Professionalism

Srivieng Pairojkul, M.D.Department of Pediatrics

Faculty of MedicineKhon Kaen University

What is professionalism?

What is a profession ?

• Specialized body of knowledge• Autonomy in practice and self-regulation• Altruistic service to individuals and society• Responsibility for maintaining & expanding

professional knowledge & skills

Medicine, Law, Clergy, Teaching, Engineering

Gruen RL. Professionalism in Surgery. J Am Coll Surg 2003;197:605-9.

Think of a doctor, whom you impress and want to have as a

role model.

Describe his/her characters.

Behaviors reflecting professionalism

• Altruism - essence of professionalism.The best interest of the patients, not self-interest

• Accountability to individual patients,society and the profession

• Excellence - conscientious effort to exceed normal expectations and make a commitment to life-long learning

ABIM Project Professionalism 1999 www.abim.org/pubs/p2/index.htm

• Duty - commitment to service • Honour and integrity - consistent regard

for the highest standards of behaviour and refusal to violate ones personal and professional codes.

• Respect for others (patients and their families, other physicians and professional colleagues such as nurses, medical students, residents, subspecialty fellows,and self) is the essence of humanism…"

ABIM Foundation, ACP-ASIM Foundation and European Federation of Internal

Medicine (2002) created :

“A Physician Charter: Medical Professionalism in the New Millennium”

Sox H. Medical Professionalism in the New Millennium: A Physician Charter. Annals of Internal Medicine 2002 136: 243-246.

A PHYSICIAN CHARTER

• Fundamental Principles– Primacy of patient

welfare– Patient autonomy– Social justice

A PHYSICIAN CHARTERSet of professional commitment to:

– Professional competence– Honesty with patients– Patient confidentiality– Maintaining appropriate relations

with patients– Improving quality of care– Improving access to care– Just distribution of finite resources– Scientific knowledge– Maintaining trust by managing conflicts of interest– Professional responsibilities

19991999-- David Leach inspired effortDavid Leach inspired effort--define define residents by new residents by new ““Outcome measurementsOutcome measurements””

Creation of six new general competenciesCreation of six new general competenciesGoals of theGoals of the-- ACGME/RRC: alter some ACGME/RRC: alter some

of the focus of residency education by of the focus of residency education by measuring new outcomesmeasuring new outcomes

Patient CarePatient CareMedical KnowledgeMedical KnowledgeProfessionalismProfessionalismSystemsSystems--based Practicebased PracticePracticePractice--based Learning and based Learning and ImprovementImprovementInterpersonal and communication Skills Interpersonal and communication Skills

•• CompassionateCompassionate•• AppropriateAppropriate•• Effective Effective

–– For treatment of health problemsFor treatment of health problems–– For the promotion of healthFor the promotion of health

•• Established and evolving scienceEstablished and evolving science–– BiomedicalBiomedical–– ClinicalClinical–– Cognate (epidemiological & socialCognate (epidemiological & social--

behavioral)behavioral)

•• Application of this knowledge to patient Application of this knowledge to patient carecare

•• Ability to critically assess Ability to critically assess ““newnew”” knowledgeknowledge

•• Investigation and evaluation of their own Investigation and evaluation of their own patient carepatient care

•• Appraisal and assimilation of scientific Appraisal and assimilation of scientific evidenceevidence

•• Improvements in patient careImprovements in patient care

•• Effective information exchange and Effective information exchange and teaming withteaming with–– PatientsPatients–– Their familiesTheir families–– Other health professionalsOther health professionals

•• Enhances therapeutic relationshipEnhances therapeutic relationship

Manifested throughManifested through•• A commitment to carrying out A commitment to carrying out

professional responsibilitiesprofessional responsibilities

•• Adherence to ethical principlesAdherence to ethical principles

•• Sensitivity to diverse patient populationsSensitivity to diverse patient populations

Manifested byManifested by•• Actions that demonstrate awareness of Actions that demonstrate awareness of

and responsiveness to larger context and and responsiveness to larger context and system of health caresystem of health care

