medical professionalism & motivation for doctors- dr vijay sardana

Medical Professionalism & Medical Professionalism & Motivation for DoctorsMotivation for Doctors

Dr Vijay SardanaMD,DM ( Neurology)

Professor & HeadDeptt. Of Neurology

Govt.MedicalCollege, Kota

The Noble Profession of MedicineThe Noble Profession of Medicine

“There is no career nobler than that of the physician. The Progress and welfare of society is more intimately bound up with the prevailing tone and influence of the medical profession that with the status of any other class…”

ElizabethBlackwell,M.D.,1889

Doctors : Definition of successDoctors : Definition of success

Having lots of patientsNew car/plot Every year/lots of

moneyPublishing papers in journalsTeaching students

Doctor : FactsDoctor : Facts

One of the every these dissatisfied due to lack of time for themselves or their families

Average life 10 year less

Depression 4 times higher than general population

Stages of careerStages of career

Entry Establishment Exploration Specialization Mastery

Stages of Professional lifeStages of Professional life

No work, No money, lots of time

Some work, some money, some time

Plenty of work, Plenty of money, no time

SuccessSuccess

Know – How.Know - Who. Who you know. Who knows you.

Today's successful doctorToday's successful doctor

Clinician Academician Manager Financial Expert CEO Family care Provider Self care taker

“ The education of the doctor which goes on after he has his degree is the most important part of his education”

John Shaw Billings

Patients satisfactionPatients satisfaction

Satisfied patient 3 other people

Dissatisfied patient 20 others

Satisfying unhappy patients 50 others

Doctor-Patient RelationshipDoctor-Patient Relationship

“ The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best pat of your work will having nothing to do with potions and powders…”

William Oster,M.D.,1925


Blind trust

Informed trust with skepticism


Has the Doctor changed?? or Doctor is facing the changed society?

Trust equation by David MaisterTrust equation by David Maister

T = C + R + I + S, WhereT = TrustworthinessC = CredibilityR = ReliabilityI = IntimacyS = Self-orientation

Credibility = can your patient trust what you say?

Reliability = can he trust your actions, confident that you will act honorably?

Intimacy = Is he comfortable discussing his feeling and emotion with you?

Self orientation = can he trust your motives, knowing that you care about him, and will act in his best interests?


Patient dissatisfaction Mistrust Medical litigation

LitigationLitigation

Professional failure in diagnosis or treatment

Lack of communication

Some form of insensitivity by the doctor to upset them emotionally – insult adding to injury.


Excessive workload?

Attitude Problem?

Attitude formation of a PhysicianAttitude formation of a Physician

Medical studentAltruismRole models behaviorPrevailing commercialismWork environmentSocial and political environment

Causes of Poor relationshipCauses of Poor relationship

Rising health cost. Over specialization. Changing patients/community

expectation. Commercialization. Poor Communication More awareness about adverse effect.

Medical professionalism : Medical professionalism : deprofessionalism- causedeprofessionalism- cause

Technology – Depersonarlise medicine & deprofessionlise a physician

Corporatization of Medicine Specialization – Most patients identified by

disease rather than human beings who happens to have disease

Patients knowing limitation of modern medicine Greed


Failure of referral system

Disproportionate work load

Unnecessary administrative responsibilities


Overinvestigation/ overtreatment

Medico-legal Aspect “ Defensive Medical Practice”


Commercialization of service

Doctor-Patient Relationship: Informed Doctor-Patient Relationship: Informed consentconsent

Condition of the patient (Disease) Purpose & Nature of intervention. Consequences of such intervention. Any alternatives available Risks involved Prognosis in the absence of intervention.


Information given to patient is selected to encourage them to consent to doctor’s decision.


Influence of drug & medical equipment manufacturer

Pardoned

Tolerated

norm

Doctor-Patient RelationshipDoctor-Patient RelationshipPatients responsibilitiesPatients responsibilities

Courteous & transparent to health care provider.

Not carried away by emotion & misinformation.

Sharing anxiety with doctor to resolve problem

Never to become violent/act unlawfully.

Doctor-Patient relationship: Doctor-Patient relationship: PoliticiansPoliticians

Political mileage.

Instigating patient to raise voice against doctor, at times unjustified.

Pressures

Ministers Ex ministers PAs Political party office bearers Other parties Regional parties Media others

Violence Against Doctors

What constitutes violence?

Telephone threats Intimidation Oral abuses Physical

manhandling

“incidents where people are abused, threatened or assaulted in circumstances relating to their work, involving an explicit or implicit challenge to their safety, well-being or health”.


