Sorry, you need to enable JavaScript to visit this website.

Chapter 5: Society and Professionalism

Chapter Authors: Richard P. Shugerman, MD & Suzanne K. Woods, MD

Pediatricians have been committed to public health and welfare since the founding of our specialty. This concept of advocacy has been defined as the application of learned skills, information, resources, and action to speak out in favor of causes, ideas or policies to preserve and improve quality of life often for those who cannot effectively speak out for themselves.1  In order to maintain and improve children’s health, pediatricians must have a deep understanding of and commitment to the broader community in which the children they care for are raised and nurtured.

In addition to these traditional components of advocacy, the pediatrician’s contract with society extends more broadly.  The Physician Charter states that “professionalism is the basis of medicine’s contract with society” and the following components of the Charter relate to this broader professional mandate:

  • Commitment to improving access to care
    • All patient care decisions must be made without regard to personal views about a patient’s lifestyle, cultural beliefs, race, ethnicity, gender, sexuality, disability, age, or socioeconomic status. Decisions about medical care must be based only on clinical judgment, patient needs, available evidence, patient’s values and the likelihood of effectiveness. Pediatricians must work with patients and families individually and at the community level to ensure that access to quality pediatric health care is available to all. In addition, pediatricians should be able to assess and address barriers to access to care, including barriers based on geography, language, cultural differences, economic forces, legal restrictions, and educational differences. To optimize access to care, pediatricians should deliver culturally sensitive care that meets the specific needs of the patient and family.
  • Commitment to a just distribution of finite resources
    • Pediatricians must work within their health care organizations to ensure  a just distribution of resources.  A commitment to following evidence based guidelines will help to ensure  that finite resources are not misused or overused. Pediatricians should continuously examine resource utilization as part of their routine practice and work to distribute limited resources fairly.
  • Commitment to scientific knowledge
    • Pediatricians are expected to support the appropriate use and development of new scientific knowledge. Even if the individual pediatrician is not personally creating new knowledge, the recognition and responsible use of new knowledge must be part of his/her practice. Pediatricians must be able to assess and use organized evidence in everyday decision making and those who are engaged in research must ensure full disclosure, obtain informed consent, and ensure confidentiality.
  • Commitment to maintaining trust by managing conflicts of interest
    • The opportunities for conflicts of interest in the patient-physician relationship are ever-present and continuously changing. Pediatricians and pediatric organizations must not compromise the trust placed in them by their patients and by society at large. Pediatricians must be cautious in interactions with for-profit medical industries such as pharmaceutical companies, equipment manufacturers, and nutritional firms. There is a special risk of conflict of interest for those in positions of leadership or those recognized as an expert in their area of research or practice. When pediatricians develop relationships with medical industries, those relationships should be disclosed when enrolling patients in studies, interpreting research results, assessing others’ research, expressing editorial opinions, creating health care guidelines or standards for care, or serving as editors or reviewers of scientific journals.

The Pediatric Competencies that are most relevant to this area of professionalism are (numbers in parenthesis indicate charter statements linked to):

  • Patient Care
    • Interview patients/families about the particulars of the medical conditions for which they seek care with specific attention to behavior, psychological, environmental, and family-unit correlates of disease  (1)  
    • Make informed diagnostic and therapeutic decisions that result in optimal clinical judgment (3) 
    • Counsel patients and families  (1) 
    • Provide effective health maintenance and anticipatory guidance  (2,3) 
  • Medical Knowledge
    • Demonstrate sufficient knowledge of the basic and clinically supportive sciences appropriate to pediatrics  (3)  
  • Professionalism
    • Professionalization ( 1)  
    • Professional Conduct (4)  
    • Humanism  (1)  
    • Cultural Competence  (1)  
  • Systems-based Practice
    • Coordinate patient care within the health system relevant to their clinical specialty (1)  
    • Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate (1,2)  
  • Practice-based Learning and Improvement
    • Identify strengths, deficiencies, and limits in one’s knowledge and expertise  (3)
    • Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems (2,3)
    • Use information technology to optimize learning and care delivery (1,2,3)
    • Participate in the education of patients, families, students, residents, and other health professionals (1)
    • Take primary responsibility for lifelong learning ( 3) 
  • Interpersonal and Communication Skills
    • Communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds (1) 
    • Demonstrate the insight and understanding into emotion and human response to emotion that allow one to appropriately develop and manage human interactions (1)
  • Personal and Professional Development
    • Manage conflict between personal and professional responsibilities (4) 
    • Recognize that ambiguity is part of clinical medicine and respond by utilizing appropriate resources in dealing with uncertainty

The specific goals of this chapter are to describe the professional responsibilities of pediatricians with respect to our contract with society, to provide examples of professional behavior and of lapses in professional conduct, and to suggest some exercises that can be used in discussions with learners regarding this topic.

Behavioral Statements

The components of professionalism and society listed above provide general goals. In discussions with learners, it may be helpful to identify specific behaviors or practices that exemplify professionalism in this domain and some that would represent lapses of professionalism.

