PROFESSIONALISMPROFESSIONALISM
Richard Cruess OC, MD, FRCSCRichard Cruess OC, MD, FRCSC
Sylvia Cruess MD, CPSQSylvia Cruess MD, CPSQ
McGill UniversityMcGill University
How to reference this document: Cruess R., Cruess S., Professionalism. CanMEDS Train-the-Trainer Program on Professionalism. 2009
TAKE AWAY MESSAGESTAKE AWAY MESSAGES
1. Professionalism has a cognitive base which includes definable attributes
2. Professionalism is the basis of medicine’s social contract with society
3. Both medicine and society have legitimate expectations- “each of the other”
4. Medicine’s obligations arise from societal expectations5. There are consequences if these expectations are not met6. Linking professionalism to the social contract is beneficial
to the teaching of professionalism
VIGNETTEVIGNETTE
Your daughter is scheduled to graduate from high school this afternoon. As you are preparing to sign out to a colleague, one of your long time patients present in the ER with chest pain. You enter the ER and a partner in your group practice is already there to evaluate the situation. As you know that he is competent and conscientious, you go to reassure your patient. He pleads with you to stay.
Think about what aspects of professionalism are demonstrated by this situation
Professional Status is Professional Status is NotNot an Inherent an Inherent RightRight
IT IS GRANTED BY SOCIETYIT IS GRANTED BY SOCIETY
It Must Be Constantly Earned by It Must Be Constantly Earned by Meeting the Obligations Expected Meeting the Obligations Expected
of a Professionalof a Professional
IF MEDICINE FAILS TO MEET ITS IF MEDICINE FAILS TO MEET ITS OBLIGATIONSOBLIGATIONS
SOCIETY WILL CHANGESOCIETY WILL CHANGE
ITS STATUSITS STATUS
• IT CONFERS»Prestige and Respect»Trust»Autonomy in Practice»Physician-Led Regulation»Financial Rewards
PROFESSIONAL STATUS ISPROFESSIONAL STATUS ISIMPORTANT TO MEDICINEIMPORTANT TO MEDICINE
“ Neither economic incentives, nor technology, nor administrative control has proved an effective surrogate for the commitment to integrity evoked in the ideal of professionalism ”
Sullivan, 1995
PROFESSIONALISM ALSO BENEFITS PROFESSIONALISM ALSO BENEFITS SOCIETYSOCIETY
• A questioning society• A complex health care system• The commodification of health• Failure of the professions to
meet their obligations•
PROFESSIONALISM IS PROFESSIONALISM IS THREATENEDTHREATENED
• Healer
• Professional
• Served simultaneously
• Analyzed separatelyProfessionalism as the word is used generally
includes both roles
PHYSICIANS HAVE TWO ROLESPHYSICIANS HAVE TWO ROLES
Antiquity
technology“curing”
THE HEALER THE PROFESSIONAL
Code of Ethics
Middle ages“Learned professions”clergy, law, medicine
1850:Legislation monopoly
1900:University linkageScience
AsclepiusHippocrates
THE PRESENT
HEALING AND HEALING AND PROFESSIONALISMPROFESSIONALISM
Autonomy
MD-led regulation
associations
institutions
Responsibility to society
Team work
Caring/ compassion listening
Insight
OpennessRespect for the healing functionRespect patient dignity/ autonomy
Presence/Accompany
PHYSICIANHEALER PROFESSIONALL
Based on the Literature
ATTRIBUTESATTRIBUTES
Competence
CommitmentCommitment
ConfidentialityConfidentiality
AltruismAltruism
TrustworthyTrustworthy
Integrity/HonestyIntegrity/Honesty
code of ethicscode of ethics
Morality/Ethical Morality/Ethical
Behavior Behavior
Responsibility to Responsibility to professionprofession
• Definition: As professionals, physicians are committed to the health and well-being of individuals and society through ethical practice, professional-led regulation, and high personal standards of behavior
-RCPSC, 2005
DEFINITION AND DESCRIPTION DEFINITION AND DESCRIPTION PROFESSIONALPROFESSIONAL
Description: • Physicians have a unique societal role as professionals who are
dedicated to the health and caring of others. Their work requires the mastery of a complex body of knowledge and skills, as well as the art of medicine. As such, the professional role is guided by codes of ethics and a commitment to clinical competence, the embracing of appropriate attitudes and behaviors, integrity, altruism, personal well-being, and the promotion of the public good within their domain.
