Category Archives: Professionalism

A set of values, norms, and expectations within the medical profession that constitute a covenant with society.

Key Ethics Term: Trust & Trustworthiness

Trust and the virtue of trustworthiness are integral to the moral life. At a very basic level, society requires trust to function (e.g. what if you couldn’t trust your bank to hold your money?, or e.g. what if you couldn’t trust that teachers were doing their best to provide accurate information?, or e.g. what if you couldn’t trust your doctors to keep their interactions with you confidential?). In order to survive and flourish with those around us, we must be able to trust each other.

It is important to note that trust also makes us vulnerable. To trust in another is to make oneself vulnerable to that person or system. This point is a key feature of patient care. Physicians depend on patient’s to trust them in their care for them to be successful. Likewise, patients depend on physicians not to abuse their trust. When physicians and patients are able to engage in trusting relationships and be trustworthy, we have a better chance of enhancing the wellbeing of the patient, the physician, and the relationship.

Relations of trust are also vulnerable to social norms and history. Norms that categorize a particular population as not trustworthy can affect patient care and pose significant challenges to clinician-patient relationships. For instance, it is common for clinicians to distrust the demands of patients with Sickle Cell Disease, particularly by doubting the validity of their requests for stronger pain medications in a crisis. This mistrust is tied up in social perception of opioids as well as the visible identity of being black (as many sickle cell patients are). So, when building trust and trustworthiness in relations with patients, we must acknowledge how social norms and history can affect those efforts.


Review these Key Ethics Terms:

Read: Excerpts from Aristotle’s Nicomachean Ethics

Reading Aristotle is hard! But we think you can do it! It will create some discomfort for everyone. We do NOT expect you to master these concepts – it is more important in this session to be open, brave, vulnerable, and interested in growth than it is to be ‘right’. See what you can gather from the reading and use the PDF’s highlighting and prompts to guide you if you’re having trouble.

Consider: the role of empathy in medical student education while reading Walking a mile in their patients’ shoes:empathy and othering in medical students’ education. The article discusses the barriers for medical education to promote empathy and offers up a paradigm that may help trainees deal with these barriers and possible ideas of how they could be surmounted.

 

Read over this Facebook Post and reflect on how values and virtues can or cannot be demonstrated on social media.

 

If you’re feeling eager for more… explore this article on How to Teach Doctors Empathy which talks about the growing emphasis on empathy training for health care professionals and describes a few such trainings across the country.

Responding to Bias: Strategies and Skills

Read the JAMA article

 

Then read this post from XYZ

 

Tools for Responding to Bias

Goal: Communicate a message of disapproval without damaging interpersonal relations

Be ready 

Rehearse what you would do or say in situations before they occur

You know what feels most natural for you

Remember the Bystander effect

No one else will probably say anything

Consider saying something, even if it is a small effort

Decide whether to say anything 

Silence is often interpreted as passive complicity

Consider saying something simple like “that’s not cool” or “I don’t appreciate that”

You don’t have to take a dramatic stand if you’re not comfortable or not able

Consider taking more time if:

You know you respond badly in the heat of the moment

You fear retaliation or mistreatment and need more support

The situation is not appropriate (ie during a patient care emergency)

Stay calm 

Try to speak calmly, or consider waiting until another time

Try to avoid inducing defensiveness

Clarify or Restate what was said  

Make sure you are understanding what was said

Make the speaker think about what they said

“So I am hearing you say….” Or even “excuse me, what was that you just said?”

If a joke was made, ask the speaker to explain it to you

When identifying the behavior, avoid labeling, name-calling or the use of loaded terms. Describe the behavior; don’t label the person.

 Appeal to principles 

“I’m surprised to hear you say that.  I think of you as more… (egalitarian, open-minded, etc).”

