PROFESSIONALISM in Medical Education

1. PROFESSIONALISM in Medical Education George D. Carson MD FRCSC CSPQ FSOGC Department of Obstetrics and Gynecology Regina Qu’Appelle Health Region

2. PROFESSIONALISM in Medical Education http://www.afmc.ca/social-professionalism-e.php

3. Professionalism in Medical Education A word to my newest colleagues Over the next 4 years and all of your career you will acquire an enormous stock of knowledge and skills That is WHAT you will do As colleagues with the privilege to practice medicine you will do so with “professionalism” That is HOW you will do it It is who we are. It is why we deserve, how we earn, the special status given to us by society.

4. Professionalism in Medical Education Professionalism is the basis of medicine's contract with society We are given a monopoly by society We must earn it every day

5. Professionalism in Medical Education Cruess, S.R, Johnston, S. and Cruess, R.L. ‘Profession’: A working definition for medical educators. Teaching and Learning in Medicine, 2004; 16: 74-76. ‘Profession: An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.’

6. Professionalism in Medical Education Cruess, S.R, Johnston, S. and Cruess, R.L. ‘Profession’: A working definition for medical educators. Teaching and Learning in Medicine, 2004; 16: 74-76. ‘Profession: An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.’ It is a vocation in which knowledge …. is used in the service of others.

7. Professionalism in Medical Education Definitions of Professionalism - Medical Literature Swick, H.M. Toward a normative definition of medical professionalism. Academic Medicine, 2000; 75: 612-616. 'Medical professionalism, then, comprises the following set of behaviors: • Physicians subordinate their own interests to the interests of others. • Physicians adhere to high ethical and moral standards. • Physicians respond to societal needs, and their behaviors reflect a social contract with the communities served. • Physicians evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others, and trustworthiness. • Physicians exercise accountability for themselves and for their colleagues. • Physicians demonstrate a continuing commitment to excellence. • Physicians exhibit a commitment to scholarship and to advancing their field. • Physicians deal with high levels of complexity and uncertainty. • Physicians reflect upon their actions and decisions.

8. Professionalism in Medical Education Definitions of Professionalism - Medical Literature Swick, H.M. Toward a normative definition of medical professionalism. Academic Medicine, 2000; 75: 612-616. 'Medical professionalism, then, comprises the following set of behaviors: • Physicians subordinate their own interests to the interests of others. • Physicians subordinate their own interests to the interests of others. • Physicians adhere to high ethical and moral standards. • Physicians respond to societal needs, and their behaviors reflect a social contract with the communities served. • Physicians evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others, and trustworthiness. • Physicians exercise accountability for themselves and for their colleagues. • Physicians demonstrate a continuing commitment to excellence. • Physicians exhibit a commitment to scholarship and to advancing their field. • Physicians deal with high levels of complexity and uncertainty. • Physicians reflect upon their actions and decisions.

9. Professionalism in Medical Education

10. Professionalism in Medical Education And many, many more

11. Professionalism in Medical Education There are many, many aspects of professionalism Professionalism is fundamental to what we do. It should be taught and must be learned and practiced by all of us in the profession of medicine Marcel D’Eon has chosen just one of the aspects of professionalism: the patient comes first He has chosen the example of termination of pregnancy – although really the problem is the unintended, unwanted pregnancy

12. Professionalism in Medical Education Professionalism is the basis of medicine's contract with society It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession. Ann Int Med 2002;136:243

13. Professionalism in Medical Education Professionalism is the basis of medicine's contract with society It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession. Ann Int Med 2002;136:243 And I have only a few minutes to do this. Please read the additional material, including all the important words on all the slides. I can highlight only a few now. I would be pleased to have an ongoing discussion.

14. Professionalism in Medical Education Professionalism is the basis of medicine's contract with society It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession. Ann Int Med 2002;136:243

15. Professionalism in Medical Education Non-directive counselling entails emphasizing that decisions are patient directed, not physician directed. Frank A. Chervenak et al. Enhancing patient autonomy with risk assessment and invasive diagnosis: an ethical solution to a clinical challenge Am J Obstet Gynecol 2008; 199: 19.et-19.e4

16. Professionalism in Medical Education Social Accountability “the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region and/or nation that they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public.” Social Accountability A Vision for Canadian Medical Schools Adapted from WHO, 2001

17. Professionalism in Medical Education CMA Policy on Medical Professionalism “Medical professionalism includes both the relationship between a physician and a patient and a social contract between physicians and society. An individual responsibility A collective responsibility that can ONLY be met by each individual fulfilling her or his responsibility Society grants the profession privileges, including exclusive or primary responsibility for the provision of certain services and a high degree of self-regulation. In return, the profession agrees to use these privileges primarily for the benefit of others and only secondarily for its own benefit.”

18. Professionalism in Medical Education CMA Policy on Medical Professionalism “Medical professionalism includes both the relationship between a physician and a patient and a social contract between physicians and society. An individual responsibility A collective responsibility that can ONLY be met by each individual fulfilling her or his responsibility Society grants the profession privileges, including exclusive or primary responsibility for the provision of certain services and a high degree of self-regulation. In return, the profession agrees to use these privileges primarily for the benefit of others and only secondarily for its own benefit.”

