic breast cancer. She is in severe pain from

bony metastases and is dyspneic from pulmonary compromise. When you saw her as an outpatient two months ago, she requested a prescription for a medicine that would “help end this peacefully”. She is a DNR patient and is requesting large doses of morphine sulfate. Your medical judgment is that the dose required for pain control will cause respiratory depression, thus killing the patient.

DiscussionThe principle of beneficence dictates that physicians provide adequate pain control in

those patients who are terminally ill and suffering. Though narcotic addiction may be a clinical reality, it is rare in this setting. Moreover, concern regarding chemical addition is overshadowed by the need for compassionate end-of-life care.

The double effect addresses the potential of death when trying to provide sufficient pain control. For example, if morphine is given with the intention of relieving suffering and not killing the patient, yet the patient dies as a consequence of the known respiratory depressant effects of the drug, this is considered a morally and ethically defensible action. Support for this concept has been further offered in the language of selected opinions written by the US Supreme Court.

Euthanasia (strictly speaking) refers to the actions or omissions that result in the death of a person who is usually gravely ill. Passive euthanasia specifically deals with the with-holding of certain interventions that will lead to a more rapid demise (e.g., with-holding food and water). Active euthanasia involves the administration of an intervention that will has death (e.g., “mercy killing”). The role of the physician in any for of euthanasia is controversial and generally considered antithetical to the role of the physician as a healer. The other element that must be balanced is to avoid the application of medical technology in a manner that needlessly prolongs suffering. The avoidance of prolonged suffering and the use of passive euthanasia can be difficult to distinguish.

Study Questions1. What should you do in the above case?

Bibliography 1. Dworkin G, Frey RG, Bok S. Euthanasia and Physician-Assisted Suicide. Cambridge,

Cambridge University Press, 1998.2. Moreno JD (ed). Arguing Euthanasia. New York, Touchstone – Simon and Schuster, 1995.

V. The Physician-Patient RelationshipA. Confidentiality

Objectives1. Define confidentiality. 2. Discuss your duty of confidentiality to ED patients3. Describe threats to patient confidentiality in the ED including hospital employees, perpetrators and victims of violent crime, minors and celebrities.4. Discuss the duty to breach confidentiality including duty to warn, public health and contagious diseases and legal reporting requirements.

Example CaseA 32 year-old paramedic comes to the ED in a post-ictal state after having a grand mal

seizure. After an hour, he becomes more responsive and relates that he had a similar episode in the past. He begs you not to tell the Department of Motor Vehicles (DMV) because if he does not have a driver's license he cannot work as a paramedic. Your state law requires you to report episodes of loss of consciousness.

DiscussionConfidentiality and confide are derived from the Latin confidere -- to trust. Patients

confide in their physicians with the understanding that what they report will not be disclosed without explicit permission. Since respecting confidentiality is a basic responsibility of physicians, it is an implicit promise to patients. Confidentiality promotes full disclosure of detailed patient information that is essential for proper patient care. Confidentiality promotes societal trust, personal autonomy, and therapeutic candor.

Various codes of Western medical ethics echo the sentiment that confidentiality is an important principle in the healing arts. For example, the Hippocratic oath states:

Whatsoever in my practice or not in my practice I shall see or hear amid the lives of men, which ought not to be noised abroad, as to this I will keep silence, holding such things unfitting to be spoken.

More recently, the AMA Council on Ethical and Judicial Affairs accepted the statement: The patient has a right to confidentiality. The physician should not reveal confidential information without the consent of the patient, unless provided by law or by the need to protect the welfare of the individual or the public interest.

Thus, both ancient and modern physicians have recognized the importance of confidentiality and have included it in various oaths, principles, and rules of professional conduct.

American common law has found physicians liable for breach of confidentiality on grounds of defamation, invasion of privacy, and breach of an implied contract. On the other hand, physicians have been indicted for failing to break confidentiality when it was deemed obligatory for them to do so in order to warn or protect others. The courts have ruled against physicians for failing to warn a third party about a patient's seizures, failing to warn a third party of the danger of infection from a patient's wound, failing to warn neighbors and others living in

proximity to patients with contagious diseases, and failing to warn a woman that a patient was contemplating her murder.

In spite of its vital importance, the duty to maintain confidentiality is best viewed as a prima facie (not absolute) obligation that can be overridden when it conflicts with stronger moral duties. For example, when a patient threatens to harm others, the physician may need to breach confidentiality in order to protect the needs of identifiable victims. The probability and the magnitude of harm is balanced against the protection of confidentiality. Beauchamp and Childress (1988) prioritize four possible combinations of probability and magnitude of harm by assigning the following hierarchy:

1) major harm risk-high probability2) minor harm-high probability3) major harm risk-low probability4) minor harm-low probabilityAccording to this scale a lower number provides strong justification to breach

confidentiality. Some ethicists hold that when confronted with a situation of major harm and high probability the provider is not merely ethically justified in breaching confidentiality, but is ethically required to do so.

Moral grounds for honoring confidentiality, however convincing, may sometimes yield to stronger moral grounds for disclosure. The following situations justify disclosure:

1. Reporting related to public health laws that can include –Vital statistics (birth and death certificates)Contagious diseasesChild and elder abuseCriminally inflicted injuriesPoisoningLoss of consciousness

2. Legal proceedings3. Quality assurance review4. Protection of a third party from mortal harmIn general, physicians can disclose confidential information when patients agree to

disclose or when disclosure is required in order to fulfill a stronger moral duty to prevent harm or to obey just laws. Disclosure to professionals directly involved in the care of the patient, in most instances, is understood as having the patient's implied consent. The physician's decision to reveal information to prevent harm should be based on the certainty, duration and magnitude of the harm and the possibility of alternative methods for avoiding harm that do not require infringement of confidentiality.

Study Questions1. Should you report the patient in this case to the DMV? What are the conflicting ethical

principles?2. If the patient is a highly visible public figure what, if anything, would you report to either

the media or Department of Motor Vehicles?3. If the patient voluntarily agreed not to drive would this affect your decision to report?

Bibliography

1. American Medical Association: Council on Ethical and Judicial Affairs: Current opinions of the Council on Ethical and Judicial Affairs, Chicago, 1986, #5.09.2. Beauchamp TL, Childress JF (eds): Principles of Biomedical Ethics 3rd ed, New York, Oxford University Press, 1989.3. Siegel DM: Confidentiality in Emergency Risk Management ACEP, Dallas, pp. 181-184.4. Siegler M: Confidentiality in medicine – A decrepit concept. N Engl J Med 1982;307:1518-1521.

V. The Physician-Patient RelationshipB. Truth Telling and Communication

Objectives1. Explain why truth telling is important.2. Discuss circumstances when one might not tell a patient the truth.3. Explain the ethical foundations mandating honest patient-physician communication.4. Discuss barriers to effective communication in the ED.

Example CaseA 56 year-old man with a 60-pack year history of smoking comes to the ED with

shortness of breath. His chest x-ray shows a large mass. In preparing to admit the patient, he asks what his x-ray shows. When told of the mass, which you think is probably cancer, the patient asks, "It's not likely to be cancer, is it, doctor"? You say, "We can't be sure at this time". The patient persists in knowing what you think it is. What do you tell him?

DiscussionTelling the truth may seem to be a straightforward ethical principle in health care.

Certainly, religious and moral codes have prohibited lying. Surprisingly, the duty of truth telling in medicine has only recently become an ethical issue. In certain cultures such as Japan and Italy, truth telling is not the current norm. The Hippocratic oath does not make any mention of truth telling to patients. The prevailing ethic supported by Thomas Percival in his 1803 Principles of Ethics was one of benevolent deception; he recommended that bad news be kept from patients to avoid severe reactions. The AMA's first Code of Ethics in 1847 perpetuated this attitude. This benevolent deception was justified by the principle of non-maleficence and continued into this century. In 1961, 90% of physicians still would not tell a patient of a diagnosis of cancer. It was not until 1977 that 97% of physicians favored telling patients' their diagnosis.

Numerous factors served to change physicians' attitudes. The first was the development in the common law of the doctrine of informed consent (see section on informed consent). Another factor was the rise in emphasis on civil rights and patient autonomy. Finally, the scandals involving the rights of patients involved in experimentation led to the national commission for the protection of human subjects of biomedical and behavioral research. This commission issued a report summarizing basic ethical principles, and setting out requirements of informed consent, assessment of risks and benefits to the subjects of research, and fair procedures in the selection of human subjects.