Examples of Exemplary Professional Conduct:

  • Advocates for individual patients
  • Provides the highest standard of care for patients of all backgrounds
  • Works at all levels to promote access to care
  • Recommends care that is mindful of cost, value and limited resources
  • Allocates health care resources without bias
  • Conducts or supports the ethical conduct of research and other scholarly activities
  • Ensures full disclosure, informed consent, and confidentiality in research
  • Works to eliminate all conflicts of interest in practice
  • Discloses all potential conflicts of interest in practice
  • Discloses all potential conflicts of interest in leadership roles

Examples of Lapses in Professional Conduct:

  • Demonstrates prejudicial behavior based on race, ethnicity, religion, disability, gender, age, socioeconomic status, or lifestyle
  • Overtly demonstrates cultural insensitivity, especially if with conscious intent and without remorse
  • Intentionally distorts or misrepresents medical evidence in the development of practice guidelines or medical policies
  • Fails to take all reasonable steps to protect confidentiality of patients in clinical care or research
  • Accepts gifts from industry
  • Accepts gifts from patients/families that carry an implied or explicit intention of impacting patient care
  • Fails to participate in advocacy for the legitimate needs of patients
  • Fails to disclose conflicts of interest to the public or in the course of patient care, when those conflicts of interest affect that care
  • Falsifies research data in any public presentation or publication of that research
  • Fails to obtain IRB approval or consent for research
  • Coerces any patient participation as a subject in research in any way such as misrepresenting benefit or possible harm to that patient
  • Fails or refuses to participate in the legal process designed to protect the welfare of children and their families
  • Fails as an opinion leader to disclose relationships to industry

Teaching Professionalism

Learning Objectives for the Trainees

  • Trainees will be able to identify barriers in access to care and formulate ways to address them.
  • Trainees will recognize and address the misuse and overuse of resources and will strive for appropriate distribution of resources.
  • Trainees will promote the advancement of scientific knowledge through properly conducted research and will commit to knowing, assessing, and properly applying new knowledge.
  • Trainees will gain skills to maintain public trust by recognizing and avoiding conflicts of interest and by avoiding misuse of their position.

Reflective Exercises

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

  • After holding a discussion about professional responsibilities of physicians, ask learners to describe, in one page or less, an incident in which they were challenged with a decision that involved professionalism and the broader impact on society.
  • Using any of the vignettes below, ask learners to describe a similar real-life situation. Ask them to identify the conflicting values and what they learned from the situation.

Vignettes

The vignettes that follow were developed for use in a small group or noon conference setting to help stimulate discussions about issues of professionalism. Program directors are encouraged to expand upon these to reflect local issues and experiences.

Chapter 5 Vignettes - Society and Professionalism

Vignette 1 - Unprepared parent

One of your continuity clinic patients, a 3 year old boy, is brought by his mother to a clinic visit. Upon entering the examination room you are introduced to a 6 year old girl, the stepsister of your patient. The mother explains that this child has just come to live with them, having spent the first years of her life with her grandmother. It is two days before school is to begin and the child needs immunizations before she can enroll in school. She is not yet registered on the mother’s Medicaid policy. The mother asks that you immunize her daughter using the brother’s Medicaid number.

Points to consider during discussion:

  • Is following the mother’s request a valid way to improve access to care?
  • How does not following the mother’s request affect access to care?
  • What are your alternatives?
  • Are there any possible ramifications for the boy’s immunization status if you record her vaccines under his Medicaid number?

Vignette 2 - Teen's trust

You are a senior resident supervising an intern’s encounter with a 15-year-old girl in the Emergency Department. The intern has done a very nice job of gaining the teenager’s trust, and the adolescent has disclosed to the intern that she may be pregnant. After confirming an early pregnancy, the intern comes to you for guidance in referring the patient for prenatal care. You ask whether the patient has considered abortion. The intern states that as a Catholic she is not willing to present abortion as an option to the patient.

Points to consider during discussion:

  • How do you reconcile personal beliefs with medical decision-making?
  • How does this difference in beliefs affect access to care?
  • What are your options for this patient?
  • What are your options in working with this learner?

Vignette 3 - Alternative therapy?

A patient presents to the Emergency Department with increased seizure activity. He was recently started on phenobarbital; however, the level at the time of evaluation is found to be zero. The mother explains that she is not giving the phenobarbital and produces a bottle of liquid that she is using as an alternative therapy for the child’s seizures. She reports that she was told at the alternative medicine store to not give the phenobarbital and to give the herbal liquid instead.

Points to consider during discussion:

  • How could you try to reach a compromise with this family?
  • What is the role for child protective services?
  • How would you address the situation if the child started to seize while in the ED?

Vignette 4 - Problem prescription

A physician colleague that you work closely with requests that you write her a prescription for antibiotics. She states that she has had a cold for the past week and is concerned she may be developing sinusitis or pneumonia. She does not have a primary care provider.

