THE CHANGING FACE OF

MEDICAL

PROFESSIONALISMVictor Lim

International Medical University

Malaysia

OUTLINE OF PRESENTATION

What is medical professionalism

A short history

Challenges in the 21st Century

Meeting the challenges – ABIM Foundation

Physician Charter

MEDICAL PROFESSIONALISM

“a set of core beliefs and values that

guide the behavior of physicians caring

for patients”

Lucey and Souba (2010)

MEDICAL PROFESSIONALISM

Encompasses 3 elements

(i) the ethic of service

(ii) autonomy and self-regulation

(iii) benefit to society

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)

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

HISTORY

Thomas Percival (1740-1804)

Manchester physician

Code of professional conduct

Reinterpretation of Hippocrates

Self-regulating, paternalistic

and benign

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”

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

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)

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

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

28 July 2015

Kaiser Health News 25 Oct 2012

A Case Study in Conflict of Interest

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

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

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

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)

3 Fundamental Principles

1.Primacy of patient welfare

2.Patient autonomy

3.Social justice

American Board of Internal Medicine Foundation 2002

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

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