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Chapter 2: Professionalism in Patient Care

Chapter Authors: Michael A. Barone, MD & Joseph Gilhooly, MD

The specific objectives for this chapter are to:

  1. Describe the professional responsibilities of physicians with regards to the care they provide for their patients,
  2. Provide examples of these professional behaviors as well as lapses in professional conduct in a way that complements The Pediatrics Milestone Project,1
  3. Provide some exercises that can be used in discussions with trainees about the many aspects of professionalism that are involved in everyday clinical care.

Patient care is a core physician competency. Providing patient care with an understanding of professional responsibility and demeanor is at the heart of what society values in a “good doctor”. Every medical student, resident, colleague, and patient can provide examples of physicians they admire because of the care they provide and their manner as they provide that care. Individual components of professionalism in clinical care however often are not identified. “Bedside manner” - the way a physician identifies with, converses with, and empathizes with the patient’s family - is important. But an empathetic, caring relationship is not enough. A physician who is loved by patients but who provides care based on unproven, anecdotal information is not providing professional clinical care. Similarly, the physician whose management decisions are based on the most recent, evidence-based information is not providing professional care if that care is not documented in a timely manner in the electronic health record, or confidentiality of protected health information is not respected.

The following components from the American Board of Internal Medicine Foundation Physician Charter2 relate to professionalism in patient care:

  • Commitment to professional competenceAchieving and maintaining competence involves a commitment to lifelong learning and maintaining clinical and team skills. Professionalism is one of the domains of competence defined by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties, but it is important to recognize that deficits in any of the other domains (patient care, medical knowledge, practice- based learning, interpersonal and communication skills, and systems-based practice) also reflects a lack of professional commitment.
  • Commitment to honesty with patientsHonesty with patients and their families requires not only truthfully informing them about their condition (or their child’s condition) and the treatment you recommend, but also informing them about potential adverse reactions to treatments and about medical errors, whether or not those errors result in actual harm.
  • Commitment to patient confidentialityTrust and confidence of patients and families depend upon their knowledge that the physician will safeguard patient information. In some situations,  adolescent sexual health care for example, confidentiality can be maintained even if the patient is a minor. The physician must be aware of the laws regarding physician-patient confidentiality in their practice area. The electronic health record presents unique challenges to the maintenance of confidentiality, and protocols must be followed to keep access secure. Although confidentiality must sometimes yield to overriding considerations of public welfare (e.g., when harm may come to the patient or others), the patient and/or family should be informed of the intention to divulge clinical findings to appropriate authorities.
  • Commitment to maintaining appropriate relations with patientsPatients and families are dependent upon the knowledge and decision-making of the physician. Their vulnerability and dependence should not be exploited. Appropriate emotional, physical and financial boundaries should be maintained between the physician and his or her patients and their families.
  • Commitment to improving quality of careContinuous improvement of care involves not only ongoing, informed review of the medical literature and maintenance of clinical competence, but also working with colleagues, health care systems, and other professionals to improve patient safety and provide high value care, reduce medical errors, improve accessibility and efficiency of care, minimize overutilization and underutilization of medical resources, and improve health outcomes.

The Pediatric Competencies that are most relevant to this area of professionalism are:

  • Patient Care
    • Organize and prioritize responsibilities to provide patient care that is safe, effective and efficient 
    • Interview patients/families about the particulars of the medical condition for which they seek care, with specific attention to behavioral, psychosocial, environmental, and family-unit correlates of disease 
    • Counsel patients and families 
  • Practice-based Learning and Improvement
    • Identify strengths, deficiencies and limits in one’s own knowledge and expertise 
    • Identify and perform appropriate learning activities to guide personal and professional development 
    • Participate in the education of patients, families, students, residents, and other health professionals 
  • Interpersonal and Communication Skills
    • Demonstrate the insight and understanding into emotion and human response to emotion that allows one to appropriately develop and manage human interactions 
  • Professionalism
    • Professionalization 
    • Professional Conduct 
    • Humanism 
    • Cultural Competence 
  • Systems-based Practice and Improvement
    • Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate 
    • Advocate for quality patient care and patient care systems 
  • Personal and Professional Development
    • Develop the ability to use self-awareness of knowledge, skills, and emotional limitations to engage in appropriate help-seeking behaviors  
    • Manage conflict between personal and professional responsibilities 
    • Demonstrate trustworthiness that makes colleagues feel secure when one is responsible for the care of patients 
    • Demonstrate self-confidence that puts patients, families, and members of the health care team at ease 

Behavioral Statements

The dimensions of professionalism related to patient care that are listed above provide general goals. In discussions with trainees, it may be helpful to identify specific behaviors or practices that exemplify professionalism in this domain, and others that would represent lapses of professionalism.