• These commitments form the basis of a social contract between a physician and society. Society in return grants physicians the privilege of profession-led regulation with the understanding that they are accountable to those served, to the profession, and to society.
-after RCPSC, 2005
DEFINITION AND DESCRIPTION DEFINITION AND DESCRIPTION PROFESSIONALPROFESSIONAL
• Cruess, Johnston, & Cruess
• Swick
• Royal College/CMA/ABIM/ ACGME
• The International Charter
• Self-generated: must be based on the literature
ALL ARE ACCEPTABLE
OTHER DEFINITIONSOTHER DEFINITIONS
• Specialized knowledge
Science
Art• Service to others
• Morality
CORE OF PROFESSIONALISMCORE OF PROFESSIONALISM
• Society uses the concept of the profession as a means of organizing the delivery of complex services which it requires, including that of the healer.
““The Professional Model”The Professional Model”
•Bureaucratic
•Free Market
Neither Share the Values of the Healernone pure>
OTHER MODELS ARE AVAILABLEOTHER MODELS ARE AVAILABLE
• The Social Contract in health care hinges on professionalism.
• It serves as the basis for the expectations of medicine and society.
“The rights and duties of the state and its citizens are reciprocal and the recognition of this reciprocity constitutes a relationship which by analogy can be called a social contract”
-Gough, “The Social Contract”, 1957
•
SOCIAL CONTRACT
• PROPOSES RIGHTS, PRIVILEGES, AND OBLIGATIONS ON BOTH SIDES
• “BARGAIN” (Klein)
• Professions are given prestige, autonomy, the privilege of physician-led regulation, and rewards on the understanding that they will be altruistic, regulate well , be trustworthy, and address the concerns of society
•
THE SOCIAL CONTRACTTHE SOCIAL CONTRACT
• A Mix of: • The explicit and the implicit • The written and the unwritten
licensing laws certification standards health care legislation
codes of ethics • Legal and moral obligations • The universal and the local
•
THE SOCIAL CONTRACTTHE SOCIAL CONTRACT
ExpectationsObligations
PROFESSIONALISMTHE MEDICALPROFESSION
SOCIETY
IndividualPhysicians
Medicine’sMedicine’sInstitutionsInstitutions
Patients
GeneralGeneral PublicPublic
GovernmentPROFESSIONALISM
PoliticiansCivil Servants
Managers
POLITICAL
Cruess & CruessPerspectives in Biol & Med. 2008
THE SOCIAL CONTRACTTHE SOCIAL CONTRACT
1. Health Care System2. Regulatory Framework3. The Commercial Sector4. Other Stakeholders5. The Media
after Rosen & Dewar, 2004
MEDIATORS OF THE SOCIAL MEDIATORS OF THE SOCIAL CONTRACTCONTRACT
Society’s Expectations of Medicine
• to fulfill the role of the healer• assured competence
• timely access to care
• respect for patient autonomy
• altruistic service
• morality, integrity, & honesty
• accountability and transparency
• team health care
• source of objective advice
• promotion of the public good
Medicine’s Expectations of Society
• trust • autonomy• MD-led regulation• reasonable lifestyle• health care system
-value-laden -adequately funded & staffed - reasonable freedom• role in public policy• monopoly• rewards
- financial- non-financial
• respect• status•
THE SOCIAL CONTRACTTHE SOCIAL CONTRACT
NOTELinking professionalism with the social contract
provides a rational basis for medicine’s obligations, both individual & collective
It seems empowering to students and residents.The concept implies that medicine can negotiate the
terms of the contract
•Mandate
•state sanctioned authority
•Collegiality
•major regulatory role
•set and maintain standards
•discipline
•advise public
•They Must•demonstrate morality and virtue
•assure competence
•be open and transparent
• be governed by an institutional code