Despite this new emphasis on truth telling, the therapeutic privilege is still accepted as morally acceptable when there is substantial evidence that offering the patient the truth has a significant probability of causing harm. However, physicians must be very cautious in using this paternalistic argument for not sharing bad news with the patient. Studies show that patients generally do want to know their diagnoses when physicians assume they do not, and that harms from disclosure are less than physicians think, and the benefits are greater.

Telling the truth may be more difficult for the physician than the patient, especially when the physician must bear stressful news such as the death of a loved one to the family. We are only one generation removed from a centuries' old medical norm that practiced benevolent

deception. The better practice is to compassionately inform the patient of bad news so that she or he is able to control the medical decision-making process – thus braving the truth.

Study Questions1. What answer should be given to the patient in this situation?2. You diagnose a patient with gonorrhea and believe his wife needs

treatment. He asks you to treat her, but not tell her now she acquired the infection. What should you say to the man's wife?

3. A patient comes to the ED requesting opiate pain medication for his back pain. He is known to have a history of drug abuse. You prescribe an injectable anti-inflammatory medication. The patient asks what he is getting. Is it ethically justified to lie or "stretch the truth"? Does it make a difference if the patient has engaged in deception?

Bibliography1. Novack DH, Detering BJ, Arnold R et al: Physicians attitudes toward using deception to resolve difficult ethical problems JAMA 1989;261:2980-2985.2. Pellegrino ED: Is truth telling to the patient a cultural artifact? JAMA 1992;268:1734-1735.3. Schmidt TA, Norton RL, Tolle SW: Sudden death in the ED: Educating residents to compassionately inform families J Emerg Med 1992; 10:643-647.

V. The Physician-Patient RelationshipC. Compassion and Empathy

Objectives 1. Describe the importance of compassion and empathy in the ED. 2. Describe how compassion and empathy improve patient care, physician satisfaction, and

patient satisfaction.

Example CaseA patient with metastatic terminal prostate cancer comes to the ED for a "pain shot". He

is on Dilaudid, but lately the bone pain is severe. He is unable to take oral medications because of severe nausea and vomiting. He is anxious and frightened about dying. The department is busy, but he wants to talk to you about his fears. What ethical principles apply to this situation?

DiscussionAlthough empathy is a desirable attribute, it is not contained within the ethical principles,

yet provides depth and human feeling to them. Empathy is a central tenant of all aspects of medical ethics, without which the principles are barren, lifeless and lacking in color. The ability to “trade places” emotionally with the sick person allows health care providers to feel the anguish of the illness. Throughout history, physicians did little but provide a caring, empathetic ear to patients for whom they had no cure.

It is easy to be nice to patients whom we like and who have illnesses which impress us. Compassion and empathy are harder to feel when the patients are distasteful and non-compliant. Major tragedy may rarely move us, we may scoff at the "minor" complaints which generate so much concern. If we neither understand nor connect with the grief, fear and concern of our patients, however, we cannot address the feelings. Ignoring the emotional component of patients and families leaves them unsatisfied and leaves the physician, at best, ignorant of the patient's perspective. Compassion and empathy improve patient and physician satisfaction by promoting communication, minimizing conflict, and maximizes patient confidence in the diagnosis and treatment plan.

Study questions1. How should the physician respond in the above case?2. Can empathy be taught?3. How do we encourage empathy in physicians and trainees?

Bibliography1) Bellet P, Maloney M: The importance of empathy as an interviewing skill. JAMA 1991;266:1831-1832.2) Grumet G: Pandemonium in the modern hospital. N Engl J Med 1993;328:433-437.3) Novack DH, Dube C, Goldstein MG: Teaching medical interviewing Arch Intern Med 1992; 152:1814-1820.4) Nelson AR: Humanism and the art of medicine. JAMA 1989;262:1228-1230.

VI. Issues Related to JusticeA. Health Care Rationing

Objectives1. Define rationing.2. Define allocation.3. Explain how rationing and allocation impact emergency care.

Example CaseA 45-year-old man cuts his finger and then goes to the ED. In the ED he is noted to have

hypertension. The patient states that he was on medication for hypertension. However, because he lost his health care coverage he has not seen a physician and no longer takes his medication. He is given a prescription for a once a day ACE inhibitor, and the phone numbers of several physicians. When he goes to the pharmacy, he learns that the medication is expensive. He contacts each of the physicians to whom he was referred and none of them will accept new uninsured patients. He is referred to a local clinic, which has a 3-month waiting list. Because he was prescribed only enough medications for two weeks, he returns to the ED for follow-up.

DiscussionDistributive justice is a basic principle of medical ethics. It demands that we seek a

morally correct distribution of benefits and burdens in society. Distributive justice requires an equitable, but not necessarily, an equal allocation of health care resources. Norman Daniels has described equitable distribution as requiring that there be no information barriers, financial barriers or supply anomalies which prevent access to a "decent basic minimum" of health care.

Distributive justice affects allocation of health care resources at three separate levels. First, health care is but one of many societal interests. When society allocates its resources, health care competes with other interests including housing, education, defense, and the environment. Health care accounts for about 14% of the gross national product (GNP), and has been growing more rapidly than any other government program. Given our limited resources and a constrained federal budget, continued increases in health care expenditures will result in reductions in other programs.

At a second level, distributive justice affects allocation decisions involving health care resources. Health care is rationed (rationing is the distribution of a limited amount of goods and services) in all societies; the major difference is the criteria used for rationing. These criteria should be developed at the societal level, not the bedside. Our society must decide the appropriate allocation of limited resources to various medical interventions such as public health and preventive medicine, child and maternal health, new technologies, prehospital and emergency care, comfort, and palliation. The impact of poor nutrition, lack of adequate housing, inadequate education, pollution and violence on an individual's health must be considered.

At a third level, distributive justice affects allocation at the institutional level and bedside. In emergency medicine, the allocation of scarce resources is the ethical principle underpinning triage decisions. Physicians also consider distributive justice when making decisions about costs and resource allocation. Although some physicians believe it is unethical to allow costs to influence clinical decisions, a physician who ignores all cost considerations ignores the adverse consequences such decisions will have on their patient as well as others.

Physicians have enormous influence on health care expenditures. One of the basic tenets of our profession is the duty to work for the best interests of our patients. This implies that physicians must use resources that benefit the patient, without creating undue burden. Unfortunately, we frequently lack the outcome data to determine whether a specific treatment produces benefit, marginal benefit, no benefit or harm. In these cases we must use our best judgement about the potential benefits -- cost can and should be a part of that consideration. Despite the conventional view that physicians and patients make decisions at the bedside based solely on the best interests of the patient, many external factors including ability to pay, health insurance coverage, insurance mandates for a second opinion, and scarcity of resources can influence decision making.

Patients with no health insurance seek medical care for nonemergent problems in the emergency department. Appropriate care often requires follow-up by a primary care physician who may be unavailable to these patients. This issue is starkly defined because of the association between lack of insurance and increased mortality.

Decisions about health care allocation must be made both at the level of society (macroallocation) and at the level of the individual patient (microallocation). Although beneficence must be the guiding principle for microallocation decisions, distributive justice guides macroallocation decisions and also plays a role in microallocation decisions in our current system.

Study Questions1. What is distributive justice and how does it apply to health care?2. How does this case illustrate problems in our current delivery of health care?3. How do we currently ration health care?4. In your opinion, how should we ration health care?

Bibliography1. American College of Physicians Ethics Manual Ann Intern Med 1992; 117:947-960.2. Callahan D: Rationing medical progress: the way to affordable health care. N Engl J Med 1990;322:1810-1813.3. Daniels N: Just Health Care Cambridge University Press, Cambridge, 1985.4. Eddy DM: Rationing by patient choice. JAMA 1991;265:105-108.5. Iserson KV: Assessing values: Rationing emergency department care. Am J Emerg Med 1992;10:263-264.

VI. Issues Related to JusticeB. Duty

Objectives1. Define the "Good Samaritan" statute in your state.2. Explain the applicability of the "Good Samaritan" statute to emergency physicians in the prehospital setting and in the ED.3. Define your ethical and legal duty to patients who present to the ED.

Example CaseA patient presents to the ED with nausea, vomiting, and mild diarrhea. The patient

belongs to an HMO that requires pre-approval for emergency care. The HMO denies approval for the patient to be seen in the ED, since the patient has no fever, no significant abdominal pain, and is not dehydrated.

