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. This was a post by a fellow student.

 

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

Start by reading this JAMA Piece of My Mind “Speak Up” which describes one physician’s experience with speaking up when witnessing micro-aggressions or biased comments or behavior in the clinical workplace.

Then read this post from STAT News that describes a medical student’s experience with racist comments during her clinical training and how it felt when no one spoke out against it.

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.

History of Medicine as a Profession

ABIM Medical Professionalism: A Physician Charter

This document reviews the importance of professionalism is the basis of medicine’s contract with society and that understanding the principles and responsibilities of medical professionalism is key to physicians social contract with society.

Why Does Professionalism Matter? : Trust, Transparency and Accountability

This video (3:34) shows senior physicians from around the country exploring why professionalism is integral to physicians maintaining trust with patients. It stresses that trust and accountability are key focuses to continue to keep at the center of physicians practice. At 1 minutes 30 seconds, the provider talks about how at times there will be conflict when there are competing needs but that it is important to embrace and face the conflict to better understand it.

Association Between Physician Burnout and Identification With Medicine as a Calling

This research paper seeks to evaluate the association between degree of professional burnout and physicians’ sense of calling. Study identifies that physicians who experience more burnout are less likely to identify with medicine as a calling. It implies that loss of the sense of medicine as a calling may have adverse consequences for physicians and patients

 

 

 

Bridging Difference: An approach to conflict with colleagues

Conflict is frequent and inevitable in healthcare.  Why?

  • We have different personal and professional values. Moral issues and values often play a role in medical care and decision-making, and the values of individual team members may at times conflict.
  • We may have a different understanding of the same patient or situation. For example, one physician may see a patient as having a potentially treatable illness, while another sees him as someone who is suffering and should be allowed to die peacefully.
  • There is often not a single “right” or evidence-based answer. The different experiences of team members may lead to different approaches to the same patient or issue.
  • We come from diverse cultural backgrounds. Team members – including patients – all bring their personalities and cultures to the table, and icebergs can bump.
  • Working in healthcare is stressful and can cause individual ‘resource depletion’. Fatigue, stress, and burnout all make conflict more likely.
  • We may have inadequate institutional resources, leading to tussles to get our patients what they need – the next operating room, an expensive medication, etc.

Health professionals AND medical students need to have a constructive approach to conflict

  • To provide the safest and highest quality care for patients
  • To create a safe learning and working environment for ourselves and our colleagues
  • To build and maintain relationships with each other. Health care team members often work together for years.  Medical school classmates will be a source of support for each other, and may find themselves in the same residency programs and ultimately practicing together.

Conflict Handling Modes

TKI Conflict Handling Modes

TKI Conflict Handling Modes

Competing

A competing style is higher in assertion and lower in cooperation.  Someone using a competing style might approach the conflict by making as strong a case as they can for their own position.  They may be very amiable and polite about it – competing does NOT mean harsh – but they have a viewpoint that they strongly assert.

Perhaps someone using a competing style is very confident that hers is the correct position.  She may be in a position of power and intend to pursue this course even if it is unpopular with others – a competitive style may avoid wasting time in meaningless discussion if the course is already set.

Collaborating

A collaborating style is both assertive and cooperative.  Someone using a collaborative style might approach a conflict as an opportunity to work together to build the best possible understanding or solution.  He would express his own perspective, but would also elicit and listen to the perspectives of others.

Perhaps someone using a collaborative style knows that each member of the group is likely to have different ideas and input, and that all might be contribute to the group’s understanding of a critical issue, or to solving a challenging problem.  He may want to build strong relationships within the group, even though it might take a lot more time than a less cooperative style.

Compromising

A compromising style is medium in both assertiveness and cooperativeness.  Someone using a compromising style might approach the conflict as an opportunity to meet in the middle, to give and take to find something all group members can live with.

Avoiding

An avoiding style is low in both assertiveness and cooperativeness.  Someone using an avoiding style does not share their own perspective or listen to others – they don’t want to engage with this conflict right now!

Perhaps someone using an avoiding style needs time to process their own thoughts or cool down, and they plan to return to the topic later on.  Or perhaps the issue is unimportant to them, or they don’t think they have the power to make change.

Accommodating

An accommodating style is low on assertiveness, but high in cooperativeness.  Someone who is using an accommodating style is putting the concerns or needs of others ahead of their own.

Perhaps someone using an accommodating style knows that the issue is far more important to the other(s) than it is to them, or that the relationship is more important than the issue.

An Approach to Handling Conflict

Can we insert vital talk web page here?  http://vitaltalk.org/guides/conflicts/  ALT TEAM

 

Lexicon

This is a partial list of some important terms. For a more complete list, see the Diversity and Inclusion Dictionary.

