Medical Professionalism & Medical Professionalism & Motivation for DoctorsMotivation for Doctors
Dr Vijay SardanaMD,DM ( Neurology)
Professor & HeadDeptt. Of Neurology
Govt.MedicalCollege, Kota
The Noble Profession of MedicineThe Noble Profession of Medicine
“There is no career nobler than that of the physician. The Progress and welfare of society is more intimately bound up with the prevailing tone and influence of the medical profession that with the status of any other class…”
ElizabethBlackwell,M.D.,1889
Doctors : Definition of successDoctors : Definition of success
Having lots of patientsNew car/plot Every year/lots of
moneyPublishing papers in journalsTeaching students
Doctor : FactsDoctor : Facts
One of the every these dissatisfied due to lack of time for themselves or their families
Average life 10 year less
Depression 4 times higher than general population
Stages of careerStages of career
Entry Establishment Exploration Specialization Mastery
Stages of Professional lifeStages of Professional life
No work, No money, lots of time
Some work, some money, some time
Plenty of work, Plenty of money, no time
SuccessSuccess
Know – How.Know - Who. Who you know. Who knows you.
Today's successful doctorToday's successful doctor
Clinician Academician Manager Financial Expert CEO Family care Provider Self care taker
“ The education of the doctor which goes on after he has his degree is the most important part of his education”
John Shaw Billings
Patients satisfactionPatients satisfaction
Satisfied patient 3 other people
Dissatisfied patient 20 others
Satisfying unhappy patients 50 others
Doctor-Patient RelationshipDoctor-Patient Relationship
“ The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best pat of your work will having nothing to do with potions and powders…”
William Oster,M.D.,1925
Doctor-Patient RelationshipDoctor-Patient Relationship
Blind trust
Informed trust with skepticism
Doctor-Patient RelationshipDoctor-Patient Relationship
Has the Doctor changed?? or Doctor is facing the changed society?
Trust equation by David MaisterTrust equation by David Maister
T = C + R + I + S, WhereT = TrustworthinessC = CredibilityR = ReliabilityI = IntimacyS = Self-orientation
Credibility = can your patient trust what you say?
Reliability = can he trust your actions, confident that you will act honorably?
Intimacy = Is he comfortable discussing his feeling and emotion with you?
Self orientation = can he trust your motives, knowing that you care about him, and will act in his best interests?
Doctor-Patient RelationshipDoctor-Patient Relationship
Patient dissatisfaction Mistrust Medical litigation
LitigationLitigation
Professional failure in diagnosis or treatment
Lack of communication
Some form of insensitivity by the doctor to upset them emotionally – insult adding to injury.
Doctor-Patient RelationshipDoctor-Patient Relationship
Excessive workload?
Attitude Problem?
Attitude formation of a PhysicianAttitude formation of a Physician
Medical studentAltruismRole models behaviorPrevailing commercialismWork environmentSocial and political environment
Causes of Poor relationshipCauses of Poor relationship
Rising health cost. Over specialization. Changing patients/community
expectation. Commercialization. Poor Communication More awareness about adverse effect.
Medical professionalism : Medical professionalism : deprofessionalism- causedeprofessionalism- cause
Technology – Depersonarlise medicine & deprofessionlise a physician
Corporatization of Medicine Specialization – Most patients identified by
disease rather than human beings who happens to have disease
Patients knowing limitation of modern medicine Greed
Doctor-Patient RelationshipDoctor-Patient Relationship
Failure of referral system
Disproportionate work load
Unnecessary administrative responsibilities
Doctor-Patient RelationshipDoctor-Patient Relationship
Overinvestigation/ overtreatment
Medico-legal Aspect “ Defensive Medical Practice”
Doctor-Patient RelationshipDoctor-Patient Relationship
Commercialization of service
Doctor-Patient Relationship: Informed Doctor-Patient Relationship: Informed consentconsent
Condition of the patient (Disease) Purpose & Nature of intervention. Consequences of such intervention. Any alternatives available Risks involved Prognosis in the absence of intervention.