Examples of Exemplary Professional Conduct:

  1. Demonstrates accountability, responsibility, and respect for patients and families, including appropriate verbal and nonverbal communication
  2. Optimizes comfort and privacy of patients when performing a history and physical exam or a procedure
  3. Maintains comprehensive, timely, medical records and correspondence and protects patient confidentiality
  4. Communicates collaboratively with colleagues, health care providers, patients, and families to provide safe and effective care
  5.  Provides culturally competent care for all patients
  6. Recognizes limitations of training and experience and seeks help appropriately
  7. Accesses available information to support clinical decision-making
  8. Responds to constructive feedback and demonstrates commitment to ongoing professional development
  9. Acknowledges errors in medical care; discloses them to colleagues, affected (or potentially affected) patients, and responsible authorities; and takes steps to prevent future errors
  10. Demonstrates appropriate boundaries for patient relationships

Examples of Lapses in Professional Conduct:

  1. Provides unsupervised care of an infant, child, or adolescent without previous experience or training in the appropriate skills
  2. Excludes parents or other caretakers from involvement in management of their child’s illness when there is no valid reason for doing so
  3. Provides treatment that is inconsistent with best practice or evidence without justification
  4. Documents information that does not accurately describe the patient’s condition or the care provided
  5. Willfully misrepresents clinical data in communication with other health care providers
  6. Fails to consult a supervisor or a clinician who is more experienced in caring for the problems being confronted
  7. Provides preferential treatment to certain patients or families to the detriment of others, based upon considerations other than clinical need and available treatment
  8. Fails to recognize and apologize for discourtesy or errors in treatment or judgment
  9. Fails or inappropriately delays to respond to a request by a family or other professionals (nurse, social worker, physician colleague) to provide care for a patient for whom he/she is responsible 
  10. Participates in physical or verbal abuse toward colleagues, staff, patients, or family members

Teaching Professionalism

Learning Objectives for Trainees

  • Identify instances when personal circumstances can be at odds with professional values
  • Describe professional responsibilities in regards to patients, families, and colleagues
  • Describe how one's behavior can serve as a model for colleagues
  • Demonstrate that professionalism involves a wide array of responsibilities to the individual, their colleagues, patients, institution and society
  • Demonstrate understanding that a commitment to professional behaviors, and development as professionals, occurs throughout the entirety of one's career

Reflective Exercises

These reflective exercises can be used for individual reflection on professionalism issues or can be modified and discussed as part of a larger group meeting.

  • After holding a discussion about the professional responsibilities of physicians, ask your trainees to write, in one page or less, an incident in which they were challenged with a decision that involved professionalism in the care of patients.  
  • Ask your trainees to describe an incident in which they observed exemplary professional conduct on the part of one of their colleagues. 
  • Using any of the vignettes below, ask your trainees to describe a similar real-life situation. Ask them to identify the conflicting values and what they learned from the situation. 

Note:  Considering the different competencies and Milestones for professionalism, discuss the vignettes from the point of view of different training levels across the continuum (students, junior resident, senior resident, attending physician).  What would be the expected behaviors of different levels of professional in these vignettes?  

Vignettes

The vignettes that follow were developed for use in a small group setting to help stimulate discussions about issues regarding professionalism. Medical educators are encouraged to expand upon these to reflect local issues and experiences.

Chapter 2 Vignettes - Professionalism in Patient Care

Vignette 1 - Trustworthiness

You are on rounds with your attending and one of the medical students is presenting. The student has been working very hard and doing a good job. The attending asks the student about the results of a laboratory test that the student was supposed to have checked. You know that the student did not yet have an opportunity to get the test results, but the student responds by saying that the test was normal.

Points to consider during discussion:

  • What would you do if you were the supervising resident?
  • What should the medical student have done?
  • What are the potential consequences of ignoring the student’s actions?
  • What is the downside of pointing out the student’s behavior on rounds?

Vignette 2 - Tardy parent

A trainee in clinic is informed by a nurse that a family has arrived an hour late for their appointment. The trainee is refusing to see the two children because her schedule is already backed up, and this mother is frequently late for appointments. The mother is upset that she is being turned away because her children’s immunizations are already delayed.

Points to consider during discussion:

  • What is your reaction to this scenario?
  • What if the mother is usually on time?
  • What if the trainee has personal plans after clinic?
  • What if seeing the children would mean that the trainee would miss noon conference?
  • What if your clinic policy prevents late patients from being registered and the trainee feels that policy is not appropriate?

Vignette 3 - Error disclosure

A 6-month-old prematurely born infant you cared for in the NICU returns from surgery to the PICU. You learn that during surgery the endotracheal tube had been in the right main stem bronchus for several hours. You are no longer directly responsible for the infant, but the father continues to talk to you about his infant’s progress. The next three weeks are stormy. The infant contracts RSV, improves, and then dies suddenly. The autopsy is unrevealing. The father asks you if anything went wrong.

Points to consider during discussion:

  • Describe what you know about your institution’s policy for error disclosure to patients and families.
  • How does one balance responsibilities to patients/parents with colleagues/departments/ institutions?
  • If endotracheal tubes in the right main bronchus during surgery became a chronic occurrence in patients, what action would you take?
  • To whom would you raise your concerns?
  • What if you believe that the problem with the endotracheal tube and the nosocomial RSV infection had nothing to do with the infant’s ultimate death?

Vignette 4 - Elevator chats

You are on your hospital’s elevator and you overhear another physician discussing the behavior of a parent of one of her patients.