Discussion Emergency physicians have both an ethical and legal duty to evaluate and treat any

patient who requests treatment. These patients must at least be screened to ensure that no illness exists that will cause harm to the patient if untreated. This obligation also has been codified into federal law by the COBRA-EMTALA legislation. Reimbursement issues do not affect this duty; all patients must be evaluated regardless of ability to pay. If potentially significant illness or injury is present, the patient must be stabilized or treated.

In an effort to control costs, more third party payors attempt to limit access to specialists and other services. Nonetheless, the ED must maintain their availability to all patients who seek services, and, at a minimum, screen patients to determine the extent of their urgent medical need.

However, other circumstances exist that may limit the obligation to treat patients. Although all health care providers assume some personal risk in choosing to treat patients, emergency physicians do not have to place themselves in excessive physical danger. Patients who are threatening physical harm to staff or other patients do not have a right to treatment. Weapons can also be removed from patients as a condition of treatment. We do have an ethical obligation to treat patients despite the risk of exposure to contagious diseases.

In addition to defining the responsibility of health care workers on the job, society has an interest in promoting the willingness of physicians to assist others in need even when the person with expertise is not on the job. "Good Samaritan" statutes have been instituted to serve this end. These laws generally state that a person who has no duty to another and expects no payment for services is protected by law as long as no gross and willful negligence is committed. The "Good Samaritan" rule does not generally apply to physicians in the ED since a duty is generally recognized to all patients present, but would apply to an emergency physician who comes upon an automobile accident or witnesses a cardiac arrest.

Study Questions1. What is the duty of the emergency physician to the patient in this case?2. Under what circumstances might you refuse treatment to a patient?

3. Is it acceptable for the emergency physician to look at the patient, briefly examine the abdomen, and provide detailed, written instructions of signs and symptoms that signify an emergency?

Bibliography1. Curran WJ: Economic and legal considerations in emergency care. N Engl J Med 1985;312:374-375.2. Derlet RW, Nishio DA: Refusing care to patients who present to an emergency department: Ann Emerg Med 1990:19:262-267.3. Miles SH: What are we teaching about indigent patients? JAMA 1992;268:2561-2562.4. Shaw KN, Selbst SM, Gill FM: Indigent children who are denied care in the emergency department. Ann Emerg Med 1990;19:59-62.5. Zuger A: professional responsibilities in the AIDS generation. Hastings Cent Rep June 1987;17:16-20.

VI. Issues Related to JusticeC. Moral Issues in Disaster Medicine

Objectives1. Discuss the scope and limits of medical effectiveness in disaster situations.2. Identify the moral principles underlying triage.3. Discuss criteria for making triage decisions and their ethical justification.

Example Case A plane crashes, resulting in many injured patients. The victims range in age from 1 year

old to 93 years old. One of the victims is a US senator. Some of the patients have severe burns, others blunt head, abdominal, or chest trauma. There are eight patients in cardiopulmonary arrest. One patient has agonal respirations, and another has almost 100% body burns. A woman is in labor and at least five patients are in shock. At least fifteen patients have minor injuries. You are the sole physician present.

DiscussionIn disasters, when resources are scarce, the primary ethical principle becomes justice.

The goal is to treat people equitably and fairly. This has led to the practice of triage. Triage is based on the ethical principle of providing the greatest benefit to the greatest number. However, there will always be some uncertainty as to what benefit a particular patient will derive from any action. Based on this principle, the first treatment priority is given to firefighters, public safety, and medical personnel who might be able to return to the rescue effort. Next, those injuries that are most amenable to treatment, such as airway obstruction and bleeding, and those activities most useful in alleviating suffering, such as administration of pain medication, are emphasized.

Should there be any differentiation based on age or social worth? Thus, although it is tempting to consider the value of the various victims, the general consensus of most ethicists is that social worth is an unfair criterion for the distribution of resources. Rather, treatment is based on medical need and the likelihood of benefit.

Study questions1. How should you proceed to care for patients in this case?2. Would you give some priority attention to the US Senator?3. Could any patient distract you and cause you to pay extra attention or provide longer, more attentive care?

Bibliography1. Bell NK: Triage in medical practices: An unacceptable model? Soc Sci Med 1981;15F:151-156.2. Jonsen AR, Siegler M, Winslade WJ: Clinical Ethics 3rd ed, McGraw-Hill Inc, New York, 1992, p 139.3. Pledger HG: Triage of casualties after nuclear attack. Lancet 1986;678-679.4. Triage in Reich W (ed) Encyclopedia of Bioethics 2nd ed The Free Press, New York, 1992.

5. Winslow GR: Principles for triage, in Triage and Justice, Berkeley, University of California Press, 1982, pp 60-109.

VI. Issues Related to JusticeD. Research

Objectives1. Define the moral principles for research on human subjects.2. Describe the unique moral challenges that face research in an emergency setting.3. Describe how to obtain informed consent for research.

Case Example A 39-year-old man took 30 mg of lorazepam. He was somnolent but arousable and his

vital signs were stable. He and his family were informed that he would be transported to the medical center across town "since they have a medicine to treat this overdose." (The center was conducting trials with a benzodiazepine antagonist).

DiscussionAs a result of the atrocities of medical experiments carried out by the Nazis in World War

II, the infamous Tuskegee Syphilis Study, and other unethical research, governments and professional organizations made a concerted effort to develop ethical principles for biomedical research. The Nuremberg Code, the Helsinki Declaration and the Belmont Report serve as a foundation for developing ethical principles for research. These principles include respect for people as autonomous agents, truth telling, beneficence in maximizing the benefits and minimizing the burdens for research subjects, and justice in equitably distributing the benefits and burdens of research.

Because physicians depend on research to improve patient care, we must be conversant with the ethical issues in research. Among the most important issues are scientific misconduct (fraud, plagiarism, the fabrication of data), unethical treatment of human and nonhuman subjects, conflict of interest, and responsibilities to colleagues, student and other trainees.

A particularly difficult area for emergency medicine is informed consent for resuscitation and other research when time is critical and the patient does not have decision-making capacity. In the past, guidelines have allowed the use of deferred consent, in which consent was obtained after the study intervention. Deferred consent is criticized as an illogical concept, and recent developments suggest that waived consent is more appropriate. The current criteria for waived consent are:

1) minimal risk to subjects2) the waiver will not adversely affect the rights and welfare of the subjects3) the research could not be carried out without the waiver4) subjects will be provided information following participationIn recent years, the federal government, professional organizations and institutions have

developed policies and procedures to address some other ethical concerns. One example of this is the "Uniform Requirements for Manuscripts Submitted to Biomedical Journals" developed by the International Committee of Medical Journal Editors.

Study Questions1. Is it appropriate for patients to be transported to a particular hospital in order to enroll them in a research protocol?

2. How should consent be obtained for resuscitation research?3. Is it possible to obtain informed consent for emergency research?

Bibliography1. International Committee of Medical Journal Editors: Uniform requirements for manuscripts submitted to biomedical journals Ann Intern Med 1988; 108:258-265.2. Sieber JE: Ethical considerations in planning and conducting research on human subjects Academic Medicine 1993; 68 (supp):s9-s13.3. Spivey WH, Abramson NS, Iserson KV, MacKay CR, Cohen MP: Informed consent for biomedical research in acute care medicine. Ann Emerg Med 1991;20:1251-1265.

4. US Government: The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research US Government Printing Office, Washington D.C., 1988.VII. Teaching

Objectives1. Describe the ethical issues surrounding the use of animals for teaching and research.2. Describe the ethical issues surrounding the use of the newly dead for education.

Example CaseCardiopulmonary resuscitation is attempted on an 88-year-old patient. Efforts were

discontinued after 35 minutes – the patient is pronounced dead. One of the residents asks to extubate then reintubate the patient for practice.

Clinical TeachingA major obligation of academic physicians is to ensure that future generations of

physicians possess the requisite skills to effectively provide medical care. Physicians share an obligation to be skilled and competent when they hold themselves out as medical professionals. The unskilled professional-in-training must acquire the professional attributes prior to assuming full responsibility for patient care. These professional attributes include the requisite knowledge, appropriate behavior, and technical abilities.

Educational programs must balance the resident's need for graded responsibility with the patient's right to be treated by a fully qualified physician. In the past, an implicit assumption was made that indigent patients paid for their health care by allowing “learners” to treat them. With health care reform this may change, however, students and residents will continue to need access to patients and learning opportunities.