UKUK

Half of all doctors – some degree of violence or abuse, 20% of these physical (BMJ, 2003)

Among GPs, threat of violence at 1 in 500 consultations


OthersOthers

Kuwait – 86% doctors – verbal insults or imminent violence, 28% physical attacks

Israel – 54% to 79% rate of violence in physician surveys

Europe – Intoxicated patients flooding ERs

Australia – half of doctors physically attacked at least once


Why?Why?

More demanding society More availability of knowledge More aggression in society More violence on roads, public

places, even schools


How to deal?How to deal?

Not meet anger with anger Address the grievances, but also

call for help Doctors must form groups, which

can take over in such instances


LawLaw Non-bailable offence

Offenders liable to pay up to twice the purchase price of damaged equipment

Doctor-Patient Relationship: policeDoctor-Patient Relationship: police

Rajasthan Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage to Property) act 2008

304-A


Communication

Communication, communication, communication about costs, complications and challenges

Doctors must make efforts to educate and inform the public at large about diseases and medical problems


Time Barrier to Time Barrier to CommunicationCommunication

Lack of time can be managed Use paramedical staff Delegate the work of repeated

explanations Counselors

PreventionPrevention


Display information on boards, counters etc.

Try not to escalate costs later or change plans frequently

Also display rules regarding consequences of violence in hospital


Doctors’ ExpectationsDoctors’ Expectations

From administration - Implement laws by the letter and spirit

Media – 1. publish both views, avoid sensationalism, seek an expert opinion preferably from another city2. more positive

3. do not ascribe wrongful intentions


Display of Warnings & Other Display of Warnings & Other informationinformation

Display warning in hospital premises mentioning the consequences of violence against doctors in hospital

Display flow chart/plan in Emergency Room

Trouble ShootingTrouble Shooting

Relatives & attendants Fight Disperse 10 Min

1st degree friends More Attendants30 Min

Hospital Administration

Police, Media30 Min

Media & Police Strengthening 2nd degree friends

1 Hour

Strike FIRs

1-2 DaysStrike Continues

1-2 DaysSolution, Often Face saving arrived

Forgotten, gone with the wind

Medical Students/ Medical Students/ Residents/ DoctorsResidents/ Doctors

Professional Nonprofessional

Carrier Conscious No carrier so no fear

Socio-cultural trauma Mostly no Trauma

Can go to certain extent Can go to any extent

Friends

Power

Vigilance - NegligenceSilence - ViolenceTolerance - IntoleranceDiscipline - IndisciplineSeriousness - CarelessnessGood Sense - Nuisance

If too many anxious attendants, send them one or another job. eg. Bringing medicines, arranging blood- Energy utilization

Never argue with attendants

Argument will trigger them, at the same time your calmness and promptness will even calm down a triggered person.

If patient is sick, attend patient periodically and talk to attendants.

Check emergency tray for drugs.

Try to solve/resolve crisis immediately

Do’sDo’s

Do’sDo’s

Patients should be attended promptly: - Error in Decision making is Excusable but not

attending patients timely is not.

Identify a Prominent Person: - Important person/relative and explain initial

assessment of patient immediately. - Explain them management has started.

Ask if they have any questions

Call senior consultant as per requirement, talk to them telephonically if possible delay in arrival.

Don’tsDon’ts

Never argue with attendants. this situation teaches you how to remain calm in provocative circumstances. No book in the world can teach this.

Never overlook a call, especially if call is by a attendant.

DO’SDO’S

If there is Gang War- call Police force

Codes of ethics and DeclarationCodes of ethics and Declaration

Duties to patient. Duties to public. Duties towards law Enforcers. Duties not to violate professional ethics. Duties not to do anything illegal or hide

illegal acts. Duties to each other.

Standard CareStandard Care

Standard, suitable, equipment in good repair.

Standard assistance. Non standard drug is a poison by

definition. Standard procedure and indicated

treatment and surgery. Standard proper reference to

appropriate specialist.

Duty to provide information to Duty to provide information to patient/attendantpatient/attendant

Regarding necessity of treatment. Regarding duration of treatment. Regarding prognosis. Do not exaggerate

nor minimize gravity of patients condition.

Regarding the expenses and break-up thereof.

Emergency careEmergency care

A doctor is bound to provide emergency care on humanitarian grounds, unless he is assumed that other are willing and able to give such care. It may be noted that prior consent is not necessary for giving emergency/first aid treatment. In emergency medico-legal cases condition of first being seen by medical jurist is not essential.

