Professionalism in Medicine

1. Professionalism in Medicine Dr Naomi Lee Legal Counsel Acknowledgement : Prof Michael Agrez

2. Professionalism • What does this mean to you? • Is it important? • What are the elements? • Is it a list of behaviours/qualities? • Dictionary definition The conduct, aims or qualities that characterise a group of individuals with a calling

3. Professionalism • No common understanding on what is understood by medical professionalism • Fundamental principles: • primacy of patient welfare • patient autonomy • social justice in the healthcare system • Characteristics difficult to define and measure

4. The Roles of a Doctor • Two distinct but overlapping roles: • Clinician • Professional • Society judges us in both roles • Education and assessment emphasises clinical teaching

5. Guess Who

6. Hippocratic Oath • Good of patients • Keep patients from harm and injustice • Recognition of limitations (I will not use the knife…) • Benefit of the sick • Patient confidentiality (such things shameful to be spoken about) • Student support of their teachers (To hold him who has taught me this art as equal to my parents, if he is in need of money, give him a share of mine)

7. Elements of Professionalism • Literature review (57 ref) • 90 elements identified • Altruism (26) • Accountability (23) • Respect (21) • Integrity (21) van de Camp et al., 2004

8. Elements of Professionalism • Technical Competence (1) • Willingness to admit errors (1) • Ask for help when necessary (1) • Dress Code (0) Conclusion Professionalism is surrounded by ambiguity and a generally accepted definition is lacking • van de Camp et al., 2004

9. Elements of Professionalism • Interpersonal professionalism • meeting demands for contact with patients and healthcare professionals • Public professionalism • meeting society’s demands • Intrapersonal professionalism • meeting demands to function as an individual - van de Camp et al., 2004

10. Elements of Professionalism • Lifelong learning -commitment to knowledge • Commitment to ethical practice • Honesty • Compassion • Commitment to excellence • Good communication • Self-regulation and recognition of limits • Ability to reflect on mistakes • Service • Ability to accept responsibility

11. What about Appearance/ Dress Code Relevant measure or element?

12. Who would you trust to do your hair?

13. Who would you trust to train you?

14. Who would you trust to treat your mother?

15. Work environment • Relevant? • Is behaviour contextual?

16. Work environment • You are taking care of a patient with congestive heart failure. • During ward round, the AMO asks you to report the patient’s blood potassium level . • You do not recall the exact value, but believe that it was normal. • Your AMO is a stickler for details and will become quite upset if you do not report the exact potassium level and you are likely to be ridiculed and reprimanded in front of the team. • If you make up a plausible laboratory value, it is unlikely that the patient would be harmed if you were to fabricate a potassium value. How likely would you be to tell the AMO that you do not recall the exact value?

17. Clinical Vignette – Scenario 2b • You are taking care of a patient with congestive heart failure. • During ward round, the AMO asks you to report the patient’s blood potassium level . • You do not recall the exact value, but believe that it was normal. • Your AMO is easy going and well liked. If you say you do not know it is unlikely that you will be ridiculed or reprimanded. • If you make up a plausible laboratory value, it is doubtful the AMO will find out and it is unlikely that the patient would be harmed if you were to fabricate a potassium value. How likely would you be to tell the AMO that you do not recall the exact value?

18. Standards • Fundamental Ethical Principles • Common law- duty of care, informed consent • Legislation • Health Practitioner Regulation National Law Act • Health Services Act • MBA • Good Medical Practice • NSW Ministry of Health and HNEH • Code of Practice and Policy Directives • email, social networking, respectful workplace etc.

19. Risks to you when things go wrong • Loss of reputation • Career opportunities • College applications • MCCC • Internal complaint/Health Care Complaints Commission/Privacy Commissioner • Referral to Medical Board • Professional Development stream • Professional Standards Committee • Medical Tribunal • Personal litigation

20. Particular issues- Communication “When patients ask me questions I just use bigger words”

21. Communication

22. Trends in Complaints - HCCC • Treatment (48.8 %) • Communication (12.6%) 1048 total issues • 736 Attitude/manner • 188 inadequate information • 80 wrong/misleading information • Professional conduct (11.2%) 928 total issues • 246 illegal practices • 171 competence • 81 inappropriate disclosure of information • 80 issues of impairment • 78 sexual misconduct

23. Outcomes of Complaints in NSW2010-2011 • 1424 complaints received against medical practitioners in NSW (NSMC and HCCC) (cw 1249 in 09-10) • HCCC assessment • 930 declined • 90 referred for investigation by HCCC • 227 referred to back to NSMC (disciplinary counselling, health or performance pathway) • Of the 90 investigated, 55 referred to Director of Proceedings to assess whether disciplinary proceedings warranted • 27 cases concerning 22 practitioners referred to Medical Tribunal (power to deregister and suspend) • 16 cases concerning 15 practitioners to the Prof StdsComm

24. Matters commenced in Tribunal • Boundary crossing 8 (8) • Prescribing 5 (8) • Breach conditions 0 (4) • Treatment 3 (3) • Competence/impairment 0 (0) • Fraud 0 (2)

