Medicine is a vocation in which a doctor’s knowledge, clinical skills, and judgement are put in the service of protecting and restoring human well-being. This purpose is realised through a partnership between patient and doctor – one based on mutual respect, individual responsibility and appropriate accountability.1
As doctors or medical students, one gets the unique experience of providing a service to people in exceptional moments of anxiety and doubt, often with the patient in a vulnerable position placing a great deal of trust in you. Medical professionalism is the tool by which we earn, establish and repay this trust in the stride towards a successful partnership.
Professionalism is required as an integral competency in both undergraduate and post-graduate education. Given that a high proportion of complaints to the GMC regarding doctors are about their behaviour, this further strengthens the case for the importance of professionalism in medicine. It has been shown that unprofessional behaviour as a medical student correlates with disciplinary action further down the line as practising physician.2
The idea of professionalism in medicine dates as far back as the Hippocratic Oath. Hippocrates lived by exemplary moral values and ethical medical practice which was passed on to practitioners of the vocation through the Hippocratic Oath. Here is an excerpt which refers to the commitment to confidentiality in relation to professionalism:
Whatever, in the course of my practice, I may see or hear (even when not invited), whatever I may happen to obtain knowledge of, if it be not proper to repeat it, I will keep sacred and secret within my own breast.3
In contemporary medicine, the Hippocratic Oath does not act as a guide but rather it represents the ideal medical ethic. It has been modified over the years in line with changes to the views and values in Western medicine. For example, the view relating to abortion is no longer consistent with beliefs in Western society.
The underlying principles of professionalism are dynamic, reflecting the changing role and responsibilities of doctors today alongside the shifts in public expectation and attitudes towards them. In a society where doctors are increasingly mistrusted due to a variety of reasons, professionalism is threatened and the stakes are increasingly higher for poor practice. A remarkable difficulty in assessing and determining medical professionalism is the lack of comprehensive description or definition.
According to the Royal College of Physicians, medical professionalism comprises a set of values, behaviours and relationships that underpins the trust the public has in doctors. These values set a standard of what patients will expect from their doctors and sets the scene for the patient-doctor relationship.1 There are different domains to medical professionalism and these are delivered as commitments which correlate with the attributes described in the GMC’s Good Medical Practice4:
A survey for the BMA found that nine out of ten members of the public trust doctors to tell the truth. Honesty is the transparency that doctors display to patients and this plays a role in informed consent. This does not mean patients should be informed about every possible side effect of a treatment for example, a side effect with a 0.001% chance might be deemed negligible but that of above 5% is significant.
Honesty should be absolute when medical failures occur. Open, honest and timely disclosure should be the only approach to errors.5 Doctors are human and medical errors do occur, in these cases patients should be informed promptly with due apologies given and steps taken to report and analyse to prevent future errors. It is also important to ensure that the patient is given due support and compensation.6 However, there is a mixed bag of views as to how medical errors should be approached. Some physicians dispute disclosure when trivial and non-harmful errors have occurred; this is a grey area for medical ethics. However, the view on harmful errors is very clear and hospitals will have set procedures in place regarding such errors.
Confidentiality is the right of a patient to have personal, identifiable medical information kept private unless approval is given for it to be shared. The issue of confidentiality is now more critical given the rapid transition to electronic systems across hospitals. Patient data should not leave the hospital environment unless to said patient and confidentiality should be observed even while dealing with persons acting on a patient’s behalf. The only situation where it is ethical and legal to breach confidentiality is when the patient poses a threat to others/society or when required to do so by law. In the former, the bar must be set very high and the doctor should explore the reasons why and inform the patient of their intention to breach confidentiality.7
Confidentiality is key to delivering the best possible care as patients will more likely provide accurate and substantial information if there is no risk of public exposure. The commitment to confidentiality extends to all healthcare professionals involved in the care of a patient including medical students. Discussion about confidentiality should occur at the start of any conversation in which the patient could potentially disclose information. This involves telling the patient about the manner in which the information given will be handled e.g. ‘whatever you tell me today will not be shared with anyone except the people currently in charge of your care, you are able to withdraw your consent at any point during this conversation’.8
Maintaining appropriate relationships and maintaining trust
There has been a momentous shift in the dynamics of the patient-doctor relationship from paternalism decades ago to a partnership which is based on mutual respect. The key here is mutual respect which is represented by the recognition of the patients’ vulnerability and dependency in the partnership that has been embarked on. It is imperative that one does not exploit this relationship for sexual advantage, financial gain or any other personal goals.