Acquiring technical skills such as endotracheal intubation, central line placement, and chest tube thoracostomy requires that the trainee has appropriate practice prior to performing it in time of crisis. Practice is appropriately acquired on plastic mannequins, but the mannequin remains an imperfect model. In addition, these skills can be learned in more controlled settings such as operating room intubation, central line placement in stable ICU patients and chest tubes in the stable patient with a spontaneous pneumothorax. However, these forms of training may be inadequate.

The Use of Models for Teaching

Controversy exists about the use of animals, as well as the use of recently deceased human beings. Groups concerned about the use of animals in teaching and experimentation express two ethical concerns about the use of animals. Those who support animal rights express the belief that animals, like humans, have certain basic rights as sentient beings. Animals are incapable of giving informed consent and should, therefore, not be used for teaching or experimentation. Others, while not expressing concern about the rights of animals are concerned about animal welfare. These people are concerned about inhumane treatment and unnecessary harm.

Institutions have developed committees that address issues surrounding the use of animals in the same way that institutional review boards address research on human subjects. Any use of animals requires treatment and care that is as humane and discomfort-free as possible.

Controversy also exists about performing procedures on the newly dead. Those who oppose practicing procedures on the newly dead raise concerns about respect for autonomy. The patient is unable to give consent, and generally empathy and compassion preclude us from asking the bereaved family for consent. However, it may be argued that respect for autonomy is based on principles of freedom and liberty that do not apply to the dead. In addition, based on utility, little or no harm is done to the deceased and much might be gained by resident education. Some also make a distinction between non-disfiguring procedures such as intubation, and more invasive procedure such as chest tubes.

Study Questions1. Does your institution allow or encourage practice of invasive skills on recently deceased patients? 2. Should consent be obtained from the family?3. Should an attending physician see every patient who comes to the emergency department of a teaching hospital?4. What guidelines does your institution have on the use of animals for teaching? Are these guidelines ethically justified?5. What do you believe about the use of animal model in teaching as well as the use of the newly dead?

Bibliography1. Iserson KV: The supervision of physicians in training: an educational and ethical dilemma. Medical Teacher 1988; 10:195-201.2. Iserson KV: Requiring consent to practice and teach using the recently dead. J Emerg Med 1991; 9:509-510.3. Iserson KV: Postmortem procedures in the emergency department: using the recently dead to practice and teach. J Med Eth June 1993.4. Varner GE: The prospects for consensus and convergence in the animal rights debate Hastings Center Report 1994; 24 (1):24-28.5. Winkenwerder W: Ethical dilemmas for house staff physicians. JAMA 1985; 254:3454-3457.

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VIII. Relationships with the Biomedical Industry

Objectives1. Discuss promotional offerings that are clearly not to be accepted by physicians.2. Explain circumstances when gifts of nominal value can be accepted.3. Explain why the relationship with industry must remain ethically appropriate.

Example CaseA drug company representative in the ED asks to speak with the senior resident

for a moment. The senior resident sits with the representative in the charting area, and they discuss the value of his company's new antibiotic compared to other products on the market. The representative distributes promotional material. The representative then passes out company pens, note pads, and penlights to the residents, and presents a "textbook" on infectious diseases for the ED library. The resident thanks the representative for his gratuities. The representative passes out his card and offers to bring food to one of the future resident conferences, or pay for a noted speaker to come.

DiscussionThe interaction between residents and the biomedical industry is becoming an

increasing concern. As the biomedical industry competes in a free enterprise market system, they must advertise products to physician consumers. Nevertheless, physicians must base their pharmacotherapy on the scientific literature. Promotional materials developed by the biomedical industry do not always provide objective scientific data regarding a product. Physicians may be unaware of the impact of promotional materials and gift giving on their clinical decisions. Since biomedical industry representatives are motivated to promote only their product, a presentation from them is inherently biased.

Speakers who receive excessive compensation can also have a conflict of interest. Invitations to speak at residency or CME conferences should come from the residency organization itself and not from the biomedical company. It is the residency program's responsibility to ensure that a balanced, unbiased view of the scientific data is presented. Academic programs should set up guidelines to regulate the interaction of residents with the biomedical industry.

A gift accepted by a resident physician should provide an education to the physician, or a direct benefit to the physician's patients. Residents of a program may accept textbooks of reasonable value, provided they are publications not specifically produced by the biomedical company. It is common for physicians to accept gifts of nominal value such as pens, penlights, note pads. Gifts of significant value such as tickets to sporting functions, expensive dinners, or hospitality suite parties should be avoided. One standard to judge whether the gift is appropriate is to ask the question, "Would I be willing to defend this gift to my patients?" No gift should be accepted if it is given to reward a specific prescribing pattern or other physician behavior.

A positive and ethical relationship with the biomedical industry can exist. Scholarships, residency program support, monies to stimulate resident research or education could be directed to the residency organization itself, bypassing individual physician influence.

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Study Questions1. Why do biomedical promotional activities, such as gift giving, present potential ethical conflicts to the emergency physician?2. What aspects of promotional materials and presentations by company-sponsored speakers could subvert a balanced, unbiased medical education?3. How can physicians and residency programs interact to promote ethical relationships with the biomedical industry?

Bibliography1. American Medical Association: Gifts to physicians from industry. JAMA, 1991; 265:501.2. Kessler DA, Pines WL: The federal regulation of prescription drug advertising and promotion. JAMA, 1990; 264:2409-2415.3. Chren MM, Landefeld S, Murray TH: Doctors, drug companies, and gifts. JAMA 1989;262:3448-3451.4. Sanders AB, Keim SM, Sklar D, Adams J: Emergency physicians and the biomedical industry. Ann Emerg Med 1992;21:556-558.

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Additional Case Scenarios

Case 1The mother brings in a 15-year-old female after ingesting multiple medications in a suicide attempt. She is observed for the appropriate time in the ED where she remains asymptomatic. Laboratory tests are also normal. During her stay the patient repeatedly expresses her desire to die and is remorseful only for the fact that the medications she took “must not have been strong enough”. You explain to the mother that the patient needs emergent psychiatric evaluation. The mother states her daughter already has an appointment with a therapist and does not wish to take the daughter for emergency psychiatric evaluation because it is already 3 a.m. You explain the urgency of the situation and offer to provide transportation but the mother refuses the multiple requests and states she wants to “sign her daughter out”.

Are there any ethical principles that apply to this scenario?What are you options?

Suggestions:What does the patient wantsInvolve the father or other family membersInvolve the family doctorCourt orderCall Social Services immediatelyRelease the child but fill out an emergent social service evaluation

Case 217-year-old woman seeks treatment for “a female problem”. Her father (who brought her to the ED) leaves the room for the examination brings her. With the father absent, the patient states she has had unprotected intercourse the previous evening and wants the “morning after” pill so that she will not become pregnant. She further states that you say nothing to her father as “not only will he kill my boyfriend, but he is real religious and does not believe in birth control”. The father returns after the examination and demands to know what is wrong with his daughter.

Are there any ethical principles that apply to this scenario?What are your options?

Suggestions:Give the prescription to the daughter and say nothing and tell the father to ask his daughter.Tell the fatherUrge the daughter to tell her fatherUrge the daughter to go to Planned Parenthood for some appropriate clinic and you do not give her the prescription.Involve the mother or other family member

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Case 3An 18-month-old boy is brought to the ED for difficulty in breathing by a neighbor who is watching the child. The child is in obvious respiratory distress with an oximetry oxygen saturation of 82%. When asked if the child’s parent has been called the neighbor states that the mother is schizophrenic and would have refused treatment as she “hates hospitals”. In fact, earlier in the day when the neighbor suggested that the baby be taken to the pediatrician, the mother became angry and threatened her. The father is unknown. The mother is the guardian as far as the neighbor knows. The child is stabilized in the ED and diagnosed with pneumonia. She will require admission. The mother is called, clearly paranoid, and refuses any further medical care for her child.

Are there any ethical principles that apply to this scenario?What are your options?