Change the subject (more effective than it sounds) 

You may not change beliefs but you may change behavior

Reflect on what happened 

Journaling or meditation

Debriefing with a peer or college mentor

 It’s never too late to bring it up 

Defer until later: “let’s talk about this when we have more time”

Bring it up later: “I’ve been thinking about what you said last week…”

Don’t get discouraged 

You won’t know the lasting impact you’ll have later on, both for the speaker and those who were present

Know your resources 

College mentors and college heads

Other trusted faculty

Student Affairs office

Traps to Avoid: Avoid making light of any comments, making jokes (which often backfire!), or getting defensive

Values to Norms

What makes a good community?  What values do communities hold? In thinking about building and enriching our own medical school community, and working together to establish some ‘norms’ of how we would like to engage, it is helpful to look for lessons from other academic communities.

The concept of a community agreement in higher education was advanced by the work of Earnest Boyer and other researchers and published in their report Campus Life: In Search of Community in 1990, funded by the Carnegie Foundation for the Advancement of Teaching. In their study, Boyer and colleagues identified six characteristics that define a positive academic community:

Boyer’s Principles of Community 

Purposeful 

A college is an educationally purposeful community, a place where faculty and students share academic goals and work together to strengthen teaching and learning on the campus

Open 

A college is an open community, a place where freedom of expression is uncompromisingly protected and where civility is powerfully affirmed.

Just 

A college is a just community, a place where the sacredness of the person is honored and where diversity is aggressively pursued.

Disciplined 

A college is a disciplined community, a place where individuals accept their obligations to the group and where well-defined governance procedures guide behavior for the common good.

Caring 

A college is a caring community, a place where the well-being of each member is sensitively supported and where service to others is encouraged.

Celebrative 

A college is a celebrative community, one in which the heritage of the institution is remembered and where rituals affirming both tradition and change are widely shared.

Taken from Ernest L. Boyer’s Campus Life: In Search of Community, 1990

IPE: Teamwork and Values Conflicts, Working with Challenging Patients

Teamwork and Values Conflicts

  1. We share core professional values but sometimes our values conflict with those of another (perfectly reasonable) team member. The training and practice of an occupational therapist emphasizes safety, which was in direct conflict with patient autonomy in this specific patient case.
  2. Conflicting opinions are a normal part of working in teams.  Successful teams a) assume positive intent, b) listen to each other, c) make sure every person on the team expresses their view, and d) concludes conflicts by negotiating a plan for next step/s.
  3. Place the patient at the center of the team.  Understanding the patient’s perspective on health and healthcare places the patient at the center of the team’s conversation, and can help all team members get behind a plan that meets the patient’s needs.
  4. Listening and speaking up are critical team skills.  Listen as much (or more) than you speak.  But speaking up is important for all team members to share their concerns or new information.
  5. We can’t always be the hero.  Sometimes we can’t “save” a patient. When we have different goals or health beliefs than a patient, we may not always feel good about our what we are able to do (allowed to do) for a patient or the patient’s outcome.
  6. Don’t take it personally.  When you feel challenged by a patient, ask other team members how it’s going for them. Don’t assume you’re the problem, or are the only one having difficulty.  If you’re frustrated, it’s likely others on the team are too.
  7. Talk to your team first.  When you feel challenged by a patient, don’t go it alone. Use your team to help you problem solve. Difficult patients can split us as teams. Knowing other’s roles and responsibilities and using them to full potential can share the burden of high maintenance patients.
  8. Think broadly when you think “team”.  Physicians, nurses, pharmacists and social workers practice in close proximity, often rounding together, but other team members may not be in the loop.  Remember to include everyone in challenging care decisions.
  9. Support your team members.  Especially when we have a challenging patient, we need to rely on and trust our team members to do their jobs.  Work together to adopt a common approach.

Working with Challenging Patients

  1. “Difficult” patients:  Challenging behavior is often a sign that, from the patient’s perspective, her/his needs aren’t being met.
  2. Engaging patients:  Exploring patient’s preferences in a non-judgmental way is key to enhancing motivation and engagement, both of which are essential to effective care.
  3. Respect for patient autonomy:  Ultimately, patients make their own decisions. The challenge for providers is to take the journey with them, work creatively to bridge medical aims and patient priorities, and provide support.