Transcript The Future

PROFESSIONALISM
Richard Cruess OC, MD, FRCSC
Sylvia Cruess MD, CPSQ
McGill University
How to reference this document:
Cruess R., Cruess S., Professionalism. CanMEDS Train-the-Trainer Program on Professionalism. 2009
PROFESSIONALISM
What Is It?
Definition Before Diagnosis
TAKE 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 expectations
5. There are consequences if these expectations are not met
6. Linking professionalism to the social contract is beneficial
to the teaching of professionalism
VIGNETTE
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 Not an Inherent
Right
IT IS GRANTED BY SOCIETY
It Must Be Constantly Earned by
Meeting the Obligations Expected
of a Professional
IF MEDICINE FAILS TO MEET ITS
OBLIGATIONS
SOCIETY WILL CHANGE
ITS STATUS
PROFESSIONAL STATUS IS
IMPORTANT TO MEDICINE
• IT CONFERS
» Prestige
and Respect
» Trust
» Autonomy
in Practice
» Physician-Led Regulation
» Financial Rewards
PROFESSIONALISM ALSO BENEFITS
SOCIETY
“ 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 IS THREATENED
•
•
•
•
•
A questioning society
A complex health care system
The commodification of health
Failure of the professions to
meet their obligations
WHAT IS A PROFESSIONAL?
DEFINITIONS-PROFESS(ION)
PROFESS
PROFESSION
PROFESSIONAL
PROFESSIONALISM
PHYSICIANS HAVE TWO ROLES
• Healer
• Professional
• Served simultaneously
• Analyzed separately
Professionalism as the word is used generally
includes both roles
HEALING AND PROFESSIONALISM
THE HEALER
THE PROFESSIONAL
Antiquity
Asclepius
Hippocrates
Code of
Ethics
Middle ages
“Learned professions”
clergy, law, medicine
1850:Legislation monopoly
technology
“curing”
Science
THE PRESENT
1900:University linkage
ATTRIBUTES
PHYSICIAN
HEALER
Caring/ compassion
listening
Insight
Openness
Respect for the
healing function
Respect patient
dignity/
autonomy
Presence/Accompany
PROFESSIONAL
L
Competence
Autonomy
Commitment
MD-led regulation
Confidentiality
associations
Altruism
institutions
Trustworthy
Responsibility
to society
Team work
Integrity/Honesty
code of ethics
Morality/Ethical
Behavior
Responsibility to
profession
Based on the Literature
DEFINITION AND DESCRIPTION
PROFESSIONAL
• Definition: As professionals, physicians
are committed to the health and wellbeing of individuals and society
through ethical practice, professionalled regulation, and high personal
standards of behavior
-RCPSC, 2005
DEFINITION AND DESCRIPTION
PROFESSIONAL
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
OTHER DEFINITIONS
• Cruess, Johnston, & Cruess
• Swick
• Royal College/CMA/ABIM/ ACGME
• The International Charter
• Self-generated: must be based on the literature
ALL ARE ACCEPTABLE
CORE OF PROFESSIONALISM
• Specialized knowledge
Science
Art
• Service to others
• Morality
The Primary Role is that of
the Healer
• 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”
OTHER MODELS ARE AVAILABLE
• Bureaucratic
• Free Market
>
Neither Share the Values of the
Healer
none
pure
• The Social Contract in health care
hinges on professionalism.
• It serves as the basis for the
expectations of medicine and
society.
SOCIAL CONTRACT
“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
•
THE 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 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 CONTRACT
SOCIETY
THE MEDICAL
PROFESSION
Medicine’s
Institutions
Individual
Physicians
Patients
Expectations
Obligations
P
O
L
I
General
Public
T
I
C
A
L
Government
Politicians
Civil Servants
Managers
Cruess & Cruess
Perspectives in Biol & Med. 2008
MEDIATORS OF THE SOCIAL
CONTRACT
1. Health Care System
2. Regulatory Framework
3. The Commercial Sector
4. Other Stakeholders
5. The Media
after Rosen & Dewar, 2004
THE SOCIAL CONTRACT
Medicine’s Expectations of Society
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
• 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
•
NOTE
Linking 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
LICENSING BODIES AND
PROFESSIONAL ASSOCIATIONS
•Mandate
•They Must
•state sanctioned authority
•Collegiality
•major regulatory role
•set and maintain standards
•discipline
•advise public
•demonstrate morality and virtue
•assure competence
•be open and transparent
• be governed by an institutional
code
LICENSING BODIES AND
PROFESSIONAL ASSOCIATIONS
• MUST MANAGE CONFLICT OF ROLES
• altruism vs self-interest
• public good vs union function
POTENTIAL TO PROMOTE
OR SUBVERT THE IMAGE
OF MEDICINE
Self-Regulation
•Obligation (individual)
•Obligation (collective)
•maintain competence
•participate in and submit to the
process of self regulation
•support professional
associations and regulatory
bodies
•demonstrate morality and virtue
•assure competence
•be open and transparent
•be governed by an institutional
code
•ensure their integrity
THE EVOLUTION OF PROFESSIONAL
STATUS
THEORY OF COUNTERVAILING
FORCES
PROFESSIONS
STATE
CORPORATE
SECTOR
THE EVOLUTION OF PROFESSIONAL
STATUS
1850-1960: PROFESSIONS DOMINANT
“NOSTALGIC PROFESSIONALISM”
Solo Practitioner-Single Payer
Modest Income
Accountable to Patient
Altruism-Indigent
High Trust & Influence
THE EVOLUTION OF PROFESSIONAL
STATUS
• 1960- Present: STATE/CORPORATE
SECTOR DOMINANT
• PROFESSIONALISM HAD TO
EVOLVE
THE EVOLUTION OF PROFESSIONAL
STATUS
THE NEW PROFESSIONALISM
Accountability Autonomy
Patient Autonomy
Transparency
Financial rewards/conflicts of interest
Team Health Care
Altered Expectations (society & professionals)
A NEW SOCIAL CONTRACT
Must Preserve Core Values of the HEALER
THE SOCIAL CONTRACT
THERE ARE CONSEQUENCES WHEN
EXPECTATIONS ARE NOT MET
BREACHES IN THE CONTRACT
BREACHING THE 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
MEDICINE’S PERCEIVED FAILURES
• Altruism
individual -lifestyle
financial gain
collective -union
• Flawed MD-led regulation
• Badly managed conflicts of interest
• Lack of attention to social justice
BREACH ??
BREACHING THE SOCIAL CONTRACT
Society Fails to Meet Medicine’s
Expectations
Trust in the PESSIMISM
OPTIMISM
“system”
(contract)
Cooperation
Medicine’s Response-Two Poles
Withdrawal
Job vs Calling
Satisfaction
Involvement
community
associations
stakeholders
Negotiation
? Satisfaction
CANADA 2009
•
Funding of the System
•
Personnel
•
Personal Freedom
MAJOR CHANGE IN THE CONTRACT
?? BREACH
Trust in the system
WHAT SHOULD MEDICINE DO?
• These issues are here to stay
• Linked to societal changes
MEDICINE:
• Must address issues within its control
• Must negotiate issues which it cannot control
•
•
MEDICINE MUST ADDRESS ITS
FAILURES
THIS IS IN PART
AN EDUCATIONAL ISSUE
WHAT SHOULD MEDICINE DO?
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!
“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
ACTION PLAN
• Take a few minutes to reflect on this half-day, and
complete the relevant section of the action plan