Points to consider during discussion:

  • Whose responsibility is it to remind that physician about confidentiality?
  • What would you do in response to hearing this?
  • What if the physician is from another department?
  • What if the physician is a department chair?
  • What if the person speaking on the elevator was a student?

Vignette 5 - Work/life integration

As a trainee, you care for a 15-year old boy with a malignancy. You develop a close relationship with him during your residency. Later in your training, he is terminal, and he has begun to talk openly with you about dying. You have assured him that you will be there as a support for him whenever needed. He is admitted to the hospital conscious but close to death, and he asks one of the other residents to call you at home and ask you to come in. You are not on call, and you are on your way out the door to your 3-year-old daughter’s dance recital.

Points to consider during discussion:

  • How appropriate is it for physicians to make promises to patients?
  • In your opinion, is work-life integration a component of professionalism? Why or why not?
  • How will you decide in what circumstances a patient’s needs might take precedence over family obligations?
  • When it is said: “Professionalism demands placing the interests of patients above those of the physician (self interest).”, What does that mean to you? What is “self-interest”? How is it different than “self-sacrifice?”.

Vignette 6 - Firing a patient

A trainee asks that one of his continuity families be reassigned to another physician. He explains that he just does not see eye-to-eye with the mother, who he believes does not follow his advice. He is frustrated with her and prefers that someone else take care of her child.

Points to consider during discussion:

  • What if the trainee and the mother of the patient are of different races?
  • What if the trainee and the patient’s family are of different religious groups?
  • What is the mechanism to end care with a patient and transfer their care to another physician?

Vignette 7 - Too much or too little information?

You are a trainee participating in continuity clinic in a community pediatrician’s office. The pediatrician prescribes levetiracetam for migraine headaches to one of the patients, but he does not sufficiently review the risks and benefits related to hypersensitivity reactions. You ask, “Shouldn’t you mention the need to stop the medication if the patient gets a rash.” The pediatrician replies, “If I did that, they would never take the medication.”

Points to consider during discussion:

  • How would you discuss this with the pediatrician in the clinic, if at all?
  • What do you perceive as your responsibility to this family?
  • How would your actions change if you knew the pediatrician was responsible for an important performance evaluation on you?

Assessment Tools

An assessment of professional behavior is an essential aspect of the pediatric milestones. However, many other tools are also well suited for assessing professionalism in patient care. This includes direct observation assessments of the trainees’ behavior with actual or simulated patients. Among the most widely used tools are the Mini-CEX, the Professional Mini- Evaluation Exercise (P-MEX), and the Standardized Direct Observation Assessment Tool. The available tools vary widely in their being subject to validity measures. This is well covered in a systematic review.11

Multisource evaluation tools, which receive input from all members of the healthcare team and patients and their families, are also useful. Ad hoc evaluations are an effective method to document and assess critical incidents both for positive behaviors and when there are opportunities for improvement.

When assessing something as complex as professional behavior, it is important to remember that no one instrument can capture all dimensions. Furthemore, accurate assessment of professionalism requires a longitudinal perspective. While there are certainly unprofessional behaviors that require immediate attention and possibly action, it would not be appropriate to base a trainee’s entire professional assessment on one single event.

References:

  1. Carraccio C, Gusic ME, Hicks P.  The Pediatrics Milestone Project.  Academic Pediatrics Volume 14, Issue 2 , Supplement, S1-S98
  2. ABIM Foundation, American Board of Internal Medicine; ACP-ASIM Foundation, American College of Physicians –American Society of Internal Medicine. Medical professionalism in the new millennium; a physician charter. Ann Intern Med 2002; 136: 243-46
  3. Committee on Bioethics.  Professionalism in Pediatrics: Statement of Principles Pediatrics October 2007; 120:895-897
  4. Fallat ME, Glover J, and the Committee on Bioethics.  Professionalism in Pediatrics.  Pediatrics October 2007; 120:e1123-e1133
  5. Swick HM.  Toward a Normative Definition of Medical Professionalism.  Acad Med 2000; 75:612-616
  6. Papadakis MA, Teherani A, Banach MA, et al.  Disciplinary Action by Medical Boards and Prior Behavior in Medical School.  NEJM 2005; 353:2673-2682.
  7. The Mini-CEX Clinical Encounter Form. Available at http://www.abim.org/program-directors-administrators/assessment-tools/mini-cex.aspx
  8. Gathright M. Critical Synthesis Package: Professionalism Mini-Evaluation Exercise (P-MEX). MedEdPORTAL; 2014. Available from: https://www.mededportal.org/publication/9929  
  9. Shayne P, Gallahue F, Rinnert S, Anderson CL, Hern G, Katz E; CORD SDOT Study Group. Reliability of a core competency checklist assessment in the emer- gency department: the Standardized Direct Observation Assessment tool. Acad Emerg Med. 2006; 13(7):727-732.
  10. Goldie J. Assessment of professionalism: a consolidation of current thinking. Med Teach. 2013;35(2):e952-6.
  11. Kogan JR, Holmboe ES, Hauer KE. Tools for Direct Observation and Assessment of Clinical Skills of Medical Trainees: A Systematic Review. JAMA. 2009;302(12):1316-1326.

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