Institutional professionalism culture of patient-centredness in Sri Lankan medical schools Rasnayake Mudiyanse1 Madawa Chandratilake2 Shamila de Silva2 1 Faculty of Medicine, University of Peradeniya, Sri Lanka 2Faculty of Medicine, University of Kelaniya, Sri Lanka

BACKGROUND Patient-centredness Working definition: Acknowledgement of the patient as a person with unique needs and life history (Stewart 1984)

BACKGROUND Patient-centredness ‘Good doctors’ make the care of their patients their first concern. (GMC Good Medical Practice 2009) Professionalism is the basis of medicine’s contract with society.  patient autonomy (ABIM 2002) ‘Patient practice’ (SLMC)

BACKGROUND Patient-centredness ‘Old’ Professionalism ‘New’ Professionalism Detachment Empathy Paternalism Emotional Engagement Restricted communication with patients  Open Communication Patient-centeredness Medical beneficence as the most prominent ethical principle Patient autonomy as the most prominent ethical principle (Borgstrom et al. 2010)

BACKGROUND Cultural context e.g. Cultural dimensions theory (Hofstede 2010) Western cultures (UK, Europe and North America) Eastern cultures (Arabic Gulf region, Asian subcontinent ) Individualists Collectivists Unequal power distribution in-between social strata is unacceptable Unequal power distribution in-between social strata is acceptable

METHODS Study design: Cross sectional descriptive study using self- administered paper-based C3 instrument Setting: Faculty of Medicine, University of Kelaniya Faculty of Medicine, University of Peradeniya Subjects: Final-year medical students (n=378) Ethics: Ethics committees of both faculties

METHODS The instrument: Communication, Curriculum and Culture C3 Instrument Use: Characterize and understand the institutional hidden curriculum on patient-centredness (Haidet et al 2005 Characterizing the Patient-Centeredness of Hidden Curricula in Medical Schools: Development and Validation of a New Measure. Academic Medicine; 80:44–50.)

METHODS C3 instrument Validated to be used in Sri Lanka

RESULTS Response rate: 340/378 (90%) Internal consistency (Cronbach alpha): Overall: 0.84 Domains: ‘Role model’ - 0.92 (high) ‘Student experience’ - 0.53 (moderate) ‘Support’ - 0.61 (moderate)  The findings can be interpreted with acceptable credibility

RESULTS Faculty Mean (out of 100) SD p Role model Peradeniya 68.01   Faculty Mean (out of 100) SD p Role model Peradeniya 68.01 14.37 0.01  Kelaniya 63.87 15.04 Student experience 60.32 8.72 0.43  61.15 9.50 Support for students 71.83 19.51 0.77  72.47 17.24

Results Highly rated items by both groups Consultants communicate concern and interest in patients as unique persons Intern house officers develop good rapport with patients Consultants take seriously patients’ concerns about their conditions or care Intern house officers take seriously patients’ concerns about their conditions or care Registrars / senior house officers develop good rapport with patients Registrars / senior house officers take seriously patients’ concerns about their conditions or care

Results Poorly rated items by both groups You have to convey bad news to a patient without any teaching or discussion about how to break the news in a caring manner. A SHO, Registrar or intern house officer observes you while you interview a patient and provides you with feedback on your bedside manner. You are asked to interview a patient and you are provided with feedback on how well you listened to the patient. (Either from the patient or an observer). You and your ward team have to convey bad news to a patient. Sometime after the bad news is conveyed, you find yourself having to answer many of the patient’s questions about the news without any teaching.

Conclusions The tool appears measure what it purports to measure. Although the institutional culture is somewhat conducive for patient- centred practice there is room for improvement. ‘Role models’ appear to advise on patient-centred practice. The demonstration of patient-centred behaviours by ‘role models’ may need to be improved

references ABIM Foundation (2002). Medical Professionalism in the New Millennium: A Physician Charter. Annals of Internal Medicine, 136(3):243. Borgstrom, E., S. Cohn, et al. (2010). Medical professionalism: conflicting values for tomorrow's doctors. Journal of General Internal Medicine 25(12): 1330-1336. GMC (2009). Tomorrow's doctors. London General Medical Council 25 - 29. Haidet et al 2005 Characterizing the Patient-Centeredness of Hidden Curricula in Medical Schools: development and Validation of a New Measure. Academic Medicine; 80:44–50. Hofstede, G., G. J. Hofstede, et al. (2010). Culture and organisations; software of the mind. New York, McGraw Hill. Stewart M. What is a successful doctor-patient interview? A study of interactions and outcomes. Social Sciences in Medicine. 1984;19:167–75.

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