This leads on to the commitment of maintaining trust and the issue of personal gains. There are various opportunities which can jeopardise professional duties to the patient and potentially break trust. These most commonly manifests in dealing with industries, big pharma and insurance companies. Just as scientists are obliged to, doctors have a responsibility to disclose any potential conflicts of interests that might arise during dealings with patients. 9
Improving quality of care and access to care
The quality of medical care is assessed by patient-oriented outcomes. A satisfactory standard of care can be attained by sustaining clinical competence, making strides to increase patient safety (the recent WHO surgical checklist has been a roaring success, setting a precedent for measures to ensure patient safety) and improving health outcomes. The most common method of assessing quality of care in the clinical environment is by performing audits which are gaining more popularity and making invaluable contributions to medical care.
A clinical audit is a quality improvement cycle that involves measurement of the effectiveness of healthcare against agreed and proven standards for high quality, subsequently reflecting on the results and taking action to bring practice in line with these standards so as to improve the quality of care and health outcomes.10
Audits go through a cycle which consists of: initiation; setting the standards to be measured against; measuring current performance; comparing to previously set standards; putting improvement strategies in place to implement change and re-auditing after a set time to see if there has been an improvement.11
The other setting for maintaining quality of care is in the clinic, although this can be problematic with the current focus on achieving targets which have been set which might conflict with the patients’ needs. For example, the set target for a consultation is 10 minutes, which many will argue is not the standard time people will expect to spend with the doctor. In these cases it becomes more difficult to maintain professional values which form the ethos of medical practice and at the same time cater to the patients requirements; this can result in a diminished overall patient experience.
Just distribution of finite resources
Doctors are in an interesting position of being both managers and clinicians. The NHS has a limited amount of funds and resources – as an employee and advocate, it falls upon the doctor to manage these resources and distribute them to the patient population in a just manner. This domain highlights the interesting interplay between politics; societal expectations and values; economics and ethics. The medical profession is required to promote justice in health care and this includes fair distribution of heath care resources whilst keeping in mind the available resources and making cost-effective decisions. This translates into everyday practice as avoidance of unnecessary procedures and tests. This is a skill dependent on clinical acumen which emphasises the importance of clinical competence. It also protects the patients from exposure to avoidable harm e.g. unnecessary radiation from X-rays and ensures that the resources are preserved for cases that are justifiable.12
Science forms the backbone of medical diagnostics and intervention. Commitment to scientific knowledge does not necessarily mean involvement with research instead it includes the ability to apply knowledge garnered from discoveries for the benefit of the patient. This is also known as translational medicine in which scientific parameters are translated into clinical tools.
Although it is essential to keep up to date with the body of knowledge, the interpretation, engagement and awareness of uncertainty about knowledge is more valuable than the holding of knowledge. Another facet to knowledge is ensuring one follows guidelines as set out by NICE or other relevant bodies. This ensures that the care given to patients are evidence-based and the best proven practice.9
In the current climate of easily accessible, widespread information on health and disease of doubtful validity, it can be challenging for healthcare professionals to fulfill the ‘provision of knowledge’ aspect of professionalism to patients who might have prior conflicting information.
Competence and Professional duties
There is a lot of overlap between competence and professional duty. Competence in medicine is defined as the ability of the provider to administer safe and reliable care on a consistent basis.13 This is expressed in the ability to fulfill one’s professional duties. Competence is checked continuously throughout one’s career from medical school to continuing professional development as a doctor. Professional duties besides the obvious duty to the patient include but are not exclusive to leadership and working with colleagues. This is crucial to keep up with the rise of the Multi-Disciplinary Team (MDT) which is composed of healthcare specialists involved in the care of a particular patient. There should be a proper partnership between all members of the team in order to maximise contribution. This leads on to proper teamwork, with the nurse-doctor relationship central to this. Being able to work as part of a team can be especially challenging in acute care settings where teams are more unstable.