Doctor-Patient RelationshipDoctor-Patient Relationship
Information given to patient is selected to encourage them to consent to doctor’s decision.
Doctor-Patient RelationshipDoctor-Patient Relationship
Influence of drug & medical equipment manufacturer
Pardoned
Tolerated
norm
Doctor-Patient RelationshipDoctor-Patient RelationshipPatients responsibilitiesPatients responsibilities
Courteous & transparent to health care provider.
Not carried away by emotion & misinformation.
Sharing anxiety with doctor to resolve problem
Never to become violent/act unlawfully.
Doctor-Patient relationship: Doctor-Patient relationship: PoliticiansPoliticians
Political mileage.
Instigating patient to raise voice against doctor, at times unjustified.
Pressures
Ministers Ex ministers PAs Political party office bearers Other parties Regional parties Media others
Violence Against Doctors
What constitutes violence?
Telephone threats Intimidation Oral abuses Physical
manhandling
“incidents where people are abused, threatened or assaulted in circumstances relating to their work, involving an explicit or implicit challenge to their safety, well-being or health”.
Violence Against Doctors
UKUK
Half of all doctors – some degree of violence or abuse, 20% of these physical (BMJ, 2003)
Among GPs, threat of violence at 1 in 500 consultations
Violence Against Doctors
OthersOthers
Kuwait – 86% doctors – verbal insults or imminent violence, 28% physical attacks
Israel – 54% to 79% rate of violence in physician surveys
Europe – Intoxicated patients flooding ERs
Australia – half of doctors physically attacked at least once
Violence Against Doctors
Why?Why?
More demanding society More availability of knowledge More aggression in society More violence on roads, public
places, even schools
Violence Against Doctors
How to deal?How to deal?
Not meet anger with anger Address the grievances, but also
call for help Doctors must form groups, which
can take over in such instances
Violence Against Doctors
LawLaw Non-bailable offence
Offenders liable to pay up to twice the purchase price of damaged equipment
Doctor-Patient Relationship: policeDoctor-Patient Relationship: police
Rajasthan Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage to Property) act 2008
304-A
Violence Against Doctors
Communication
Communication, communication, communication about costs, complications and challenges
Doctors must make efforts to educate and inform the public at large about diseases and medical problems
Violence Against Doctors
Time Barrier to Time Barrier to CommunicationCommunication
Lack of time can be managed Use paramedical staff Delegate the work of repeated
explanations Counselors
PreventionPrevention
Violence Against Doctors
Display information on boards, counters etc.
Try not to escalate costs later or change plans frequently
Also display rules regarding consequences of violence in hospital
Violence Against Doctors
Doctors’ ExpectationsDoctors’ Expectations
From administration - Implement laws by the letter and spirit
Media – 1. publish both views, avoid sensationalism, seek an expert opinion preferably from another city2. more positive
3. do not ascribe wrongful intentions
Violence Against Doctors
Display of Warnings & Other Display of Warnings & Other informationinformation
Display warning in hospital premises mentioning the consequences of violence against doctors in hospital
Display flow chart/plan in Emergency Room
Trouble ShootingTrouble Shooting
Relatives & attendants Fight Disperse 10 Min
1st degree friends More Attendants30 Min
Hospital Administration
Police, Media30 Min
Media & Police Strengthening 2nd degree friends
1 Hour
Strike FIRs
1-2 DaysStrike Continues
1-2 DaysSolution, Often Face saving arrived
Forgotten, gone with the wind
Medical Students/ Medical Students/ Residents/ DoctorsResidents/ Doctors
Professional Nonprofessional
Carrier Conscious No carrier so no fear
Socio-cultural trauma Mostly no Trauma
Can go to certain extent Can go to any extent
Friends
Power
Vigilance - NegligenceSilence - ViolenceTolerance - IntoleranceDiscipline - IndisciplineSeriousness - CarelessnessGood Sense - Nuisance
If too many anxious attendants, send them one or another job. eg. Bringing medicines, arranging blood- Energy utilization
Never argue with attendants
Argument will trigger them, at the same time your calmness and promptness will even calm down a triggered person.