•• Ability to effectively call on system Ability to effectively call on system resources to provide care that is of resources to provide care that is of optimal valueoptimal value

Patient-centered careShared Decision

Making

Patient-centered careShared Decision

Making

Evidence-Based Care

Evidence-Based Care

Working EffectivelyIn Teams

Working EffectivelyIn Teams

Quality Improvement

Quality ImprovementPatient

SafetyPatient

Safety

Reflective Practice

Reflective Practice

DefiningProfessionalism

DefiningProfessionalism

Cultural Competence Cultural

Competence

Stanford Professionalism in Contemporary Practice

Reflection : A key skill

Self-awareness & Reflection: key skill todevelop and enhance professionalism at every level of training and practice

Hilton S & Slotnick H. Proto-professionalism: how professionalisation occurs across the continuum of medical education.

Med Educ 2005; 39: 58-65.

Epstein RM. Mindful practice. JAMA 1999; 282: 833-839.

Exercise #1a

• What’s the most frustrating clinical experience you’ve had in the past week?

• How did you response ?________________________________________________________________________________________________

Exercise #1b

• Now, in retrospect, how might you havehandled this differently?

____________________________________________________________________________________________________________________________________________

Reflective practiceFramework

Schön, 1983

Concrete experience

Critical reflection

Identify new perspective

Incorporate

Reflection“Considering the larger context, the meaning, and

the implications of an experience or action”

• Reflection-on-action– Understanding what just happened– Example: “How do you think that went?”

• Reflection-in-action– Simultaneously performing while making continuous

adjustments according to what you discern about the process

– Example: • The baseball pitcher• The jazz musician

Schön, 1983

Exercise #2a

• Turn to your neighbor -- one of you share your story of a frustrating clinical situation

• Discuss with goal of finding one new insight.

Reflective practice• Self-reflection• Reflection with others• Reflection with pre-established criterias

Other activities to foster reflection

• Reflective journaling• Reflective seminars• Portfolios

Branch, 2

Learning about professionalism

By instruction

From peers

From patients

From other colleagues

From experience

From feedback

By reflection

From medical staff

What is the KKU’s formalcurriculum for

Professionalism?

BRAINSTORMING

ความสามารถในการศึกษาตอเนื่องตลอดชีวิต มีทักษะการจัดการความรู ความสามารถในการทํางานเปนทีมทั้งกับแพทยและบุคลากรทางการแพทยสาขาอื่นๆ รวมทั้งกับประชาชน

ความสามารถในการคิดเชิงระบบ การคิดอยางมีวิจารญาณ และคิดเชิงจริยธรรม เพื่อใหสามารถตรวจสอบ และปรับปรุงคุณภาพ

ของระบบบริการไดอยางตอเนื่อง

ความสามารถในการสื่อสารและเขาใจในมนุษย เพื่อใหคําปรึกษา ใหความรูแกประชาชนไดอยางเปนองครวม

ความสามารถในการวิเคราะหปญหาสุขภาพ โดยเขาใจความเชื่อมโยงกับปจจัยตางๆ ภายนอกระบบบริการสุขภาพ เพื่อใหสามารถทํากิจกรรมสงเสริมสุขภาพและปองกันโรคอยางไดผล

Bring some to medical school with Bring some to medical school with themthem

Learn some through the formal Learn some through the formal curriculumcurriculum

Learn some from role modelsLearn some from role models

LLectures ectures SSeminars eminars RReadingeading

PPassiveassive:: readingreading,, listeninglistening,, thinkingthinking

GGeneral clinical experience eneral clinical experience PPeer interactions eer interactions Ward Ward rounds rounds MMulti disciplinary teamsulti disciplinary teamsRole modelRole model

PPowerfulowerful embedded in actionembedded in action

Year 2Year 2•• Small group activitiesSmall group activities•• How to learnHow to learn•• Preparation for preclinical yearsPreparation for preclinical years