Duties to the publicDuties to the public

Health Education Medical help when natural calamities like

drought, flood, earthquakes, etc occur. Medical help during train accidents. Compulsory notification of births, deaths,

infections, disease, food poisoning etc. To help victims of house collapse, road

accidents, fire, etc

Duties towards Law enforcers, Police Duties towards Law enforcers, Police Courts, etcCourts, etc

To inform the police all cases of poisoning, burns, injury, illegal abortion, suicide, homicide, manslaughter, grievous hurt and its natural complication like tetanus, gas-gangrene, etc. This includes vehicular accidents, fracture, etc

To call a Magistrate for recording dying declaration.

Duty not to violate Professional ethicsDuty not to violate Professional ethics

Not to indulge in self-advertisement except such as is expressly authorized by the MCI code of Medical Ethics.

No fee sharing Not to attend pts under Alcohol Not to issue false certificate and bills. not to talk loose with colleagues. Patients identity not to be disclosed Not to run Medical store Recovering any money in connection with service

rendered to a patient other than a proper professional fee, even with the knowledge of the patient.

Duty not to do anything illegal or hide Duty not to do anything illegal or hide illegal actsillegal acts

Perform illegal abortions/sterilizations Issue death certificated where cause of

death is not known. Not informing police a case accident,

burns, poisoning, suicide, grievous hurt, gas gangrene.

Not calling Magistrate for recording dying declaration.

Medical ProfessionalismMedical Professionalism

“Contributing those attitude and behaviors that serves to maintain patients’ interest above Physicians’ self interest.”

Professional Responsibilities 1-3Professional Responsibilities 1-3

Commitment to Professional competence *lifelong learning of medical knowledge and clinical and

team skills Commitment to honesty with patients *Assuring that patient are completely and honestly

informed before and after treatment, including disclosure of errors

Commitment to patient confidentiality *Applying safeguards to the disclosure of patient

information

Am Board Int Med Foundation, Am Coll Physician, Eur.Foundation Int Med. Am intern Med & Lancet 2002


Commitment to maintaining appropriate relation with patients

* Avoiding the exploitation of patients for sexual advantage, personal financial gain, or any other private purpose

Commitment to improving the quality of care * Working collaboratively to create system contributing to

continuous quality improvement in health care. Commitment to improving access to care * Reducing barriers to equitable health care based on

education, laws, geography, and social discrimination


Commitment to a just distribution of finite resources

* Providing health care based on wise and cost-effective management of limited resources.

Commitment to scientific knowledge * Uploading current scientific standards and

promoting the creation and appropriate use of knowledge

Commitment to maintaining trust by managing conflicts of interest

* Compromising professional responsibilities by pursing private or personal gain

Professional Responsibilities 10Professional Responsibilities 10

Commitment to Professional Responsibilities

* Working collaboratively and treating one another with respect

Communication skillsCommunication skills

“ Patients don’t care how much you know them, they know how much you care”

CommunicationCommunication

7% - Spoken words

38% - Voice quality like Tone, Tempo, intonation

55% - Body language

How to perfect non verbal How to perfect non verbal signalsignal

Smile Open Posture Forward lean Touch Eye contact Nod

Communication skills in clinical skills in clinical practice- Introductionpractice- Introduction

“Its an art to talk medicine in the language of a non medical men”

not an option but a necessity

separates successful doctors from

unsuccessful ones

include ability to engage with patients at

emotional level, to listen, to convey

information with clarity & sympathy

What do patients wantWhat do patients want

- Patient dissatisfaction with doctors relate to problems of communication rather than clinical competence

- They want - quality information about their problems - risks & benefits of treatment - relief of emotional distress - to be active participate in medical decision

making

Barriers to communicationBarriers to communication

- Work over load on doctors

- Shortage of man power- less time for individual patient

- Lack of training in communication skills during medical education

- Individual attitude & personality traits

Components of clinical communication Components of clinical communication skillsskills

RAPPORT BUILDING starts with taking history of patient Give adequate time to history taking & clinical

examination keeping in mind Bio-Psycho-Social approach

Do not make false promises regarding prognosis

Explain the rationality of Lab Investigations prescribed

Do not criticize previous doctors prescription Use patients name whenever possible, it

makes rapport building easier

2. EMPATHIC LISTENING2. EMPATHIC LISTENING

Show empathy & respect – let your patients know that you care & understand their experience