Suggestions:Emergent Social Service evaluationDeclare the mother incompetent and admit child anywayContact mother’s psychiatrist

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Code of Ethics for Emergency Physicians

Approved by the ACEP Board of Directors June 1997Reaffirmed October 2001 by ACEP Board of DirectorsThis statement replaces Ethics Manual approved January 1991

Contents

I. Principles of Ethics for Emergency PhysiciansII. Ethics in Emergency Medicine: An Overview

A. Ethical Foundations of Emergency Medicine 1. Moral pluralism 2. Unique duties of emergency physicians

B. The Emergency Physician-Patient Relationship 1. Beneficence 2. Respect for patient autonomy 3. Fairness 4. Respect for privacy 5. Nonmaleficence 6. Patient's responsibilities

C. The Emergency Physician's Relations with Other Professionals 1. Relationships with other physicians 2. Relationships with nurses and paramedical personnel 3. Impaired or incompetent physicians 4. Relationships with business and administration 5. Relationships with trainees 6. Relationships with the legal system as expert witness7. Relationships with the research community

D. The Emergency Physician's Relationships with Society 1. The emergency physician and society 2. Resource allocation and health care access: problems of justice 3. Central tenets of the emergency physician's relationship with society:

a. Access to emergency medical care is a fundamental right b. Adequate inhospital and outpatient resources must be available to guard

patients' interests c. Emergency physicians should promote cost effectiveness without

compromising quality d. The duty to respond to out-of-hospital emergencies and disasters e. The duty to oppose violence The duty to promote the public

health

III. A Compendium of ACEP Policy Statements on Ethical Issues (Approved 1997; Revised 2000; Revised 2001; Revised 2002)

A. ACEP Business Arrangements

B. Agreements Restricting the Practice of Emergency Medicine

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C. Alcohol Abuse and Motor Vehicle Safety

D. Animal Use in Research

E. Antitrust

F. Appropriate Interhospital Patient Transfer

G. Collective Bargaining, Work Stoppages, and Slowdowns

H. Cultural Competence and Emergency Care

I. Delivery of Care to Undocumented Persons

J. Discontinuing Resuscitation in the Out-of-Hospital Setting

K. "Do Not Attempt Resuscitation" Directive in the Out-of-Hospital Setting

L. Economic Credentialing

M. Emergency Medicine's Role in Organ and Tissue Donation

N. Emergency Physician Contractual Relationships

O. Emergency Physician Rights and Responsibilities

P. Emergency Physician Stewardship of Finite Resources

Q. Emergency Physicians' Patient Care Responsibilities Outside of the Emergency Department

R. Ethical Issues of Resuscitation

S. Evaluation and Treatment of Minors

T. Expert Witness Guidelines for the Specialty of Emergency Medicine

U. Filming in the Emergency Department

V. Gifts to Emergency Physicians from the Biomedical Industry

W. Good Samaritan Protection

X. Hospital, Medical Staff, and Payer Responsibility for Emergency Department Patients

Y. Managed Care and Emergency Medical Ethics

Mandatory Reporting of Domestic Violence to Law Enforcement and Clinical Justice Agencies

Z. Nonbeneficial ("Futile") Emergency Medical Interventions

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AA. Patient Confideniality

BB. Physician Impairment

CC. Positive Promotions

DD. Responsibilities of Acute Care Hospitals to the Community

EE. Role of the Emergency Physicians in the Prevention of Pediatric Injury

FF. Universal Health Care Coverage

GG. Use of Patient Restraints

I. PRINCIPLES OF ETHICS FOR EMERGENCY PHYSICIANS

The basic professional obligation of beneficent service to humanity is expressed in various physicians' oaths. In addition to this general obligation, emergency physicians assume more specific ethical obligations that arise out of the special features of emergency medical practice. The principles listed below express fundamental moral responsibilities of emergency physicians.

Emergency Physicians Shall:

1. Embrace patient welfare as their primary professional responsibility.2. Respond promptly and expertly, without prejudice or partiality, to the need for emergency

medical care.

3. Respect the rights and strive to protect the best interests of their patients, particularly the most vulnerable and those unable to make treatment choices due to diminished decision-making capacity.

4. Communicate truthfully with patients and secure their informed consent for treatment, unless the urgency of the patient's condition demands an immediate response.

5. Respect patient privacy and disclose confidential information only with consent of the patient or when required by an overriding duty such as the duty to protect others or to obey the law.

6. Deal fairly and honestly with colleagues and take appropriate action to protect patients from health care providers who are impaired, incompetent, or who engage in fraud or deception.

7. Work cooperatively with others who care for, and about, emergency patients.

8. Engage in continuing study to maintain the knowledge and skills necessary to provide high quality care for emergency patients.

9. Act as responsible stewards of the health care resources entrusted to them.

10. Support societal efforts to improve public health and safety, reduce the effects of injury and illness, and secure access to emergency and other basic health care for all.

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II. ETHICS IN EMERGENCY MEDICINE: AN OVERVIEWA. Ethical Foundations of Emergency MedicineAlthough professional responsibilities have been a concern of physicians since antiquity, the last twenty-five years have seen dramatic growth of both professional and societal attention to moral issues in health care. This increased interest in medical ethics is because of such factors as the greater technologic power of contemporary medicine, the medicalization of societal ills, the growing sophistication of patients, efforts to protect the civil rights of disadvantaged groups in our society, and most recently, the rapidly escalating cost of health care. All of these factors contribute to the centrality, the complexity, and the urgency of moral questions in contemporary emergency medicine.

1. Moral pluralism

In addressing these questions, emergency physicians can consult a variety of sources for moral guidance. Professional oaths and codes of ethics are an important source of guidance, as are general cultural values, social norms as embodied in the law, religious and philosophical moral traditions, and professional role models. All of these sources claim moral authority and together they can inspire physicians to lead rich and committed moral lives. Problems arise, however, with the realization that different sources of moral guidance can, and often do, come into conflict in our pluralistic society. Numerous attempts have been made to find an overarching moral theory able to assess and prioritize moral claims from all of their various sources. Lacking a conclusive argument for the primacy of any one of these theories, we are left with a pluralism of different sources of moral guidance. The goal of bioethics, then, is to help us understand, interpret, and weigh our competing moral values as we seek reasoned and defensible solutions to the moral problems.

2. Unique duties of emergency physicians

The special setting and goals of emergency medicine give rise to a number of distinctive ethical concerns. First, patients often arrive at the emergency department with acute illnesses or injuries that require immediate care. Thus, emergency physicians have little time to gather additional data, consult with others, or deliberate about alternative treatments. Instead, in emergent situations, there is a presumption for quick action guided by predetermined treatment protocols. Second, patients in the ED often are unable to participate in decisions regarding their health care because of acute changes in their mental state. Thus, emergency physicians often are unable to consult with patients about their treatment preferences. Third, emergency physicians typically have had no prior relationship with their patients in the ED. Patients often arrive in the ED unscheduled, in crisis, and sometimes against their own free will. Thus, emergency physicians cannot rely on earned trust or on any prior knowledge of the patient's condition, values, or wishes regarding medical treatment. Fourth, emergency physicians typically practice in an institutional setting, the hospital ED, and in close working relationships with other physicians, nurses, emergency medical technicians, and other health care professionals. Thus, emergency physicians, to function appropriately, need to understand and respect institutional regulations and inter-professional norms of conduct. Fifth, emergency physicians have, in the United States, been given the social role and responsibility to act as health care providers of last resort for patients who have no other ready access to health care. Sixth, emergency physicians have a societal duty to render emergency aid outside their normal health care setting when such intervention may save life or limb. Finally, by virtue of their broad expertise and training, emergency physicians are expected to be a resource for the community in prehospital care, disaster management, toxicology, cardiopulmonary resuscitation, public health, injury control, and related areas. All of these special circumstances shape the moral dimensions of emergency medical practice in important ways.

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B. The Emergency Physician-Patient Relationship

The physician-patient relationship has been and remains the moral center of medicine and the major defining element in biomedical ethics. Broad principles can help to categorize the emergency physician's (and the patient's) ethical duties, but the unique nature of emergency medical practice, and the diversity of emergency patients, pose special moral challenges for the emergency physician. For example, the emergency physician-patient relationship is usually episodic, dictated by the patient's urgent need for care. Thus, the patient's willingness to seek emergency care and to trust the physician is based on institutional and professional assurances rather than on a personal acquaintanceship. The emergency physician's ethical duties in these relationships may be categorized into those dealing with beneficence, autonomy, fairness and nonmaleficence. Patients have ethical responsibilities in these relationships as well.

1. Beneficence

Physicians serve the best interest of their patients by treating or preventing disease or injury and by informing patients about their conditions. Emergency physicians respond quickly to acute illnesses and injuries to prevent or minimize pain and suffering, loss of function, and loss of life. In achieving these goals, emergency physicians serve the principle of beneficence, that is, they are acting in the best interests of their patients.

