Anita R. Webb, PhD JPS Family Medicine Residency Fort Worth, Texas PROFESSIONALISM Anita R. Webb, PhD JPS Family Medicine Residency Fort Worth, Texas

Goals Awareness of your professions’ expectations Awareness of your specialty’s expectations Awareness of your colleagues’ expectations Awareness of the public’s expectations Awareness of your own expectations

WHY? Claims of declining public image of physicians “Dehumanization” in medical care “Physicians have become less compassionate and too detached.” Hojat M et al. Physician empathy in medical education and practice. Seminars in integrative med 2003;1:25-41. The Business Case: building a successful practice Regulatory bodies: Seeking tools to address breakdowns in professionalism

Alarm in Regulatory Bodies The Joint Commission (JCAHO) Rude language and hostile behavior threaten patient safety and quality of care “Sentinel Event Alert” July 2008 “Zero tolerance” beginning January 2009 www.jointcommission.org/NewsRoom/NewsReleases/nr_09_08.htm Powers K. Joint commission alert: stop bad behavior among health care professionals.

Social Contract Does the profession of medicine have a “contract” with society? Purpose of contract? What does society expect from physicians according to this contract?

Expectations (cont.) What would physicians expect from society according to this contract?

HISTORICALLY Hippocratic Oath Classical version Modern version (1964) www.pbs.org/wgbh/nova/doctors/oath_modern.html

Professionalism Is Expected Professional competence is 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 community being served. Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287:226-235.

U.S.A. American Medical Association Nine principles of medical ethics (2001/2004) (next two slides) www.ama-assn.org/ama/pub/category/print/2512.html

AMA: Nine Principles 1. Medical care: competent, compassionate 2. Professional standards: honesty, etc. 3. Law abiding, advocacy for patients 4. Confidentiality, privacy, respect rights 5. CME, collaboration, referral

AMA (cont.) 6. Physicians’ freedom of choice 7. Community involvement, public health 8. Responsibility to patient as paramount 9. Access to care for all people

International “A Physician Charter” “Professionalism Project” The Lancet, Feb. 9, 2002 (vol.359): 520-522 www.thelancet.com “Professionalism Project” Medical Professionalism in the New Millennium: “A Physician Charter” Ann Int Med 2002:136(3) 243-246 What is a charter? Guarantee of basic rights

Preamble What society expects of physicians: 1. Altruism 2. Competence 3. Integrity 4. Expert advice

Foundation Three “Fundamental Principles” 1. Primacy of patient welfare 2. Patient autonomy 3. Social justice Fair distribution No discrimination

Specific “Responsibilities” Competence Honesty Confidentiality Appropriate relationships Improving access Improving quality Just distribution of finite resources Commitment to scientific knowledge

U.S. Residency Setting ACGME Outcome Project In response to consumer demands Six Competencies required Implemented 2003, enforced 2006 All residency programs, all medical specialties Interpret, implement, evaluate, document Accreditation Council for Grad Medical Education - http://www.acgme.org/outcome

Six Competencies 1. Patient care: compassionate, effective 2. Medical knowledge 3. Practice-based learning and improvement 4. Interpersonal and communication skills 5. Professionalism 6. Systems-based practice

#5: Professionalism As manifested through: I. Commitment to carrying out professional responsibilities II. Adherence to ethical principles III. Sensitivity to diverse patient populations

I. Responsibilities 1. Respect, compassion and integrity 2. Responsiveness to the needs of patients and society that supercedes self-interest 3. Accountability to patients, society, and the profession 4. Commitment to excellence and on-going professional development

II. Ethical principles Must demonstrate commitment to ethical principles pertaining to: 1. Provision or withholding of clinical care 2. Confidentiality of patient information 3. Informed consent 4. Business practices

III. Sensitivity Must demonstrate sensitivity and responsiveness to patients’ Culture Age Gender Disabilities

Local Policies State Board County Hospital District Family Medicine Department

Example: Resident Contract Incorporates ACGME Competencies 1. Patient care Transfers, referral, documentation 2. Medical knowledge Rotations, exams 3. Practice-based learning & improvement Lectures, QI, supervision of lower levels

Contract (Continued) 4. Interpersonal and communication skills Patients, peers, team, staff, advisor 5. Professionalism: Confidentiality, honesty, respect Personal mental health 6. Systems-based practice Completion of records, assignments

Family Medicine Department Expectations Respect, timeliness, notification, sign-outs, pages, reporting questionable conduct, personal property, rotation evaluations, attendance Formal process for investigation of conduct Institutional Committees

Summary Professionalism has historically been an expectation in medicine. Now: The public demands accountability. State medical boards are under pressure. Must measure and document competence. Our Program has policies and procedures for addressing professionalism.

Example: Professional Improvement Plan Recall the JCAHO Alert “Rude language and hostile behavior threaten patient safety and quality of care.” Targeted behavior: “Angry outbursts” Process: Educate, Monitor, Enforce, Support Written Behavioral Plan with specific: 1. Professional requirements (educate) 2. Behavioral expectations (monitor, support) 3. Predetermined consequences (enforce)

“Outbursts”: Implement Plan GOAL: Learn to manage your emotions. Strategies: Emotional intelligence coaching and/or Cognitive Behavioral methods 1. Identify situations which have the potential for triggering your outbursts. 2. Learn and practice strategies to control your emotions in those situations.

“Outbursts”: Expectations Specific Requirements: 1. No angry outbursts for 90 days 2. Keep a log of situations in which you controlled/prevented your outbursts. 3. Submit your completed log every 30 days. 4. Self-report if you have an outburst. Prior to someone else reporting it.

“Outbursts”: Consequences If learning contract expectations are not met 1. Review and revise the contract. 2. Consider psychological counseling. 3. Implement the new plan.

When is an event is reportable? If the unmet expectation: Endangered a patient May endanger a patient in the future Was reported by an agency or department that requires a response Performance objectives are still not met after a second PIP attempt

SUMMARY Professionalism has historically been an expectation for physicians. Now: The public is demanding accountability. State Medical Boards are under pressure. In residency programs, professionalism must be defined, “taught,” measured and documented. The goal is education, not punishment.

Is PROFESSIONALISM the basis of medicine’s contract with society? THE END Is PROFESSIONALISM the basis of medicine’s contract with society?