If patient is sick, attend patient periodically and talk to attendants.
Check emergency tray for drugs.
Try to solve/resolve crisis immediately
Do’sDo’s
Do’sDo’s
Patients should be attended promptly: - Error in Decision making is Excusable but not
attending patients timely is not.
Identify a Prominent Person: - Important person/relative and explain initial
assessment of patient immediately. - Explain them management has started.
Ask if they have any questions
Call senior consultant as per requirement, talk to them telephonically if possible delay in arrival.
Don’tsDon’ts
Never argue with attendants. this situation teaches you how to remain calm in provocative circumstances. No book in the world can teach this.
Never overlook a call, especially if call is by a attendant.
DO’SDO’S
If there is Gang War- call Police force
Codes of ethics and DeclarationCodes of ethics and Declaration
Duties to patient. Duties to public. Duties towards law Enforcers. Duties not to violate professional ethics. Duties not to do anything illegal or hide
illegal acts. Duties to each other.
Standard CareStandard Care
Standard, suitable, equipment in good repair.
Standard assistance. Non standard drug is a poison by
definition. Standard procedure and indicated
treatment and surgery. Standard proper reference to
appropriate specialist.
Duty to provide information to Duty to provide information to patient/attendantpatient/attendant
Regarding necessity of treatment. Regarding duration of treatment. Regarding prognosis. Do not exaggerate
nor minimize gravity of patients condition.
Regarding the expenses and break-up thereof.
Emergency careEmergency care
A doctor is bound to provide emergency care on humanitarian grounds, unless he is assumed that other are willing and able to give such care. It may be noted that prior consent is not necessary for giving emergency/first aid treatment. In emergency medico-legal cases condition of first being seen by medical jurist is not essential.
Duties to the publicDuties to the public
Health Education Medical help when natural calamities like
drought, flood, earthquakes, etc occur. Medical help during train accidents. Compulsory notification of births, deaths,
infections, disease, food poisoning etc. To help victims of house collapse, road
accidents, fire, etc
Duties towards Law enforcers, Police Duties towards Law enforcers, Police Courts, etcCourts, etc
To inform the police all cases of poisoning, burns, injury, illegal abortion, suicide, homicide, manslaughter, grievous hurt and its natural complication like tetanus, gas-gangrene, etc. This includes vehicular accidents, fracture, etc
To call a Magistrate for recording dying declaration.
Duty not to violate Professional ethicsDuty not to violate Professional ethics
Not to indulge in self-advertisement except such as is expressly authorized by the MCI code of Medical Ethics.
No fee sharing Not to attend pts under Alcohol Not to issue false certificate and bills. not to talk loose with colleagues. Patients identity not to be disclosed Not to run Medical store Recovering any money in connection with service
rendered to a patient other than a proper professional fee, even with the knowledge of the patient.
Duty not to do anything illegal or hide Duty not to do anything illegal or hide illegal actsillegal acts
Perform illegal abortions/sterilizations Issue death certificated where cause of
death is not known. Not informing police a case accident,
burns, poisoning, suicide, grievous hurt, gas gangrene.
Not calling Magistrate for recording dying declaration.
Medical ProfessionalismMedical Professionalism
“Contributing those attitude and behaviors that serves to maintain patients’ interest above Physicians’ self interest.”