A marked contrast between the pre-clinical and clinical years as a medical student is the wardrobe. As superficial as this seems, one of the notable guidelines on professional values for medical students is dressing in an appropriate and professional manner.14This highlights an important point regarding the lack of clarity as to what professionalism means to the doctor/governing bodies and what it means to the patient. A study conducted on focus groups among patients, nurses and doctors found that dress code did not meet the criteria for importance as a behavioural sign of professionalism.15 Yet, guides sent to students attending interviews or starting clinicals will almost invariably contain statements regarding dress codes.
Professionalism is an age-old ethic which is a backbone of modern medicine. It is the basis of medicine’s contract with society and a two-way system through which medicine’s expectations of society and society’s expectations of medicine are met. Members at all echelons of the medical profession should aim to embody these values and do justice to the ideal that the Hippocratics set to achieve when drafting the Hippocratic Oath.
1 Working Party of the Royal College of Physicians. Doctors in society: medical professionalism in a changing world. Clin Med [Internet]. 2005 Jan [cited 2015 Sep 17];6(1):109–13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16408403
2 Papadakis MA, Teherani A, Banach MA, Knettler TR, Rattner SL, Stern DT, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med. Mass Medical Soc; 2005;353(25):2673–82.
3 Edelstein L. The Hippocratic oath: text, translation and interpretation [Internet]. The Johns Hopkins Press; 1943 [cited 2015 Sep 24]. 64 p. Available from: https://books.google.com/books?id=XnRKkd6JiYcC&pgis=1
4 General. Medical. Council. The duties of a doctor registered with the General Medical council [Internet]. 2002 [cited 2015 Sep 19]. Available from: http://www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp
5 Lamb R. Open disclosure: the only approach to medical error. Qual Saf Heal Care [Internet]. 2004 Feb 1 [cited 2015 Sep 21];13(1):3–5. Available from: http://qualitysafety.bmj.com/content/13/1/3.full
6 ABIM. Medical professionalism in the new millennium: a physician charter. Ann Intern Med [Internet]. 2002 Jan [cited 2015 Sep 19];136(3):243–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11827500
7 McHale J V. Medical Confidentiality and Legal Privilege [Internet]. Routledge; 2002 [cited 2015 Sep 21]. 176 p. Available from: https://books.google.com/books?id=FvyJAgAAQBAJ&pgis=1
8 Confidentiality. General Medical Council; [cited 2015 Sep 21]; Available from: http://www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp
9 Medical professionalism in the new millennium: a physician charter. Ann Intern Med [Internet]. Jan [cited 2015 Sep 19];136(3):243–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11827500
10 Burgess R. New Principles of Best Practice in Clinical Audit [Internet]. Radcliffe Publishing; 2011 [cited 2015 Sep 24]. 198 p. Available from: https://books.google.com/books?id=DKDu7nkSVUwC&pgis=1
11 Benjamin A. Audit: how to do it in practice. BMJ [Internet]. 2008 May 31 [cited 2015 Sep 24];336(7655):1241–5. Available from: http://www.bmj.com/content/336/7655/1241hwshib2=authn%3A1443193150%3A20150924%253A9adc28a0-c90f-4859-8d5f-1f8168cdd9fd%3A0%3A0%3A0%3AHKyAazO7dY8FeQsKdyl4ww%3D%3D
12 Spandorfer J. Professionalism in Medicine: A Case-Based Guide for Medical Students [Internet]. Cambridge University Press; 2010 [cited 2015 Sep 21]. 464 p. Available from: https://books.google.com/books?id=liZ-BSAMWZsC&pgis=1
13 Miller-Keane. Encyclopedia and Dictionary of Medicine, Nursing and Allied Health [Internet]. Seventh. O.Toole MT, editor. Saunders Elsevier; 2003. 2272 p. Available from: http://medical-dictionary.thefreedictionary.com/competence
14 General.Medical.Council. Medical students: professional values and fitness to practise. Guid from GMC MSC [Internet]. 2009;142. Available from: http://www.gmc-uk.org/education/undergraduate/26601.asp
15 Green M, Zick A, Makoul G. Defining Professionalism From the Perspective of Patients, Physicians, and Nurses. Acad Med [Internet]. 2009;84(5). Available from: http://journals.lww.com/academicmedicine/Fulltext/2009/05000/Defining_Professionalism_From_the_Perspective_of.11.aspx