Putting yourself in patients situation

Develop listening skills

Give a 2-4 seconds pause between listening & responding

Maintain eye to eye contact

Avoid changing the topic mid way by interrupting

Empathic listening is most useful in dealing emergency cases

3. Effective questioning skills3. Effective questioning skills

elicit maximum information in shortest possible time using purposeful & inoffensive questions

Ask one question at a time

Wait until the previous question is fully answered

5. Answering skills5. Answering skills

weakest communication skills among Indian Medical Professionals

In Indian context patient satisfaction is largely decided by the quality of answers & explanation given by doctors

Understand the question clearly, answer fully, & clearly but briefly

Avoid major technical terms

5. Answering skills (contd..)5. Answering skills (contd..)

Compliment the patient on asking a good question

If you can’t give a ready answer give non committal answer like- “ let me observe you for some more time, certain tests are awaited”

Take feedback whether they have understood answer

Information sharing & decision makingInformation sharing & decision making

Most important when there is life threatening illness

When different management options exist with varying costs, benefits & when outcome is unpredictable

Discuss risks & benefits of each option

It not only increases patient satisfaction but also reduces the chance of litigation if any adverse outcome results

While prescribing any drug with life threatening side effects- informed consent to be taken

Specific situationsSpecific situations

Pediatric practice-

• May be more emotionally taxing as you have to manage the parents in addition to the patient

• Adopt a positive attitude in responding to parental concern

• Explain them signs of worsening or severity of illness & explain when they need to seek prompt advice

• Information on OTC medications & antibiotics

Communicating prognosis, hope & riskCommunicating prognosis, hope & risk

Misunderstandings in these areas can lead to patient dissatisfaction & litigation

Prognostication is like weather forecasting uncertain but based on sound scientific principles

Stage of illness at presentation of patient Curability of disease

In face of uncertainty there is nothing wrong with providing hope

Provide evidence based risks

Never create guilt for negligence on part of patient

Dealing with chronic disease & dyingDealing with chronic disease & dying

Chronic illness/ incurable illness e.g. HIV, Cancer cause stress for patient & attendants

Counseling plays a big role

Breaking news can be done in steps- news given too bluntly may lead to denial & psychiatric problems

Encourage him to hope for the best

Give example of person who have lived with such illnesses for longer periods with positive attitude & will power

Dealing with relatives during Dealing with relatives during resuscitation resuscitation

Routinely relatives are excluded

Studies have found no adverse psychological effects if some mature person observes the process

One of the doctors of team should explain the procedure being done to relatives- it builds better rapport & communication regarding adverse outcome easy

Remember that bereaved relatives are also your patients- counsel them & give medical help

Anticipate & handle common reactionsAnticipate & handle common reactions

Disbelief- Is he really gone- for their satisfaction show them proof- eg. ECG

Guilt- by giving logical & rational explanation & saying that he tried his best

Offer help to manage transport

Resident Evaluation checklist on Resident Evaluation checklist on ProfessionalismProfessionalism

Marking 0 1 2 3 4 5 6 7 8 9 10 Unsatisfactory Satisfactory Exemplary

(1) Empathy in patient care.(2) Appropriate fund of knowledge.(3) Soundness of clinical judgment.(4) Technical expertise with diagnostic and therapeutic procedures.(5) Communication with patients, families and staff.(6) Sensitivity and responsiveness to individual patient differences in

economic status,ethinicity,age,gender and disabilities.(7) Honesty in dealing with patients and colleagues.(8) Accountability for action.(9) Conflict-resolution skills.(10) Adherence to regulatory, institutional and departmental norms.

UCLA PCAT 12-CommunicationUCLA PCAT 12-Communication

RATE EACH ITEM:Strongly agree: Agree: Neutral: Disagree: Strongly disagreeNot applicable: Not Observed

The resident: Made himself or herself easily accessible

to you Encourage your input in discussion Clarified the objectives, expectations and

goals of care Listen to your concerns Explained and discussed progress and

any unforeseen problems.

UCLA PCAT 18UCLA PCAT 18

honesty/accountability/Response to Error

Make up information, tries to cover error, or blames others

Minimizes error and/or is unable to learn from errors

Recognizes error, apologizes and alters behavior.

Recognizes error, apologizes and alters behavior, but takes errors too personally

Excessive self-criticism/self-doubt interferes with work performance.

Emotional Intelligence (EQ)Emotional Intelligence (EQ)

Def – “The ability to monitor one’s own & other feelings & emotion to discriminate among them, and to use this information to guide one’s thinking and action”

IQ Average citizen - 100 Doctor - 120

EQ Average citizen - 100 Doctor - 90

EQ ComponentsEQ Components

Knowing your own emotions (Self awareness) Managing your own emotion (Self regulation) Motivating yourself Recognizing and understand other people’s emotion (

Empathy) Managing relationships or social skills- Skills in managing emotions in others determines

popularity, leadership & interpersonal effectiveness.