Professional Responsibilities 1-3Professional Responsibilities 1-3
Commitment to Professional competence *lifelong learning of medical knowledge and clinical and
team skills Commitment to honesty with patients *Assuring that patient are completely and honestly
informed before and after treatment, including disclosure of errors
Commitment to patient confidentiality *Applying safeguards to the disclosure of patient
information
Am Board Int Med Foundation, Am Coll Physician, Eur.Foundation Int Med. Am intern Med & Lancet 2002
Professional Responsibilities 4-6Professional Responsibilities 4-6
Commitment to maintaining appropriate relation with patients
* Avoiding the exploitation of patients for sexual advantage, personal financial gain, or any other private purpose
Commitment to improving the quality of care * Working collaboratively to create system contributing to
continuous quality improvement in health care. Commitment to improving access to care * Reducing barriers to equitable health care based on
education, laws, geography, and social discrimination
Professional Responsibilities 7-9Professional Responsibilities 7-9
Commitment to a just distribution of finite resources
* Providing health care based on wise and cost-effective management of limited resources.
Commitment to scientific knowledge * Uploading current scientific standards and
promoting the creation and appropriate use of knowledge
Commitment to maintaining trust by managing conflicts of interest
* Compromising professional responsibilities by pursing private or personal gain
Professional Responsibilities 10Professional Responsibilities 10
Commitment to Professional Responsibilities
* Working collaboratively and treating one another with respect
Communication skillsCommunication skills
“ Patients don’t care how much you know them, they know how much you care”
CommunicationCommunication
7% - Spoken words
38% - Voice quality like Tone, Tempo, intonation
55% - Body language
How to perfect non verbal How to perfect non verbal signalsignal
Smile Open Posture Forward lean Touch Eye contact Nod
Communication skills in clinical skills in clinical practice- Introductionpractice- Introduction
“Its an art to talk medicine in the language of a non medical men”
not an option but a necessity
separates successful doctors from
unsuccessful ones
include ability to engage with patients at
emotional level, to listen, to convey
information with clarity & sympathy
What do patients wantWhat do patients want
- Patient dissatisfaction with doctors relate to problems of communication rather than clinical competence
- They want - quality information about their problems - risks & benefits of treatment - relief of emotional distress - to be active participate in medical decision
making
Barriers to communicationBarriers to communication
- Work over load on doctors
- Shortage of man power- less time for individual patient
- Lack of training in communication skills during medical education
- Individual attitude & personality traits
Components of clinical communication Components of clinical communication skillsskills
RAPPORT BUILDING starts with taking history of patient Give adequate time to history taking & clinical
examination keeping in mind Bio-Psycho-Social approach
Do not make false promises regarding prognosis
Explain the rationality of Lab Investigations prescribed
Do not criticize previous doctors prescription Use patients name whenever possible, it
makes rapport building easier
2. EMPATHIC LISTENING2. EMPATHIC LISTENING
Show empathy & respect – let your patients know that you care & understand their experience
Putting yourself in patients situation
Develop listening skills
Give a 2-4 seconds pause between listening & responding
Maintain eye to eye contact
Avoid changing the topic mid way by interrupting
Empathic listening is most useful in dealing emergency cases
3. Effective questioning skills3. Effective questioning skills
elicit maximum information in shortest possible time using purposeful & inoffensive questions
Ask one question at a time
Wait until the previous question is fully answered
5. Answering skills5. Answering skills
weakest communication skills among Indian Medical Professionals
In Indian context patient satisfaction is largely decided by the quality of answers & explanation given by doctors