2. Respect for patient autonomy

Adult patients with decision-making capacity have a right to, and physicians the concomitant duty to respect, their preferences regarding their own health care. This right is grounded in the legal doctrine of informed consent. According to this doctrine, patients with decision-making capacity must give their voluntary consent to treatment after receiving appropriate and relevant information about the nature of the affliction and expected consequences of recommended treatment and treatment alternatives. Emergency physicians also should respect decisions about a patient's treatment made by surrogate decision makers or agents named in a health care durable power of attorney, if the patient lacks decision-making capacity. Emergency physicians should be able to determine whether a patient has decision-making capacity and who can act as a decision maker if the patient is unable to do so.

Emergency physicians may treat without securing informed consent when immediate intervention is necessary to prevent death or serious harm to the patient. This is, however, a limited exception. When the initiation of treatment can be delayed without serious harm, informed consent should be obtained. Even if all the information needed for an informed consent cannot be provided, the emergency physician should, to whatever extent time allows, inform the patient (or, if the patient is incompetent, a surrogate) about the treatment he or she is providing, and should not violate the competent patient's explicit refusal of treatment. Federal regulations also permit the waiver of consent for a limited number of emergency research protocols, provided they are ethical, approved by the appropriate governing bodies, and obtaining consent is not otherwise feasible.

To act autonomously, patients must receive accurate information on which to base their decisions. Emergency physicians should relay sufficient information to patients for them to make an informed choice among various diagnostic and treatment options. Emergency physicians, when speaking to patients and families, must not overstate their experience or abilities, or those of their colleagues or institution. Neither should they overstate the potential benefits or success rates of the treatment, procedures, or the research they propose. In some cases, for personal and cultural reasons, patients will ask that information be given to family or friends and that these third parties be allowed to make treatment choices for the patient. Patients may, if they wish, transfer

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decision-making authority over their care to others. Emergency physicians should rarely be the persons assuming this role.

Special moral issues may arise in the care of terminally ill patients. Emergency physicians should, for example, be willing to respect a terminally ill patient's wish to forgo life-prolonging treatment, as expressed in a living will or through a health care agent appointed under a durable power of attorney for health care. Emergency physicians should also be willing to honor "Do Not Attempt Resuscitation (DNAR)" orders appropriately executed on behalf of terminally ill patients. Emergency physicians should understand established criteria for the determination of death and should be prepared to assist families in decisions regarding the donation of a patient's organs for transplantation.

3. Fairness

Emergency physicians should act fairly toward all persons who rely on the ED for unscheduled episodic care. They should respect and seek to understand people from many cultures and from diverse socioeconomic groups. In the United States emergency physicians provide necessary emergency care to all patients, regardless of ability to pay. Emergency physicians also should strive to avoid having patient finances govern access to appropriate inpatient or follow-up medical care. Provision of emergency medical treatment should not be based on gender, age, race, socioeconomic status, or cultural background. No patient should ever be abused, demeaned, or given substandard care.

4. Respect for privacy

Emergency physicians should be compassionate and truthful in all of their communications with patients. Emergency physicians also have a responsibility to protect the confidentiality of patient information. Sensitive information may only be disclosed when such disclosure is necessary to carry out a stronger conflicting duty, such as a duty to protect an identifiable third party from serious harm or to comply with a just law.

5. Nonmaleficence

Nonmaleficence, or not harming patients, is a key to maintaining the emergency physician's integrity and the patient's trust. Emergency physicians must never endanger patient safety or subject their patients to excessive harms or risks. Acting on the principle of nonmaleficence, emergency physicians also should do what is necessary to physically protect themselves, their coworkers, and their patients from violent acts by known perpetrators, other patients, or by visitors to the ED. Emergency physicians should also strive to protect patients from impaired health care providers or other third parties that place the health of patients at risk. Physicians who lack appropriate training, experience, and knowledge of emergency medicine should not misrepresent themselves as emergency physicians. Physicians without adequate training and knowledge should not practice unsupervised in the ED or prehospital setting.

6. Patient responsibilities

Any relationship has two sides. Patients also have ethical responsibilities in the emergency physician-patient relationship. Patients should use emergency services only when they either have what they believe to be an emergency or when they have no access to health care elsewhere. Patients also should deal openly and honestly with their emergency physicians to foster understanding, trust, and therapeutic success. Patients must also strive to respect triage decisions and seek to understand the need to prioritize emergency patients.

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C. Emergency Physicians Relationships with other Professionals

The practice of emergency medicine requires multidisciplinary cooperation and teamwork. Emergency physicians interact with other participants in the health care system, usually more directly than physicians from other specialties. General ethical rules governing these interactions include honesty, respect, appreciation of other perspectives and needs, and an overriding concern for patient benefit.

1. Relationships with other physicians

Emergency physicians, keeping patient benefit as a primary goal, must participate with other physicians in the provision of health care. Channels of communication between health care providers must remain open to optimize patient outcomes. However, communication may be interrupted when a sick patient requires immediate and definitive intervention before discussion with other physicians can take place. When possible, emergency physicians should cooperate with the primary physician to provide continuity of care that satisfies the needs of the patient, and minimizes burdens to other providers. Although the patient's primary physician has a moral, legal, and often financial interest in coordination of care, patient benefit must remain paramount. Concerns regarding the extent of primary care rendered and referral required should be discussed with the primary physician whenever possible.

Physicians who provide on-call services to ED patients usually are fulfilling an obligation of medical staff membership; they may also be financially supported for these services. On-call physicians, like the emergency physicians, are morally obligated to provide appropriate medical care. In turn, the emergency physician should strive to treat consultants fairly, and to make efficient care possible. Consultant choice may be guided by the preferences of both the primary care physician and the patient or by a rotation system of some sort. The hospital and its medical staff are obligated morally and legally to provide appropriate and timely "back-up" care for patients who present to the ED requiring such care. If a designated consultant refuses to evaluate a patient in the ED, the emergency physician may have to call another consultant, discuss the situation with the hospital administrator, or transfer the patient to another facility that has the resources available to care for the patient.

If multiple physicians work in the ED, each patient should have a clearly identified physician who is responsible for his or her care. Transfer of this responsibility should be clear to the patient, families, and staff involved, and should be clearly documented on the patient's medical record. When a patient is discharged from the ED, there must be a clear transfer of responsibility to the admitting or follow-up physician. This transfer must be clearly communicated to the patient when possible.

Contractual relationships between an emergency physician and an emergency physician group should be fair to all parties involved. Compensation should take into account both clinical and administrative services rendered by the physician. Disagreements arising from contractual arrangements should be arbitrated appropriately using a due process approach, whenever possible. Physicians with disabilities, injuries, or infections such as HIV may practice emergency medicine if their duties do not constitute a threat of harm to patients or others.

2. Relationships with nurses and paramedical personnel

Although the emergency physician assumes primary responsibility for patient welfare, emergency medicine is almost always a team effort. For any specific patient, the physician must coordinate the efforts of nurses and support staff. For patient care in general, physicians must work with others to develop systems and protocols that provide effective care for patients who present to the ED. The specific skills and expertise of nurses and other support staff are most effectively

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utilized if there is input from all involved in the design and execution of these systems and protocols.

In the prehospital setting, emergency medical technicians of all levels rely on, and rightfully expect the cooperation of emergency physicians with whom they work. Base station command physicians and other emergency providers should strive to work harmoniously with prehospital personnel to optimize care for the patient. Patient-centered, nonjudgmental, and open communication is an important part of ethical medical command. Hospital and prehospital providers must respect patient confidentiality and the dignity of all personnel involved.

While the emergency physicians may have greater expertise in scientific and technical matters, the physician shares equal expertise with other health care workers with regard to moral judgment. Physicians should encourage involvement of other providers and staff when ethically problematic cases arise.

3. Impaired or incompetent physicians

The principle of nonmaleficence dictates that patients be protected from physicians who are incompetent or impaired. While no physician is perfect, emergency physicians should strive for technical and moral excellence. They should perform in a manner that exemplifies high levels of skill and character, avoiding fraud or deception. When any physician is found deficient through peer review or other means, it is morally imperative to protect patients and to assist that physician in addressing and possibly overcoming such deficiencies. Corrective action may include internal discipline and/or remedial training. Appropriate remediation will ensure that only physicians with appropriate training and skill will practice as attending emergency physicians.