19. Professionalism in Medical Education SASKATCHEWAN COLLEGE OF PHARMACISTS Statement Regarding Pharmacists' Refusal to Provide Products or Services for Moral or Religious Reasons Adapted by SCP from the National Association of Pharmacy Regulatory Authorities “Model Statement Regarding Pharmacists' Refusal to Provide Products or Services for Moral or Religious Reasons” Pharmacists shall hold the health and safety of the public to be their first consideration in the practice of their profession. Pharmacists who object, as a matter of conscience, to providing a particular pharmacy product or service, must be prepared to explain the basis of their objection. Objecting pharmacists cannot abandon their ethical duty of care to the patient, and respect of the patient’s right of autonomy to make informed decisions to receive pharmacy products and services based on objective and accurate information.

20. Professionalism in Medical Education SASKATCHEWAN COLLEGE OF PHARMACISTS Statement Regarding Pharmacists' Refusal to Provide Products or Services for Moral or Religious Reasons Adapted by SCP from the National Association of Pharmacy Regulatory Authorities “Model Statement Regarding Pharmacists' Refusal to Provide Products or Services for Moral or Religious Reasons” Pharmacists shall hold the health and safety of the public to be their first consideration in the practice of their profession. Pharmacists who object, as a matter of conscience, to providing a particular pharmacy product or service, must be prepared to explain the basis of their objection. Objecting pharmacists cannot abandon their ethical duty of care to the patient, and respect of the patient’s right of autonomy to make informed decisions to receive pharmacy products and services based on objective and accurate information.

21. Professionalism in Medical Education To illustrate this, we are asked to consider termination of pregnancy – induced abortion In some ways this is too easy We, in and out of the profession of medicine, start with OPINIONS These may be strongly held There are also FACTS about abortion: • It is legal • It is ethically acceptable to many • A majority of Canadians think it should be legally available and accessible

22. Professionalism in Medical Education We should frame the issue properly The clinical problem is The Unintended, Unwanted Pregnancy

23. The Unintended, Unwanted Pregnancy George D. Carson MD FRCSC CSPQ FSOGC Director of Maternal Fetal Medicine Regina Qu’Appelle Health Region Clinical Professor of Obstetrics, Gynecology and Reproductive Sciences University of Saskatchewan

24. The Unintended, Unwanted Pregnancy

25. The Unintended, Unwanted Pregnancy This clinical problem necessarily includes the option of pregnancy termination – abortion. This is a topic that must include facts in its teaching and learning, but it also includes feelings – perhaps more than most medical procedures. Let us consider some of the feelings. George D. Carson MD FRCSC CSPQ FSOGC

26. The Unintended, Unwanted Pregnancy Let us consider some of the feelings. In the time that we do this educational session, in the world one woman will die a direct obstetrical death EVERY MINUTE 1/6 of these will be complications of abortion, nearly all due to unsafe abortion because the legal, safe alternative is denied. 99% will be in the developing world. George D. Carson MD FRCSC CSPQ FSOGC

27. Let us consider some of the feelings. The Unintended, Unwanted Pregnancy

28. The Unintended, Unwanted Pregnancy Women are not dying because of a disease we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving. Mamoud Fathalla, President of the International Federation of Gynecology and Obstetrics (FIGO), World Congress, Copenhagen 1997

29. Why Does It Happen? • Contraception Use And Effectiveness • Frequency of Problem The Unintended, Unwanted Pregnancy

30. The Unintended, Unwanted PregnancyWhy Does It Happen? Contraceptive Effectiveness When real people use contraception in real life the failure rate is 10 to 20 % per year

31. The Unintended, Unwanted PregnancyWhy Does It Happen? Who Uses Contraceptives? When only fertile, sexually active women who do not want to become pregnant are considered, 9 in 10 are practicing contraception

32. The Unintended, Unwanted PregnancyWhy Does It Happen? Who Uses Contraceptives? If only 5% of the women aged 15-44 in need of contraception are not using a method, but 50% of pregnancies are unplanned, then 45% of pregnancies happen to women who are using contraception - the imperfect best that we have- and get pregnant anyway. They are not using abortion as their method of birth control - a popular, pejorative myth.They are using contraception.

33. The Unintended, Unwanted PregnancyWhy Does It Happen? Canadian PerspectiveUnintended versus Intended Pregnancies 2002 Intended 229,256 220,014 Unintended Unintended births 101,085 Elective Abortions 119,056 ~ 15% miscarriages Henshaw: Fam Plann Perspect 1998;30:24-29 & Statistics Canada data 2002.