Understand the question clearly, answer fully, & clearly but briefly
Avoid major technical terms
5. Answering skills (contd..)5. Answering skills (contd..)
Compliment the patient on asking a good question
If you can’t give a ready answer give non committal answer like- “ let me observe you for some more time, certain tests are awaited”
Take feedback whether they have understood answer
Information sharing & decision makingInformation sharing & decision making
Most important when there is life threatening illness
When different management options exist with varying costs, benefits & when outcome is unpredictable
Discuss risks & benefits of each option
It not only increases patient satisfaction but also reduces the chance of litigation if any adverse outcome results
While prescribing any drug with life threatening side effects- informed consent to be taken
Specific situationsSpecific situations
Pediatric practice-
• May be more emotionally taxing as you have to manage the parents in addition to the patient
• Adopt a positive attitude in responding to parental concern
• Explain them signs of worsening or severity of illness & explain when they need to seek prompt advice
• Information on OTC medications & antibiotics
Communicating prognosis, hope & riskCommunicating prognosis, hope & risk
Misunderstandings in these areas can lead to patient dissatisfaction & litigation
Prognostication is like weather forecasting uncertain but based on sound scientific principles
Stage of illness at presentation of patient Curability of disease
In face of uncertainty there is nothing wrong with providing hope
Provide evidence based risks
Never create guilt for negligence on part of patient
Dealing with chronic disease & dyingDealing with chronic disease & dying
Chronic illness/ incurable illness e.g. HIV, Cancer cause stress for patient & attendants
Counseling plays a big role
Breaking news can be done in steps- news given too bluntly may lead to denial & psychiatric problems
Encourage him to hope for the best
Give example of person who have lived with such illnesses for longer periods with positive attitude & will power
Dealing with relatives during Dealing with relatives during resuscitation resuscitation
Routinely relatives are excluded
Studies have found no adverse psychological effects if some mature person observes the process
One of the doctors of team should explain the procedure being done to relatives- it builds better rapport & communication regarding adverse outcome easy
Remember that bereaved relatives are also your patients- counsel them & give medical help
Anticipate & handle common reactionsAnticipate & handle common reactions
Disbelief- Is he really gone- for their satisfaction show them proof- eg. ECG
Guilt- by giving logical & rational explanation & saying that he tried his best
Offer help to manage transport
Resident Evaluation checklist on Resident Evaluation checklist on ProfessionalismProfessionalism
Marking 0 1 2 3 4 5 6 7 8 9 10 Unsatisfactory Satisfactory Exemplary
(1) Empathy in patient care.(2) Appropriate fund of knowledge.(3) Soundness of clinical judgment.(4) Technical expertise with diagnostic and therapeutic procedures.(5) Communication with patients, families and staff.(6) Sensitivity and responsiveness to individual patient differences in
economic status,ethinicity,age,gender and disabilities.(7) Honesty in dealing with patients and colleagues.(8) Accountability for action.(9) Conflict-resolution skills.(10) Adherence to regulatory, institutional and departmental norms.
UCLA PCAT 12-CommunicationUCLA PCAT 12-Communication
RATE EACH ITEM:Strongly agree: Agree: Neutral: Disagree: Strongly disagreeNot applicable: Not Observed
The resident: Made himself or herself easily accessible
to you Encourage your input in discussion Clarified the objectives, expectations and
goals of care Listen to your concerns Explained and discussed progress and
any unforeseen problems.
UCLA PCAT 18UCLA PCAT 18
honesty/accountability/Response to Error
Make up information, tries to cover error, or blames others
Minimizes error and/or is unable to learn from errors
Recognizes error, apologizes and alters behavior.
Recognizes error, apologizes and alters behavior, but takes errors too personally
Excessive self-criticism/self-doubt interferes with work performance.
Emotional Intelligence (EQ)Emotional Intelligence (EQ)
Def – “The ability to monitor one’s own & other feelings & emotion to discriminate among them, and to use this information to guide one’s thinking and action”
IQ Average citizen - 100 Doctor - 120
EQ Average citizen - 100 Doctor - 90
EQ ComponentsEQ Components
Knowing your own emotions (Self awareness) Managing your own emotion (Self regulation) Motivating yourself Recognizing and understand other people’s emotion (
Empathy) Managing relationships or social skills- Skills in managing emotions in others determines
popularity, leadership & interpersonal effectiveness.