Diversity: Diversity means more than just acknowledging and/or tolerating difference. Diversity is a set of conscious practices that involve:

  • Understanding and appreciating interdependence of humanity, cultures, and the natural environment.
  • Practicing mutual respect for qualities and experiences that are different from our own.
  • Understanding that diversity includes not only ways of being but also ways of knowing;
  • Recognizing that personal, cultural and institutionalized discrimination creates and sustains privileges for some while creating and sustaining disadvantages for others;
  • Building alliances across differences so that we can work together to eradicate all forms of discrimination.

Diversity includes, therefore, knowing how to relate to those qualities and conditions that are different from our own and outside the groups to which we belong, yet are present in other individuals and groups. These include but are not limited to age, ethnicity, class, gender, physical abilities/qualities, race, sexual orientation, as well as religious status, gender expression, educational background, geographical location, income, marital status, parental status, and work experiences. Finally, categories of difference are not always fixed but also can be fluid. Diversity includes respecting an individual’s right to self-identification and recognizing that even though hierarchies based on identity are built into systems, no one culture or identity is intrinsically superior to another.

Identity:  the qualities, beliefs, etc., that make a particular person or group different from others. Some ways in which we identify are connected to groups which are socially ascribed such as gender, race, age, class, sexual orientation, ability, nationality and citizenship, etc.

 Implicit Bias:  Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.  These biases, which we all hold and which encompass both favorable and unfavorable assessments, are activated involuntarily and without an individual’s awareness or control.   The implicit associations we harbor in our subconscious cause us to have feelings and attitudes about and different responses to people based on characteristics such as race, gender, age, and appearance. These associations develop over the course of a lifetime beginning at a very early age through exposure to direct and indirect messages.  In addition to early life experiences, the media and news prograaming are often-cited origins of implicit associations. Implicit biases are malleable, and since they are learned, they can be gradually unlearned through a vareity of debiasing techniques.

Intersectionality:  Though theories related to intersectionality have been around since the 19th century, Kimberlé Crenshaw professor of law and an expert on critical race study first coined the term intersectionality in 1989 to describe how social and cultural identities/categories interrelate on concurrent and multiple levels to create interlocking systems of social inequality.  Intersectionality is a theory or standpoint that allows us to see and understand the ways in which social categoris of difference like gender, race, age, class etc are woven together.  For example, if a person is transmasculine, brown, and working class with no health insurance, they may have a much more difficult time accessing trans*affirming health care than a transmasculine, white, middle class person with health insurance.

Power: One definition of power that is both simple and useful is: “the ability to get what you want.” Power is a relational term. It can only be understood as a relationship between human beings in a specific historical, economic and social setting. It must be exercised to be visible.

It is worth noting here the difference between forms of power that are ‘power-over’ and ‘power-with’. Power-over is power that is used in a discriminatory and oppressive way: It means having power over others and therefore domination and control over others (e.g. through coercion and violence). Power-with is power that is shared with all people in struggles for liberation and equality. In other words, it means using or exercising one’s power to work with others equitably.

Privilege:  A special right, advantage, or immunity granted or available only to a particular person or group of people whether they want those privileges or not, and regardless of their stated intent.  Privilege is characteristically invisible to people who have it. People in dominant groups often believe that they have earned the privileges that they enjoy or that everyone could have access to these privileges if only they worked to earn them. In fact, privileges are unearned and they are granted to people in the dominant groups whether they want those privileges or not, and regardless of their stated intent.  Unlike targets of oppression, people in dominant groups are frequently unaware that they are members of the dominant group due to the privilege of being able to see themselves as persons rather than being constantly regulated to the level of stereotype. Privilege operates on personal, interpersonal, cultural, and institutional levels and gives advantages, favors, and benefits to members of dominant groups at the expense of members of target groups.

Oppression/Target Groups: Oppression is the combination of prejudice and institutional power, which creates a system that discriminates against some groups (often called “target groups”) and benefits other groups (often called “dominant groups”). Examples of these systems are racism, sexism, heterosexism, cis-sexism, ableism, classism, ageism, and anti-Semitism. These systems enable dominant groups to exert control over target groups by limiting their rights, freedom, and access to basic resources such as health care, education, employment, and housing.

Four Levels of Oppression/”isms”:

  • Internalized / Personal Oppression: Values, Beliefs, Feelings
  • Interpersonal Oppression: Actions, Behaviors, Language
  • Institutional and Structural Oppression: Rules, Policies, Procedures
  • Cultural Oppression: Beauty, Truth, Right

Oppression Internalized (inferiority and superiority): Internalized inferiority is the process whereby people in the target group make oppression internal and personal by coming to believe that the lies, prejudices, and stereotypes about them are true. Members of target groups exhibit internalized oppression when they alter their attitudes, behaviors, speech, and self-confidence to reflect the stereotypes and norms of the dominant group. Internalized oppression can create low self-esteem, self-doubt, and even self-loathing. It can also be projected outward as fear, criticism, and distrust of members of one’s target group.