Year 3Year 3•• Small group sessionsSmall group sessions•• Preparation for clinical yearsPreparation for clinical years•• Medical ethicsMedical ethics

Medicine Surgery Obstetrics-Gynecology

Orthopedics Community Medicine

Forensic Medicine

RehabMed

Physical examPDM Med4: CVSPDM Med5: RSPDM Med6: NSPDM Med7:

AbdomenPDM Med8: Joint

& MusclesProcedural skills

PDM Med1: Universal precaution and specimen handling

PDM Med2- Venepuncture- Sample collection- Fluid analysisPDM Med3: Basic bedside labs

PDM Med11:Blood smear interpretationOthers:

PDM Med9:Report writing

PDM Med10:Learning in clinical yearsCommunication & Ethico-legal issues:

PDM Med12: Clinical reasoning and ethical decision

Procedural skillsPDM Surg1: Hand

scrubbing, Gowning, grooving, scrubbing, and painting operative field

PDM Surg2:- NG tube- Foley’s catheterization- Per rectalexamination.

PDM Surg3:- Ostomy care- ICD- Bandage:stump, arm, leg, headPDM Surg4:- Infiltration andsuture, surgical tie- Short drain, off drain- Wound dressing

PDM Surg5:Pre-post op care

(Surg-Anes)Communication & Ethico-legal issues

PDM Surg6:Consent form for procedure & medicolegal case (Surg & Anes)

Procedural skills: PDM OB-Gyn1:

- Leopold- PV, knotting- Catheterization

PDM OB-Gyn2: - NL- Repair episiotomy woundCommunication & Ethico-legal issues:

PDM OB-Gyn3: -- Professional values- Physician charter

PDM OB-Gyn4: - Counseling forgenetic diseases, HIV- Confidentiality- Unwantedpregnancy- Reproductivedilemmas

PDM Ob-gyn5: Communication with

colleagues, team, patients, & relatives.

PDM Ob-gyn6: …………………Others:

PDM OB-Gyn2EBM

History and physical exam.

PDM Ortho1:History taking and report writing

PDM Ortho2:lower limbs

PDM Ortho4:upper limbs

PDM Ortho5:spines & neurological examProcedural skills

PDM Ortho3 : - Closed reduction of fracture and dislocation- Joint aspiration

PDM Ortho6 : - Traction PDM Ortho7 : - Joint aspiration PDM Ortho8: - CastingCommunication

& Ethico-legal issues::

PDM Ortho9:History taking of OPD cases PDM Ortho10:

Giving information for health promotion

Communication & Ethico-legal issues:

PDM CM1: Communication with patientPDM CM2: พฤตกิรรมการสือ่สาร-

LawsPDM FM1: กฏหมายทีเ่กี่ยวของกับแพทย

PDM FM2: พ.ร.บ.วชิาชพีเวชกรรมและขอบังคบัแพทยสภาวาดวยการรกัษาจรยิธรรมแหงวิชาชพีเวชกรรม

PDM FM3: กฏหมายที่เกี่ยวของกับการชันสูตรพลิกศพ PDM FM4: ความผิดทางเพศPDM FM5: ฝกเขียนใบชันสตูรบาดแผล

Procedural skills: PDM Rehab1: Manual muscle testing PDM Rehab2: Stretching exercise PDM Rehab3: Stump bandagingPDM Rehab4: Mobility training and gait aids PDM Rehab5: Therapeutic exercisePDM Rehab6: Chest physical therapy

Pediatrics Medicine Surgery Community Medicine

Psychiatry Eye/ENT Anesth ForensicMed

Radiology

Procedural skills: PDM Ped1:

- Restraint techniques- IM, IV injection - Arterial puncture - ET intubation- Iinter-osseous infusionCommunication skill, ethico-legal issuesPDM Ped2:

Family centered communication & communication with adolescents

PDM Ped3: Pediatric ethic conference PDM Ped4: Parent’s self-help group PDM Ped5: Psychosocial holistic roundPDM Ped6: Palliative care case conference PDM Ped7: - Play activities for children

Physical examPDM Med12:

CVSCommunication skill, ethico-legal issuesPDM Med13:

Holistic case approach

Procedural skills

PDM Surg7: - Proctoscopy- FNA digital nerve block - Suturing and desuturing

PDM Surg8: - Biopsy superficial mass- Incision and drainage- Debridement of wound PDM Surg9: - Dressing gastroschisis- Excision and incisions - Biopsy- Excision of benign tumor and cyst of skin and subcut. tissue

Communication skill & Ethico-legal issues

PDM CM3: Ethical consideration

Procedural skillsPDM Psy1:

Mental status examinationCommunication skill, ethico-legal issues

PDM Psy2:Counseling skills

EyeProcedural skillsPDM Eye1:

Occular examPDM Eye2:

Direct ophthalmoscopeHealth promotion:

PDM Eye3:Preventive ophthalmology

ENTPhysical exam

PDM ENT1:ENT examProcedural skills:

PDM ENT3:FB removal

PDM ENT4:Nasal packing

PDM ENT5:TracheostomyCommunication skill, ethico-legal issues

PDM ENT2:Communication skills in Medicine

Procedural skills: PDM Anes1Endotracheal intubationPDM Anes2Spinal block

Procedural skills:

PDM FM9: AutopsyLaws

PDM FM6 : ผูปวยคดีPDM FM7: งานนิติเวชกับพนักงานสอบสวนPDM FM8: ตรวจศพสถานที่เกิดเหตุPDM

FM10: ดงูานพิจารณาคดทีี่ศาลPDM

FM11: พยานทางการแพทยPDM

FM13: Case study-บาดแผลPDM FM14

: Medical malpracticePDM FM15

: จรยิธรรมทางการแพทย

PDM FM16: ผูปวยคดี 2

Procedural skills PDM Radio1Clinical

radiology skillsCommunication skills & Ethico-legal issuesPDM Radio2- Writing radiologic request - Medical reports - Information giving

Medicine Surgery Obstetrics-Gynecology

Pediatrics Orthopedics

Communication & Ethico-legal issuesPDM Med : - Writing prescription

PDM Med : Breaking bad news, truth telling

PDM Med : Palliative careOthers

PDM Med :Information IT searching

Procedural skillsPDM Surg10:

- Incision and drainagePDM Surg11:

- Suture- ICD- Circumcision

PDM Surg12: - Venesection- Appendectomy

PDM Surg14: Evaluation of trauma, evaluation of severity and complication

Communication & Ethico-legal issues

PDM Surg13: Asking for organ transplantation PDM Surg15:

Malpractice and negligence

Procedural skillsPDM OB-Gyn8:

Pap smear, cervical Bx, vaginal packing, IUD, TR implant contraception

PDM OB-Gyn9: Ultrasonography

Communication skills, ethico-legal issuesPDM Ped3:

Pediatric ethic conference PDM Ped6:

Palliative care case conference PDM Ped8: Identification of child abuse and child protection lawPDM Ped9: Child protection case conference

Physical examPDM Ortho 8:

upper limbs PDM Ortho 11:

Spine

Procedural skillsPDM Ortho 7:

Emergency in orthopedics

PDM Ortho 9:Reduction and casting technique

PDM Ortho 10:Cadaveric workshop: closed reduction of common dislocation, joint aspiration and debridement

Topics DepartmentCommunication to patient Community Medicine (PDM CM1&2)

Communications in Medicine (PDM ENT2)Communication with children and adolescents

Pediatrics (PDM Ped2)

Consent for procedure Surgery (PDM Surg6)Telling the truth Medicine (PDM Med )Medical advice Pediatrics (PDM Ped2)Breaking bad news Medicine (PDM Med )Communication to relatives/parentsFamily-centered communication

Pediatrics (PDM Ped2)