EQEQ
Physician cannot perform his job without understanding his emotion & those of patients
IQ - Technical Competence EQ - People’s Competence
IQ - Gets you job EQ - Gets you promoted
IQ - Gets you higher marks EQ - Makes you happy & Productive
Keeping updated : Managing Keeping updated : Managing knowledgeknowledge
Medical books -- Become outdated fast Medical journals -- Costly Conference Medical representative Internet
Medical knowledge problem – Mammoth size - Short half life
Keeping updatedKeeping updated
Structure your knowledge around patients
Learn from your past mistakes
Master clinical protocols & Flow charts
Concentrate on carry home massages
Vulnerable times for mistakesVulnerable times for mistakes
Tired, lazy, sleepyAngryOverconfidentPatient irritatingComplex medical Problem
Mistake : ResponseMistake : Response
Blaming the system Blaming the colleagues, even patients Disconnecting of importance ( No Clinical
effectiveness) Emotionally Distancing (Everyone makes
mistakes)
Dealing with mistakeDealing with mistake
Accept responsibility for the mistake Discuss with trusted friend, colleague or
spouse Disclose & Apologize to the patients Error analysis Measures to reduce similar mistake in future
Marketing in medicineMarketing in medicine
“Marketing is Practice building not advertising”
Practice Practice building/Marketingbuilding/Marketing
Satisfied patients Volunteering at community medical service. Organizing an event – like conference Attracting Media attention Contributing article on health to magazine Public lecture News letter Website Marketing to referral base
Informing patient in information Informing patient in information ageage
Printed material Broachers
Story of a Doctor
Main 12v me ThaWo 12v me Thi
Main MBBS me ThaWo BSc me Thi
Main MBBS me ThaWo MSc me Thi
Main MBBS me ThaWo PHD me Thi
Main MBBS me ThaWo Dr ban gai
Uski Shadi huiMaine PG entrance diya
Wo do bachcho ki ma baniMain MD kar raha Tha
Bachche 5 saal ke hoker school jane lageMain post PG karne laga
Bachche 10th pass ho gayeMaine hospital shuru kiya
Afsos bas ye hai ki aaj wo Tubectomy karane aayi hai
AUR
Aaj meri Sagai hai…….
MarriagesMarriages
Perfectionism, compulsiveness & work holism – good doctor but problematic spouse
Many married to Profession – no time to cultivate intimacy with spouse
MarriagesMarriages
Stage 1 -- Romance – you are perfect Stage 2 -- Fault finding Stage 3 -- Blaming Stage 4 -- Acceptance Transformation – Growing together
MarriagesMarriages
Spend time together Respect each other Have fun together Treat your spouse as your most
important VIP patient -- A loved spouse is also loving
spouse
MarriagesMarriages
A meal together everyday Fun together once a week One holiday every year together Make sure children meet grand
parents, relatives periodically Help children honor family
traditions
Improving RelationshipImproving Relationship
Teaching of ethics & communication skills in UG curriculum.
Teaching of sociology aimed at creating cultural sensivity,empathy & respect for patients’ dignity.
Teaching legal aspect of practice. Physician has to enter patients world- to
see illness through patient’s eye
Take homeTake home
Fall in love of being a Doctor Derive pleasure in work wherever & in
whatever capacity you are working. You always have the potential to contribute to patients & society
Work & practice with Medical professionalism Use common sense. Identify local socio-
cultural practices & integrate in your working style
Take homeTake home
If you are a good professional- become trusted advisor to patient-become their friend, philosopher & guide.
“Do unto other as you would have them do unto you.”
Don’t end at result of single Prescription/consultation. Target long lasting patient doctor relationship
Take home messageTake home message
People prefer those doctors with average clinical
skills but good communication skills rather than
those with excellent clinical but poor
communication skills
Most of the complaints are made against doctors
who do not communicate
“Successful Medical Practice is like successfully driving a car where
you not only take care of your own mistakes but others mistakes also.”
Visualised yourselfVisualised yourself
Visualize your funeral with these speakers – A family Member, a Friend, a colleague & a patient.
ThanksThanks