34. The Unintended, Unwanted Pregnancy

35. Options Continuingthe Pregnancy The Unintended, Unwanted Pregnancy How does she feel about the pregnancy and her partner, family Single parent Is she keeping the baby? With partner In the family, in contact Adopted out Establish dating Evaluate re inadvertent and advertent substance use Offer substance abuse programs, if applicable Evaluate re safety / risk of violence Test for STIs. Offer test for HIV Plan parenting and support Nutrition Plan remaining in/returning to school Termination of the pregnancy

36. The Unintended, Unwanted Pregnancy

37. The Option of Pregnancy Termination The Unintended, Unwanted Pregnancy Induced abortion is a procedure commonly used throughout the world to terminate unwanted pregnancy….when performed in early pregnancy by well trained practitioners in adequate facilities, induced abortion has an excellent safety record.1 1 IPPF Medical Bulletin 2006;40:3

38. The Unintended, Unwanted Pregnancy The Option of Pregnancy Termination Restrictive abortion legislation or systematic or individual practices that restrict access do not substantially reduce the overall number of abortions but greatly increase the proportion performed unsafely.

39. Ethics/ Professionalism Every Health Care Provider’s Responsibility The Unintended, Unwanted Pregnancy

40. Canadian Medical Association Code Of Ethics

41. Ethics/ Professionalism The Unintended, Unwanted Pregnancy This Code has been prepared by the Canadian Medical Association as an ethical guide for Canadian physicians, including residents, and medical students. Its focus is the core activities of medicine –such as health promotion, advocacy, disease prevention, diagnosis, treatment, rehabilitation, palliation, education and research. It is based on the fundamental principles and values of medical ethics, especially compassion, beneficence, non-maleficence, respect for persons, justice and accountability. The Code, together with CMA policies on specific topics, constitutes a compilation of guidelines that can provide a common ethical framework for Canadian physicians.

42. Ethics/ Professionalism The Unintended, Unwanted Pregnancy • Fundamental Responsibilities • Consider first the well-being of the patient. • 2. Practice the profession of medicine in a manner • that treats the patient with dignity and as a person • worthy of respect. • 3. Provide for appropriate care for your patient, • even when cure is no longer possible, including • physical comfort and spiritual and psychosocial • support. • 4. Consider the well-being of society in matters • affecting health. • 5. Practice the art and science of medicine • competently, with integrity and without impairment.

43. Ethics/ Professionalism The Unintended, Unwanted Pregnancy This CMA Policy has 14 bullets • The patient should be provided with the option of full and immediate counselling services in the event of unwanted pregnancy. • Since the risks of complications of induced abortion are lowest in early pregnancy, early diagnosis of pregnancy and determination of appropriate management should be encouraged. • There should be no delay in the provision of abortion services. • A physician should not be compelled to participate in the termination of a pregnancy. Here are relevant ones And so the physician who first sees the patient MUST meet or facilitate meeting the patient’s needs It is not about the doctor

44. Ethics/ Professionalism The Unintended, Unwanted Pregnancy • Induced abortion should be uniformly available to all women in Canada.

45. The Unintended, Unwanted Pregnancy Ethical IssuesFIGO Statement

46. The Unintended, Unwanted Pregnancy Ethical IssuesFIGO Statement Ethical Guidelines and Conscientious Objection The primary conscientious duty of obstetrician gynecologistsis at all times to treat, or provide benefit and prevent harmto, the patients for whose care they are responsible. Anyconscientious objection to treating a patient is secondary tothis primary duty.

47. The Unintended, Unwanted Pregnancy Legalities

48. The Option of Pregnancy Termination Legality The Supreme Court has deemed abortion a Criminal Law matter that is within Federal jurisdiction. Consequently, provincial legislatures have very little power to regulate abortion, even if done indirectly. Thus, the discussion on the law on abortion in Canada turns almost entirely around the state of the Criminal Law. Section 287 of the Criminal Code is the abortion provision passed in 1969. Prior to 1969, taking steps to cause an abortion was an offence liable to life imprisonment. The Section 287 scheme made an exception for abortions performed in a hospital with the approval of that hospital’s three-doctor therapeutic abortion committee. The committee would have to certify that the pregnancy would be likely to endanger the life or health of the mother. The term health was not defined, and therapeutic abortion committees were free to develop their own theories as to when a likely danger to “health” (which might include psychological health) would justify a therapeutic abortion. The Unintended, Unwanted Pregnancy

49. The Option of Pregnancy Termination Legality In 1988, the Supreme Court of Canada in the Morgentaler decision declared this entire section to be of no force or effect because it was held to violate section 7 of the Canadian Charter of Rights and Freedoms. Section 7 states that: “Everyone has the right to life, liberty, and the security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice.” The majority of the Court held that “the structure of the system regulating access to therapeutic abortions is manifestly unfair. It contains so many potential barriers to its own operation that the [exception] it creates will in many circumstances be practically unavailable to women who would prima facie qualify”. As such, the provision was held to violate the principles of fundamental justice and was struck down. The Unintended, Unwanted Pregnancy

50. The Option of Pregnancy Termination Legality In its decision (Morgentaler et. al. v. Her Majesty The Queen [1988] (1 S.C.R. 30) at 37), the Supreme Court stated: "The right to liberty... guarantees a degree of personal autonomy over important decisions intimately affecting his or her private life. ... The decision whether or not to terminate a pregnancy is essentially a moral decision and in a free and democratic society, the conscience of the individual must be paramount to that of the state." The Unintended, Unwanted Pregnancy