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THE CHANGING FACE OF
MEDICAL
PROFESSIONALISMVictor Lim
International Medical University
Malaysia
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OUTLINE OF PRESENTATION
What is medical professionalism
A short history
Challenges in the 21st Century
Meeting the challenges – ABIM Foundation
Physician Charter
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MEDICAL PROFESSIONALISM
“a set of core beliefs and values that
guide the behavior of physicians caring
for patients”
Lucey and Souba (2010)
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MEDICAL PROFESSIONALISM
Encompasses 3 elements
(i) the ethic of service
(ii) autonomy and self-regulation
(iii) benefit to society
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PROFESSION VS TRADE
The moral dimension is a primary characteristic of the so-called learned professions – medicine, clergy and law
“in so far as accepted professions are prosecuted at a mercenary or selfish level, law and medicine are ethically no better than trades. In so far as trades are honestly carried on, they tend to rise towards the professional level”
Flexner (1915)
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HISTORY
Hippocrates ( 500 BC)
Hippocrates Oath
Use skill for the benefit of the sick
Keep them from harm and injustice
Maintain confidentiality
Avoid inappropriate sexual
relationships
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HISTORY
Thomas Percival (1740-1804)
Manchester physician
Code of professional conduct
Reinterpretation of Hippocrates
Self-regulating, paternalistic
and benign
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HISTORY
John Gregory (1724-1773)
Scottish physician and moralist
Lectures on the Duties and Qualifications
of a Physician
Deplored the unscientific state of
medical practice in the 18th century
“ready to acknowledge and rectify his
mistakes”
“to lay medicine open to the public”
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AUTHORITY OF PHYSICIANS
Moral authority through altruism
Sapiential authority through exclusive
possession of a body of knowledge
Charismatic authority as exemplified by the
consultant with his retinue of registrars, house
officers and medical students
Hilton, 2008
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PURPOSE OF PROFESSIONALISM
Most important purpose is to secure the trust of
the patient
2 levels of trust
Trust in the individual providing the care (individual
professionalism)
Trust in the system where the care is provided
(organizational professionalism)
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CHALLENGES TO PROFESSIONALISM IN
THE 21ST CENTURY
Doctor-Patient Relationship
Crucial in building trust in the doctor
Time : Financial, logistic and resource constraints
IT : Use of computers can draw attention away from the patient
Cultural competence
Increasing diversity of ethnicity among patients
Affected communication and understanding
Continuity of care
Shift work, restriction in working hours, subspecialisation, attitude of “keeping the ship afloat” until the next shift
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CHALLENGES TO PROFESSIONALISM IN
THE 21ST CENTURY
Conflicts of interest
Influence of the
pharmaceutical industry
Influence prescribing
Using physicians to lend
academic repute to flawed
and misleading research
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28 July 2015
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Kaiser Health News 25 Oct 2012
A Case Study in Conflict of Interest
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CHALLENGES TO PROFESSIONALISM IN
THE 21ST CENTURY
Technology
Technological imperative : medicine as a series of tests accompanied by prescriptions of medicines
Drawn attention away from the humanistic aspects of medicine
Financial incentives for tests and procedures but little for counselling and helping patients make decisions
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CHALLENGES TO PROFESSIONALISM IN
THE 21ST CENTURY
Medicine as a business
What in the past has been a balance between
business and service has given way to blatant
commercialization fueled primarily by profit
margins
Doctors who prey on the patient’s physical and
mental vulnerabilities by offering unproven
remedies
“Boutique” and “concierge medicine”, medical
tourism
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CHALLENGES TO PROFESSIONALISM IN
THE 21ST CENTURY
Structures
Structural context within which the care is
delivered
Increasing bureaucracy – 14% (USD 50
billion)of health care cost in the US is
administrative cost
Professional behavior of physicians now
impeded by systems which they have little
control over
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ADDRESSING THE CHALLENGES
Updating codes of practice and conduct
Medical professionalism in the 21st century
should entail not just caring for the individual
but also the systems that shape their care
Responsibility to create care environments that
encourage and support physicians to act in a
professional manner (Lesser, 2010)
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3 Fundamental Principles
1.Primacy of patient welfare
2.Patient autonomy
3.Social justice
American Board of Internal Medicine Foundation 2002
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Professional responsibilities and commitments
1. Professional competence
2. Honesty with patients
3. Confidentiality
4. Maintaining appropriate relationships with patients
5. Improving quality of care
6. Improving access to care
7. Just distribution of finite resources
8. Scientific knowledge
9. Maintaining trust by managing conflict of interest
10.Professional responsibility
http://www.abimfoundation.org/Professionalism/Physician-
Charter.aspx
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BEYOND THE PHYSICIAN CHARTER
THE VIRTUOUS CHARACTER
“the Physician Charter addresses only basic
professionalism and is virtually silent about the
higher professionalism that is so critical to
medicine. It speaks to the duties and
competencies of a physician, while the highest
measures of professional behaviours lie not in
the realm of duty or competence, but in the
realm of virtues. Duty alone is not enough.”
Swick, 2006