Points to consider during discussion:

  • What are the laws regarding prescribing for people who are not under your care as a provider?
  • What may be the consequences for the physician who writes such a prescription?
  • What may be the consequences for the individual who requested the prescription?
  • Are there other ways to assist the individual rather than just writing the prescription?

Vignette 5 - Headaches

A fourteen year old girl is brought to your clinic for an acute appointment. The father states that she has been having headaches approximately every two weeks for the last four months since school started. The headaches only occur on weekdays. She states that headaches are accompanied by nausea and seeing “bright spots”. The pain is pulsatile, left sided and lasts for 4-8 hours. She denies any confusion, difficulty walking or other symptoms. The exam is completely normal. You reassure the parent that she most likely is experiencing migraine headaches. He insists on a CT or MRI of her brain and lab work to make sure she does not have a tumor.

Points to consider during discussion:

  • How can you incorporate high value care principles into your discussion with the parent and child, such as the American College of Radiology “Choosing Wisely” recommendation to not do head imaging for uncomplicated headaches?
  • What are the downsides to ordering head imaging for this patient? Would you feel differently if the request was for simple lab work only?

Vignette 6 - Informed consent

A provider fails to obtain proper informed consent (i.e., not explained at all, explained improperly, not witnessed or without a proper interpreter present) from the parent of a child who is to undergo a lumbar puncture with sedation. The procedure is complicated by respiratory depression which requires bag/mask/valve ventilation and administration of an intravenous reversal agent. The parent was present during the procedure and demands to know what is occurring with her child.

Points to consider during discussion:

  • Regarding the lack of informed consent, does it matter if this was intentional or just an oversight?
  • Are the consequences of the lack of informed consent different depending on whether the resident was intentional about it?
  • If the provider who obtained the consent was a trainee what would be a good response to the learner?
  • What are the provider’s options in addressing the parental concerns over the procedure and resultant complications?

Vignette 7 - Free ticket

A patient’s family offers you tickets to an event as gratitude for your recent care of their child during a hospitalization.

Points to consider during discussion:

  • What are the possible responses?
  • Under what circumstances would it be appropriate to accept them?
  • Under what circumstances would it be inappropriate?

Vignette 8 - Pharma Perks

A pharmaceutical company has given you financial support as a principal investigator in a drug trial.

Points to consider during discussion:

  • What must you disclose to patients to whom you prescribe this drug?
  • What must you disclose to those reading the results of your study?
  • What must you disclose to editors wanting you to review other studies involving treatments in this area?

Vignette 9 - Note needed

You are the primary care provider for a 7 year old girl with mild intellectual disability and cerebral palsy, most likely related to prematurity. The girl is enrolled in a special school program and is transported to and from school by a van each weekday from 8am to 4pm. The mother requests that you write a letter attesting to the fact that she cannot work because of her daughter’s medical condition.

Points to consider during discussion:

  • What information do you need to have before responding to her request?
  • What if you feel the mother can work while her child is away?
  • How might your response affect the care of the child?
  • How would you proceed?

Vignette 10 - No insurance or parent

A Spanish-speaking patient presents to the ED with nausea, vomiting, altered mental status and decreased urine output. Lab evaluation reveals renal failure and workup fails to find an etiology. Patient reports being eighteen years of age but you suspect he is much younger. No parent or guardian is identified and he has no insurance. You discover he is in the U.S. as an undocumented citizen. His renal function does not improve and he requires chronic dialysis. Due to lack of insurance and citizenship, he cannot be placed in an outpatient dialysis unit.

Points to consider during discussion:

  • What responsibility does your health care system assume for patients without insurance and citizenship?
  • Do you alert the authorities that patient is in the US?
  • What resources can be made available to this patient if he remains in the US?
  • How might the care of the child be affected if he is returned to his home country that has limited medical resources?

 

References

  1. Cristoffel KK.  Public health advocacy: process and product.  Am J Public Health 2000;90:722-6.

Other Sources

  • ABIM Foundation.  American Board of Internal Medicine, ACP-ASIM Foundation.  American College of Physicians – American Society of Internal Medicine, European Federation of Internal Medicine.  Medical Professionalism in the New Millennium:  A Physician Charter. Ann Internal Medicine 2002; 136:243-6.
  • Challenges to Professionalism: Social Accountability and Global environmental Change.  Pearson D, Walpole S, Barna S. Med Teach.  2015 June 1: 1-6.
  • Aiming Higher to Enhance Professionalism: Beyond Accreditation and Certification.  Chassain M, Baker D.  JAMA 2015;313(18):1795-1796.
  • More Than a List of Values and Desired Behaviors:  A Foundational Understanding of Medical Professionalism.  Wynia MK, Papadakis MA, Sullivan WM, Hafferty FW. Acad Med. 2014;89:712-714
  • Linking the Teaching of Professionalism to the Social Contract:  A call for Cultural Humility.  Med Teach 32(5):357-359
  • Pediatric Advocacy Curriculum, The Barbara Bush Children’s Hospital (Rev. 6.12)

Index of Pediatric Competencies addressed by learning activities

Go to next chapter >>