Internalized superiority is the process whereby people in the privileged group make oppression internal and personal by coming to believe that the lies, prejudices, and stereotypes about people in a target group are true, which positions people in the privileged group as superior.  Members of privileged group often exhibit internalized superiority by assuming they are smarter and more deserving of decision making power, comfort, and authority than people in the associated target group.  This is often expressed through perfectly logical explanations that justify and normalize discriminatory behavior.

Race: Someone has said that “race is a pigment of our imagination”. That is a clever way of saying that race is actually an invention. It is a way of arbitrarily dividing humankind into different groups for the purpose of keeping some on top and some at the bottom; some in and some out.  Ant its invention has very clear historical roots; namely, colonialism. “Race is an arbitrary socio-biological classification created by Europeans during the time of worldwide colonial expansion, to assign human worth and social status, using themselves as the model of humanity, for the purpose of legitimizing white power and white skin privilege” (Crossroads-Interfaith Ministry for Social Justice).

To acknowledge that race is a historical arbitrary invention does not mean that it can be, thereby, easily dispensed with as a reality in people’s lives. To acknowledge race as an invention of colonialism is not the same as pretending to be color blind or declaring, “I don’t notice people’s race!”  For example, it has been demonstrated that health professionals are less likely to prescribe painkillers for people of color who are experiencing the same symptoms as white people. So, even though race is a social construct, when someone doesn’t get the pain medication that they need because of implicit bias, race and racism have real consequences.  Our world has been ordered and structured on the basis of skin color and that oppressive ordering and structuring is racism.

 Racism: Racism is a system in which one race maintains supremacy over another race through a set of attitudes, behaviors, social structures, and institutional power. Racism is a “system of structured dis-equality where the goods, services, rewards, privileges, and benefits of the society are available to individuals according to their presumed membership in” particular racial groups (Barbara Love, 1994. Understanding Internalized Oppression). A person of any race can have prejudices about people of other races, but only members of the dominant social group can exhibit racism because racism is prejudice plus the institutional power to enforce it.

Stereotype: An exaggerated or distorted belief that attributes characteristics to members of a particular group, simplistically lumping them together and refusing to acknowledge differences among members of the group.

Cultural Competency: Cultural competency is a common, well-intentioned approach to teaching (presumably) privileged people that cultural mastery of traits, beliefs, traditions, etc. of marginalized communities is possible.  While it is certainly important to be aware of cultural practices that are outside one’s own lived experiences and world view, this definition and concept is problematic because it harbors unstated assumptions that trainees are necessarily from a privileged cultural group, that patients of a particular background share homogeneous beliefs, that the complex nuances of difference can be “mastered”, and that ethnic similarity between clinician and patient mandates mutual understanding.  Most importantly, traditional cultural competency training, like traditional medical training, is externally focused, primarily concerned with mastering the Other, rather than examining the internal cultures, prejudices, fears, or identifications of the Self in relation to that Other.

Narrative Humility/ Narrative Competence: Craig Irvine describes humility as “The sense of humility toward that which we do not know—the face of the Other, the face we cannot know but to which we are responsible.”  Narrative humility acknowledges that patients’ stories are not objects that can be mastered, but rather dynamic entities that can be engaged with, while simultaneously remaining open to their ambiguity and contradiction.  Narrative humility means engaging in constant self-evaluation and self-critique about issues such as one’s own role in the story, one’s expectations of the story, one’s responsibilities to the story, and one’s identifications with the story.  Narrative humility allows clinicians to recognize that each story heard holds elements that are unfamiliar—be they cultural, socioeconomic, sexual, religious, or idiosyncratically personal.  Narrative competency, on the other hand, is not an end point—but rather a skill set that is developed through the practice of narrative humility, which needs to be exercised just like a muscle.

References:

AMSA website: http://www.amsa.org/advocacy/action-committees/gender-sexuality/lgbt-local-projects-in-a-box/

MSU Extension Multi-Cultural Awareness Workshop and http://www.amsa.org/advocacy/action-committees/gender-sexuality/lgbt-local-projects-in-a-box/

Ignite! A Toolkit for Anti-Racist Education: http://antiracist-toolkit.users.ecobytes.net/?page_id=124

Kirwan Institute for the Study or Race and Ethnicity: http://kirwaninstitute.osu.edu/research/understanding-implicit-bias/

  Sayantani DasGupta:  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60440-7/fulltext

Queensborough Community College: http://www.qcc.cuny.edu/Diversity/definition.html

Text adapted from CEDI Resources and References