EQEQ

Physician cannot perform his job without understanding his emotion & those of patients

IQ - Technical Competence EQ - People’s Competence

IQ - Gets you job EQ - Gets you promoted

IQ - Gets you higher marks EQ - Makes you happy & Productive

Keeping updated : Managing Keeping updated : Managing knowledgeknowledge

Medical books -- Become outdated fast Medical journals -- Costly Conference Medical representative Internet

Medical knowledge problem – Mammoth size - Short half life

Keeping updatedKeeping updated

Structure your knowledge around patients

Learn from your past mistakes

Master clinical protocols & Flow charts

Concentrate on carry home massages

Vulnerable times for mistakesVulnerable times for mistakes

Tired, lazy, sleepyAngryOverconfidentPatient irritatingComplex medical Problem

Mistake : ResponseMistake : Response

Blaming the system Blaming the colleagues, even patients Disconnecting of importance ( No Clinical

effectiveness) Emotionally Distancing (Everyone makes

mistakes)

Dealing with mistakeDealing with mistake

Accept responsibility for the mistake Discuss with trusted friend, colleague or

spouse Disclose & Apologize to the patients Error analysis Measures to reduce similar mistake in future

Marketing in medicineMarketing in medicine

“Marketing is Practice building not advertising”

Practice Practice building/Marketingbuilding/Marketing

Satisfied patients Volunteering at community medical service. Organizing an event – like conference Attracting Media attention Contributing article on health to magazine Public lecture News letter Website Marketing to referral base

Informing patient in information Informing patient in information ageage

Printed material Broachers

Story of a Doctor

Main 12v me ThaWo 12v me Thi

Main MBBS me ThaWo BSc me Thi

Main MBBS me ThaWo MSc me Thi

Main MBBS me ThaWo PHD me Thi

Main MBBS me ThaWo Dr ban gai

Uski Shadi huiMaine PG entrance diya

Wo do bachcho ki ma baniMain MD kar raha Tha

Bachche 5 saal ke hoker school jane lageMain post PG karne laga

Bachche 10th pass ho gayeMaine hospital shuru kiya

Afsos bas ye hai ki aaj wo Tubectomy karane aayi hai

AUR

Aaj meri Sagai hai…….

MarriagesMarriages

Perfectionism, compulsiveness & work holism – good doctor but problematic spouse

Many married to Profession – no time to cultivate intimacy with spouse

MarriagesMarriages

Stage 1 -- Romance – you are perfect Stage 2 -- Fault finding Stage 3 -- Blaming Stage 4 -- Acceptance Transformation – Growing together

MarriagesMarriages

Spend time together Respect each other Have fun together Treat your spouse as your most

important VIP patient -- A loved spouse is also loving

spouse

MarriagesMarriages

A meal together everyday Fun together once a week One holiday every year together Make sure children meet grand

parents, relatives periodically Help children honor family

traditions

Improving RelationshipImproving Relationship

Teaching of ethics & communication skills in UG curriculum.

Teaching of sociology aimed at creating cultural sensivity,empathy & respect for patients’ dignity.

Teaching legal aspect of practice. Physician has to enter patients world- to

see illness through patient’s eye

Take homeTake home

Fall in love of being a Doctor Derive pleasure in work wherever & in

whatever capacity you are working. You always have the potential to contribute to patients & society

Work & practice with Medical professionalism Use common sense. Identify local socio-

cultural practices & integrate in your working style

Take homeTake home

If you are a good professional- become trusted advisor to patient-become their friend, philosopher & guide.

“Do unto other as you would have them do unto you.”

Don’t end at result of single Prescription/consultation. Target long lasting patient doctor relationship

Take home messageTake home message

People prefer those doctors with average clinical

skills but good communication skills rather than

those with excellent clinical but poor

communication skills

Most of the complaints are made against doctors

who do not communicate

“Successful Medical Practice is like successfully driving a car where

you not only take care of your own mistakes but others mistakes also.”

Visualised yourselfVisualised yourself

Visualize your funeral with these speakers – A family Member, a Friend, a colleague & a patient.

ThanksThanks

medical professionalism & motivation for doctors- dr vijay sardana

Health & Medicine

patient trust

instigating patient

poor relationship

doctors somedegree of

disease patients

doctors incidents

doctors decision

practice of medicine