LICENSING BODIES AND LICENSING BODIES AND PROFESSIONAL ASSOCIATIONSPROFESSIONAL ASSOCIATIONS
• MUST MANAGE CONFLICT OF ROLES
• altruism vs self-interest
• public good vs union function
POTENTIAL TO PROMOTE OR SUBVERT THE IMAGE
OF MEDICINE
LICENSING BODIES AND LICENSING BODIES AND PROFESSIONAL ASSOCIATIONSPROFESSIONAL ASSOCIATIONS
Self-RegulationSelf-Regulation
•Obligation (individual)•maintain competence •participate in and submit to the process of self regulation•support professional associations and regulatory bodies
•ensure their integrity
•Obligation (collective)•demonstrate morality and virtue•assure competence•be open and transparent•be governed by an institutional code
THEORY OF COUNTERVAILING FORCES
PROFESSIONS
STATECORPORATE SECTOR
THE EVOLUTION OF THE EVOLUTION OF PROFESSIONAL STATUSPROFESSIONAL STATUS
1850-1960: PROFESSIONS DOMINANT
“NOSTALGIC PROFESSIONALISM”
Solo Practitioner-Single Payer
Modest Income
Accountable to Patient
Altruism-Indigent
High Trust & Influence
THE EVOLUTION OF THE EVOLUTION OF PROFESSIONAL STATUSPROFESSIONAL STATUS
• 1960- Present: STATE/CORPORATE SECTOR DOMINANT
• PROFESSIONALISM HAD TO EVOLVE
THE EVOLUTION OF THE EVOLUTION OF PROFESSIONAL STATUSPROFESSIONAL STATUS
THE NEW PROFESSIONALISM Accountability Autonomy Patient Autonomy
Transparency Financial rewards/conflicts of interest Team Health Care Altered Expectations (society & professionals)
A NEW SOCIAL CONTRACTMust Preserve Core Values of the HEALER
THE EVOLUTION OF THE EVOLUTION OF PROFESSIONAL STATUSPROFESSIONAL STATUS
THERE ARE CONSEQUENCES WHEN EXPECTATIONS ARE NOT MET
BREACHES IN THE CONTRACT
THE SOCIAL CONTRACTTHE SOCIAL CONTRACT
MEDICINE FAILS TO MEET SOCIETAL EXPECTATIONS
THE RESULT- A CHANGE IN THE CONTRACT public trust in the “system” (contract) trust in physician/profession medical influence on public policy self-regulation external regulation autonomy
BREACHING THE SOCIAL BREACHING THE SOCIAL CONTRACTCONTRACT
• Altruism
individual -lifestyle financial gain
collective -union• Flawed MD-led regulation• Badly managed conflicts of interest• Lack of attention to social justice
BREACH ??BREACH ??
MEDICINE’S PERCEIVED MEDICINE’S PERCEIVED FAILURESFAILURES
Medicine’s Response-Two Poles
Trust in the “system” (contract) Cooperation Withdrawal Job vs Calling Satisfaction
Involvement community associations stakeholders Negotiation? Satisfaction
Society Fails to Meet Medicine’s Expectations
OPTIMISMPESSIMISM
BREACHING THE SOCIAL BREACHING THE SOCIAL CONTRACTCONTRACT
• Funding of the System
• Personnel
• Personal Freedom
MAJOR CHANGE IN THE CONTRACT
?? BREACH
Trust in the system
CANADA 2009CANADA 2009
• These issues are here to stay• Linked to societal changes
MEDICINE:• Must address issues within its control• Must negotiate issues which it cannot control
• •
WHAT SHOULD MEDICINE DO?WHAT SHOULD MEDICINE DO?
THIS IS IN PART THIS IS IN PART AN EDUCATIONAL ISSUEAN EDUCATIONAL ISSUE
MEDICINE MUST ADDRESS ITS MEDICINE MUST ADDRESS ITS FAILURESFAILURES
Negotiate a Social Contract which Supports the Healer and Professional Roles
• Negotiations must:-Preserve Trust -Satisfy both sides
• Negotiations not Symmetrical- Society (through government has more power
However- MEDICINE’S STRENGTH IS SOCIETY’S NEED FOR THE HEALER!
• •
WHAT SHOULD MEDICINE DO?WHAT SHOULD MEDICINE DO?
“Since time immemorial, a part of human culture has been man’s care for himself, for the body in which the spirit resides - that is for his own health. The culture of healing may be a less visible aspect of life, yet it is perhaps the most important indicator of the humanity of any society”
Vaclav Havel, Summer Meditations, 1993