Whenever a colleague or consulting physician is believed to be incompetent or impaired by drugs, alcohol, or psychiatric or medical conditions, there is a duty to report the impaired physician to the chief of service, the chief of medical staff, and appropriate committees or regulatory agencies. This should be done with great discretion and sensitivity, with a clear intention toward helping the impaired physician embark on the road toward treatment and recovery. Physicians who conscientiously fulfill this responsibility should be protected from adverse political, legal, or financial consequences.

4. Relationships with business and administration

Emergency physicians should be advocates for emergency medical care as a fundamental right. Cost effective and efficient care is important so that resources can be available to provide care when needed. Cooperation with persons whose expertise is in the management and administration of health care systems is essential for provision of efficient care. The physician's role is to keep patients' interests paramount in administrative decisions.

Incentives from businesses, including managed care organizations and biomedical companies, should not unduly influence patient-centered clinical judgment. Gatekeeping activities that threaten patient safety are unethical as are clauses that prevent physicians from informing patients about reasonable treatment alternatives. Physicians should not accept expensive gifts, trips, or items from pharmaceutical or medical equipment companies or their representatives, except when the item is specifically and solely for patient use or educational purposes.

5. Relationships with trainees

Emergency physicians must take seriously their responsibilities to medical students, residents, prehospital care personnel, and trainees of all types to teach them both the moral and technical aspects of emergency medical practice. The fundamentals of honest doctor-patient

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communication and the ethical aspects of academic emergency medicine, teaching, and research should also be taught and modeled for students by emergency physicians in practice.

Trainees, like patients, are a vulnerable population, and they must not be mistreated, abused, or coerced for faculty self-interest. Teaching physicians must fulfill their obligation to teach and provide appropriate levels of supervision for students under their tutelage. Written appraisals of performance and letters of recommendation require a careful assessment of the trainees' strengths and weaknesses. Such evaluations must be accurate and clearly identify those individuals who may jeopardize patient care. Patient interests should not be compromised in the education process, and patients should never be required to participate in teaching activities or research without their consent. Trainees, in return, must strive to master the discipline of emergency medicine, emphasizing their moral duties to patients, profession, and society.

6. Relationships with the legal system as an expert witness

To protect patients and to uphold the standards of high quality emergency care, it is morally and legally appropriate for emergency physicians with sufficient expertise to testify in a court of law. The American College of Emergency Physicians has suggested that to act as an expert witness, at a minimum, a physician should be board certified or board prepared in emergency medicine and be in the active practice of emergency medicine for three years prior to the date of the incident.

As an expert witness, the physician has a clear ethical responsibility to be objective, truthful, and impartial when evaluating a case on the basis of generally accepted standards of practice. It is unethical to overstate one's opinions or credentials, to misrepresent maloccurence as malpractice, to bear false testimony, or to use the name of the College as prima facie evidence of expertise.

Expert legal testimony should not be provided solely for financial gain lest the access to payment unduly influence the testimony one may provide. Reasonable compensation for a physician's time is ethically acceptable, but financial remuneration must remain secondary. Expert testimony by emergency physicians can be useful to patients, the profession, and society, but professional peer review of an expert's testimony is encouraged.

7. Relationships with the research community

The emergency physician researcher should abide by the basic principles as outlined by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research and the Declaration of Helsinki. Emergency physician researchers must abide by federal, institutional, and professional guidelines that govern human and animal research. To be ethical, studies must be well designed and be worth the risks to patients and society. Approval from the appropriate institutional review boards is required, but it is the responsibility of the investigator to ascertain that informed consent, confidentiality, and patient well-being are adequately protected. New federal regulations allow a limited waiver of informed consent for some critically ill patients in FDA-approved protocols. It is imperative that data be collected carefully, interpreted correctly, and reported accurately. Research misconduct and fraud are grounds for disciplinary action and loss of funding. Responsible authorship also is important; co-authors are required to actively participate in all parts of the study including literature review, study design, data collection, data analysis, and manuscript preparation.

D. The Emergency Physician's Relationship with Society

1. The emergency physician and society

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The emergency physician owes a duty not only to his or her patient, but also to the society in which the physician and patient dwell. Though the emergency physician's duty to the patient is primary, it is not absolute. The emergency physician must balance the patient's interest against the interests of society, which enables the doctor-patient relationship to prosper. Emergency physicians duties to the general public inform decision-making on a daily basis; for example, the emergency physician has duties to steward resources, oppose violence, and promote public health that sometimes transcend duties to patients. The larger community places limits on the ability of the physician to act in the patient's interest on the basis of concerns for equity and justice.

2. Resource allocation and health care access: problems of justice

In its broadest sense, justice means giving each person his or her right or due--what he or she is owed. Applying this formal notion of justice impartially to the issue of allocating resources, the community must consider how benefits and burdens should be distributed among the various members of a given population. The actual distribution of these benefits and burdens is known as allocation. Society, as a matter of distributive justice, seeks the best way to distribute scarce resources among those who have some claim to them. Emergency medical practice impacts the use of expensive technology and the distribution of health care resources; therefore, emergency physicians must attempt to reconcile the goals of equitable access to health care and just allocation of health care with the increasing scarcity of resources and the need for cost containment.

3. Central tenets of the emergency physician's relationship with society

a. Access to emergency medical care is a fundamental right

Because it is an essential part of health care, access to quality emergency care is a fundamental individual right and should be available to all who seek it. All impediments to access to emergency care should be removed. Denial of emergency care or delay in providing emergency services on the basis of race, religion, gender, ethnic background, social status, type of illness or injury, or ability to pay is unethical. Emergency physicians have an ethical duty to act as advocates for the health needs of indigent patients and to assist them in finding appropriate care. Insurers, including managed care organizations, must support insured patients' access to emergency medical care for what a prudent layperson would reasonably perceive as an emergency medical condition. Society, through its political process, must adequately fund emergency care, both for the underinsured and the indigent.

Decisions to limit access to care may be made only when the resources of the ED are depleted or when emergency care is available elsewhere in the community. If overcrowding limits access to care, that limit must be applied equitably, unless the hospital has a unique community resource such as a trauma center, in which case the selection of a special category of patient may be acceptable.

Prehospital care is an essential societal good that emergency physicians, in conjunction with government, industry, and insurers must continue to make available to all members of society. All patients seeking assistance of prehospital care providers should undergo assessment by emergency medical technicians or paramedics in a timely fashion. Decisions concerning transport to a medical facility should be made on the basis of medical necessity, patient preference, and the capacity of the facility to deal with the medical problem.

b. Adequate inhospital and outpatient resources must be available to guard emergency patient interests

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Patients requiring hospitalization for further care should not be denied access to an appropriate medical facility on the basis of financial considerations. Transfer to another appropriate accepting medical facility for financial reasons may be effected if a.) the patient provides consent and b.) there is no undue risk to the patient. Admission or transfer decisions should be made on the basis of a patient's best interest.

It is unethical for an emergency physician to participate in the transfer of an emergency patient to another medical facility unless the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the risks of the transfer or unless a competent patient, or a legally responsible person acting on the patient's behalf, gives informed consent for the transfer. Emergency physicians should be knowledgeable about applicable federal and state laws regarding the transfer of patients between health care facilities.

Although the care and disposition of the patient are primarily the responsibility of the emergency physician, it is critical for on-call consultants to share equitably in the care of indigent patients. This may include an on-site evaluation by the consultant if requested by the emergency physician.

For patients who do not require immediate hospitalization but need medical follow-up, adequate outpatient medical resources should be available both to properly continue treatment of the patient's medical condition and also to prevent the development of subsequent foreseeable emergencies resulting from the original medical problem.

c. Emergency physicians should promote prudent resource stewardship without compromising quality

Emergency physicians have the obligation to ensure that quality care is provided to all patients presenting to the ED for treatment. Participation in quality assurance activities and peer review are important for assuring that patterns of inadequate care are detected. Participation in continuing education activities, including the development of scientifically-based practice guidelines, assists the emergency physician in providing quality care.

Health care resources, including new technologies, should be used on the basis of individual patient needs and the appropriateness of the therapy as documented by medical literature. Diagnostic and therapeutic decisions should be made on the basis of potential risks and benefits of alternative treatments versus no treatment. The emergency physician has the obligation to diagnose and treat patients in a cost-effective manner and must be knowledgeable about cost-effective strategies; but, under the principle of nonmaleficence, the physician should not allow cost containment to impede proper medical treatment of the patient.