25. Particular issues- Social Media Minefield • Facebook • Online forums • Twitter • Blogs

26. Online Professionalism Violations Reported to State Medical Boards • Inappropriate patient communication online • Online misrepresentations of credentials • Use of Internet for inappropriate practice • Online violations of patient confidentiality • Failure to reveal conflicts of interest online • Online derogatory patient remarks • Online depiction of intoxication • Discriminatory language or practices online • Multiple violations of above

27. Violations of Online Professionalism Reported to State Medical Boards (US) Method of discovery (n= 48) • Reported by patient or patient’s family 31 (65%) • Reported by another physician 24 (50%) • Discovered during investigation of another complaint 24 (50%) • Reported by other health professionals 16 (33%)

28. Online Professionalism Violations Reported to State Medical Boards (US) Initial actions in response • Any disciplinary proceeding 34 (71) • Formal disciplinary meeting 24 (50) • Informal warning issued 19 (40) • Issue of consent order 19 (40) • No action taken 12 (25)

29. Online Professionalism Violations Reported to State Medical Boards (US) Subsequent outcomes of disciplinary proceedings • Any serious action (restriction, suspension, or revocation) 27 (56) • Letter of reprimand 23 (48) • Restriction of license 21 (44) • Mandated education or community service 19 (40) • Monetary fine 16 (33) • Probation 4 (8)

30. The Social Media Minefield • Protect your image • Maintain patient confidentiality • Protect Dr/Patient boundaries • Avoid defamatory statements • Limit extent of access • Sum of what you say

31. Blog- A Day in the Life of a Nurse Sometimes it is really hard to be nice to people who are just mean spirited. We as nurses are supposed to care for everyone in the same way. This guy was an exception – he brought out the worst in me. I found myself swearing right back at him! I was so happy to see him go off to the OR – I felt sorry for his girlfriend!

32. Blog -Junior doctor I’m on a morning ward round in the Intensive Care Unit and we’re discussing a patient I’d admitted the day before. Mrs Patel is a lady in her sixties with really bad respiratory failure due to a particularly nasty pneumonia. The previous afternoon I thought that if we gave her non-invasive ventilation (NIV) and adequate intravenous fluids, she may just turn the corner and start to get better.

33. Blog- Musings of a paediatric oncologist • The purpose of this blog is to write informally for anyone who is interested in paediatric oncology, cancer research, cancer treatments, and breaking medical news • Personalised medicineis the new Holy Grail of cancer therapy.  The drugs we currently use are stupid.  They don't actually target cancer cells, they target rapidly dividing cells.  Cancer cells divide rapidly, which is why chemotherapy works, but plenty of other cells in our bodies divide rapidly, and that is why chemotherapy causes so many side effects.

34. Planking – Harmless fun?

35. Planking – Harmless fun?

36. Planking – Harmless fun?

37. Clinical Scenarios

38. Scenario A • A JMO was rude and abrasive to his colleagues • Behaviour persisted throughout his rotations despite counselling by his supervisors. • Errant behaviour was noted by the Nursing Director who raised the matter to the hospital Chairman of the Medical Board. • The hospital proposed to the Singapore Medical Council to disallow the JMO from full registration.

39. Scenario B • A JMO did not complete tasks despite reminders • Falsified records. • When approached by her supervisor, she claimed to have relationship problems • Behaviour persisted despite counselling from her supervisor who then raised the matter to the HoD, recommending disciplinary action. • The HoD decided otherwise and allowed this JMO to proceed to the next rotation.

40. Scenario C • A JMO was caught trying to record video footage of a colleague using the rest/shower room. • Confronted with the evidence, he admitted to his criminal act, citing work stress and loneliness. • He was dismissed from employment immediately and referred to the Singapore Medical Council for decision regarding his registration.

41. Singapore Study • 124 new medical graduates • Anonymous, self administered questionnaire • RR 90.3 % (112) • Median age 24 • MO understanding of professionalism and professional behaviour ` Hoa and Tham

42. Results • Scenario A • 52.7% agreed that the first HoD should escalate the matter to the hospital higher authority • 70.5 % agreed that this should be escalated when behaviour failed to improve • Only 35.7% agreed registration should be disallowed

43. Results • Scenario B • 80.4% agreed behaviour inexcusable even with mitigating personal circumstances • 83 % agreed the supervisor was right in recommending disciplinary action • Only 76.8% agreed the HoD should have disciplined the HO • Only 60.7% agreed the next HoD should be informed

44. Results • Scenario C • 90.8% agreed action inexcusable • Only 83.9% agreed with dismissal • Only 52.7% agreed should not be registered

45. Professionalism Maybe in St Elsewhere But not in my town

46. Case Examples • Facebook status • Nursing graduate • Opinion re adequacy of a response to a MET call • Identified hospital and ward but not the patient • “at least the doctor was hot, so not a complete waste of time” • f bomb and other expletives dropped frequently

47. Case Examples A NEWCASTLE doctor was sacked and had his career placed in jeopardy after he was caught filming his housemate in the shower using a spy camera in a pen. • A serious of breach of trust. • Charged and convicted • Employment terminated • Job offer withdrawn. • Medical Council of NSW

48. Last thoughts • Think about a positive role model • Develop professional behaviours early in your career • You are now the role model for students