Counseling technique Psychiatry (PDM Psy2)Counseling for genetic disease/HIV OB-Gyn (PDM OB-Gyn4)Asking for autopsy/necropsyWithhold/with draw life support Medicine, Pediatrics (PDM Ped3)Asking for organ transplant donation Surgery (PDM Surg13)Death certificationPalliative care Medicine (PDM Med ), Ped (PDM Ped6)

Topics DepartmentEthical decision making Medicine (PDM Med )Team working OB-Gyn (PDM OB-Gyn5)Confidentiality OB-Gyn (PDM OB-Gyn4)Medical error Surrogate decision making Pediatrics (PDM Ped3)Professionalism OB-Gyn (PDM OB-Gyn3)Malpractice/negligence Surgery, Forensic (PDM Surg15)(PDM FM4)Abortion/unwanted pregnancy OB-Gyn (PDM OB-Gyn4)Reproductive dilemma OB-Gyn (PDM OB-Gyn4)Handling rape cases OB-Gyn- Forensic- Ped

(Integrated case)Medico-legal cases Surg/Ortho (PDM Surg6)Research in human Community Medicine(PDM CM3)Evaluation for trauma, severity of disease and complications

Surgery (PDM Surg14)

ก ารชั นสูตรพลิกศพ Forensic Medicine (PDM FM3)

ก ารเขี ยนใ บชั นสูตรใ บ/รับรองแพทย Forensic Medicine (PDM FM5)

กฏหมายที่ เกี่ ย วข องกั บแพทย Forensic Medicine (PDM FM1)

พ .ร.บ.วิช าชี พ เวช กรรมและขอบังคับแพทยสภาวาด วยก ารรักษาจริย ธรรมแหงวิช าชี พ เวช กรรม

Forensic Medicine (PDM FM2)

ความผิ ดทา งเพศ Forensic Medicine (PDM FM4)

งานนิติ เวช กั บพนัก งานสอบสวน Forensic Medicine (PDM FM7)

ผู ปวยคดี Forensic Medicine (PDM FM6)

พิจารณ าคดี ที่ศาล Forensic Medicine (PDM FM8)

พยานทางก ารแพทย Forensic Medicine (PDM FM11)Medical malpractice Forensic Medicine (PDM FM14)Child protection law, child’s rights Pediatrics (PDM Ped9)

Bioethic conference 6Bioethic conference 6--7 sessions/year7 sessions/year(Lecture/case discussion/debate)(Lecture/case discussion/debate)MedicoMedico--legal case conference legal case conference 3 session/year3 session/year

Medical law 2 sessions (Lecture/case Medical law 2 sessions (Lecture/case conference)conference)National Health System / Hospital National Health System / Hospital accreditation / Palliative medicineaccreditation / Palliative medicine

•• Training workshops for teachersTraining workshops for teachers: : -- Communication skillsCommunication skills-- Medical professionalismMedical professionalism-- Clinical teachingClinical teaching-- Other medical education trainingsOther medical education trainings

•• Training workshops for residentsTraining workshops for residents-- Communication skillsCommunication skills-- Medical professionalismMedical professionalism-- Clinical teachingClinical teaching

Unprofessional behavior in Med School predicts unprofessional behavior

in practiceProblem behaviors in Med school described in course evaluations or

administrative correspondence predicted future discipline problems

Case-control study of all UCSF graduates disciplines by California Medical Board 1990-2000.

Papadakis M et al. Unprofessional behavior in Medical school is associated with subsequent disciplinary action by a state medical board.

Acad Med 2004; 79: 244-249.

Predictive Traits:unprofessional behavior in practice

• Low academic achievement• Severe irresponsibility• Diminished capacity for self-improvement

Case-control study of 235 graduates of UCSF, Jefferson, U of Michigandisciplined by 40 state medical boards 1990-2003.

Papadakis, M et al. Disciplinary Action by Medical Boards & Prior Behavior in Medical School. N Engl J Med 2005; 353: 2673-2682.