The limitation of health care expenditures is a societal decision that should ideally be made in the political arena and not at the bedside. Lacking a societal consensus, however, emergency physicians must keep the patient's interest as a primary concern while recognizing that inappropriate, marginally beneficial and futile care is not morally required. Thus, the emergency physician has dual obligations to steward resources prudently while honoring the primacy of patient's best medical interests.

d. The duty to respond to out-of-hospital emergencies and disasters

Because of their unique expertise, emergency physicians have an ethical duty to respond to emergencies in the community and offer assistance as a special resource. This responsibility is buttressed by local Good Samaritan statutes that protect health care professionals from legal liability for good-faith efforts to render first aid. Physicians should not disrupt paramedical personnel who are under base station medical control and direction.

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In a situation where the resources of a health care facility are overwhelmed by epidemic illness, mass casualties, or the victims of a natural or manmade disaster, the prudent emergency physician must make important triage decisions to benefit the greatest number of potential survivors. When the numbers of patients and severity of their injuries overpower existing resources, triage decisions must classify patients according to both their need and their likelihood of survival. The overriding principle should be to focus health care resources on those patients most likely to benefit who have a reasonable probability of survival. Those patients with fatal injuries and those with minor injuries should be made as comfortable as possible while they await further medical assistance and treatment.

e. The duty to oppose violence

Serving as a societal resource, emergency physicians have the dual obligation to protect themselves, staff, and patients from violence and to teach EMS personnel under their supervision to do likewise. Hospitals have a duty to provide adequate numbers of trained personnel to assure a safe environment. Ensuring safety may mean that patients who appear to present a high risk of violence will lose some autonomy as they are restrained physically or chemically. Emergency physicians never should resort to restraints or medication for punitive or vindictive reasons. Restraints are indicated only when there is a reasonable possibility that patients will harm themselves or others. The need for restraint of ED patients should constantly be reevaluated.

The emergency physician has an ethical duty to prevent, diagnose, treat, and properly refer victims of domestic violence, including abused children and the elderly, and to report the violence to the appropriate governmental authorities where mandated.

f. The duty to promote the public health

Emergency physicians advocate for the public health in many ways, including the provision of basic health care for the many uninsured. As the safety net for victims of economic, physical, and emotional disaster, EDs are a vanguard against a constellation of medical and social ills.

Emergency physicians have first-hand knowledge of the grave harms caused by firearms, motor vehicles, alcohol, and other vectors of preventable illness and injury. Inspired by this knowledge, emergency physicians should participate in efforts to educate others about the potential benefits of well-designed laws, programs, and policies that advance the overall health and safety of the public.

CONCLUSION

Serving patients effectively requires both scientific and technical competence, knowledge of what can be done, and moral competence, knowledge of what should be done. The technical emphasis of emergency medicine is slowly being eclipsed by the ethical. Increasingly, the profession is being asked to help patients die comfortably rather than secure life at all costs. In the next millennium, the difficult questions of the specialty may not be scientific so much as moral.

In spite of future uncertainties and challenges, ethics will remain central to the clinical practice of emergency medicine. Both technical and moral competence can and should be nurtured through advanced preparation and training. The time and information constraints inherent in emergency practice have made reflection on important ethical principles and values difficult at the bedside. This Code is offered both for thoughtful consideration away from the bedside and as a resource when issues arise in clinical practice. The principles of emergency medical ethics identified herein may serve as a guide for the masters and students of this developing art. Through the process of

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moral reflection and deliberation, emergency physicians may be empowered to base future time-sensitive decisions on a sound moral framework.

III. A COMPENDIUM OF ACEP POLICY STATEMENTS ON ETHICAL ISSUESThe policy statements listed in the Compendium section of the Table of Contents of this policy are available from ACEP's Customer Service office (800-798-1822, touch 6) or on ACEP's Web site (http://www.acep.org).

Copyright © 2004 American College of Emergency Physicians. All Rights Reserved.

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Ingham Regional Medical CenterProfessionalism Evaluation Exercise

Interns will be directed that the purpose of this exercise is to watch how they provide feedback and patient education on a newly diagnosed, mildly retarded 60 y/o female patient. Intern is limited to 20 minutes for the history taking visit.

Professionalism Evaluation Exercise

Intern name________________________ Date___________ Pre ______ Post _____

Interns are told that the purpose of the exercise is to watch how they gather a medical history. They will be time limited (20 minutes).

Setting; direct admit patient with Type II diabetes, showing signs of peripheral neuropathy. The patient is a 60 something year-old female, mildly retarded and is hard of hearing. Her female “partner” is in the waiting room.

(Describe scoring 0-1 unsatisfactory; 2-3 satisfactory; 4-5 very good to excellent)

Item Score

1. The intern introduces him/herself and uses pt. name 0 1 / 2 3 / 4 5

2. The intern touches the patient (e.g., shakes hands) 0 1 / 2 3 / 4 5

3. The intern looks at the patient while talking to them 0 1 / 2 3 / 4 5

4. The intern refers to the patient by their last name 0 1 / 2 3 / 4 5

5. The intern does not interrupt quickly (count seconds) 0 1 / 2 3 / 4 5

6. The intern redirects history with expressing interest (or avoiding disaffirmation) 0 1 / 2 3 / 4 5

7. The intern explains what will happen next (e.g., lab tests, etc.) 0 1 / 2 3 / 4 5

8. Acknowledges patient’s pain 0 1 / 2 3 / 4 5

9. Acknowledges patient’s fear 0 1 / 2 3 / 4 5

10. Respect and equality with gender issues 0 1 / 2 3 / 4 5

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Scoring guidelines defined;

#1 0 = Does not do1 = Does introduce self but not so pt. can hear or acknowledge2 = During introduction and one other time3 = Introduction and two more4 = Introduction and three more5 = Introduction and four or more times

#2 0 = Does not do 1 = Only during introduction2 = During introduction and one other time3 = Twice4 = Three times5 = Introduction and several more with empathy

#3 0 = Does not do 1 = Only during introduction2 = During introduction and one other time3 = Twice4 = Introduction and several more with empathy5 = During entire discussion, keeps discussion at level of pt. understanding

#4 0 = Never1 = Only during introduction2 = During introduction and one other time3 = Introduction and two more4 = Introduction and three more5 = Introduction and four or more times

#5 0 = Interrupts 3 or more times, no wait time1 = Interrupts, waits 2-5 seconds2 = Does not interrupt, but appears to not listen, does not respond appropriately to pt. questions, waits 5-30 seconds3 = Listens, waits for pt. to finish, allows the pt. time to complete their thought/question 4 = Listens, responds appropriately to pt. statement5 = Listens attentively

#6 0 = Disaffirms, “Oh you don’t mean that”, etc.1 = Does not direct history, pt. rambles, interns shows little interest in process2 = Follows form, gets lost without prompts3 = Follows form, helps pt. stay on track

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4 = Makes statements; eg, I’m sorry to hear that5 = Makes statements and asks for clarification, eg, when did you first notice it?

#7 0 = Does not appear to know what to suggest is next step1 = Does not include pt. in decision making2 = Gives broad overview of what may happen, not at pt. level of understanding3 = Gives some detail, attempts to explain at pt. level 4 = Gives detail, doesn’t answer questions appropriately or give pt. opportunity to

ask5 = Gives detail, waits for response from pt., answers all questions appropriately

#8 0 = Never1 = non-verbal recognition, eg., makes eye contact when pt. discusses2 = Repeats what pt. has stated 3 = Verbally acknowledges, eg, “oh, you have a pain right there?”4 = Repeats, acknowledges, asks for description5 = Repeats, acknowledges, asks for description, gives idea for control

#9 0 = Never1 = non-verbal recognition, eg., makes eye contact when pt. discusses2 = Repeats what pt. has stated 3 = Verbally acknowledges, eg, “oh, having ‘sugar’ is scary to you?”4 = Repeats, acknowledges, asks for description of fear5 = Repeats, acknowledges, asks for description, gives idea for control

#10 0 = No, disrespectful1 = non-verbal but makes eye contact when pt. discusses problems2 = Repeats what pt. has stated in non-threatening, equality manner 3 = Verbally acknowledges that symptoms may be different for genders4 = Verbally acknowledges that symptoms may be different for genders but we’ll work together5 = Gives pt. autonomy in decision making process

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