Category Archives: Professionalism

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

Practical Topics in Professionalism for Clerkships

READ: Physician impairment: When should you report?  Current Psychiatry. 2011 September;10(9):67-71  

Read this article which describes examples of physician impairment and colleagues’ responsibilities around reporting.

READ: AMA Opinion on Romantic or Sexual Relationships 

Read this opinion piece that reviews the AMA’s position on romantic and sexual relationships with patients.

READ: Responding to Requests about Prayer 

Read this article which talks about situations when patients ask clinicians to pray with them.

READ: Gifts from Patients. AMA Ethics Opinion 

Read this opinion piece about accepting gifts from patients.  AMA Ethics opinions are good resources for discussions on professionalism and ethics issues.

Power and Hierarchy

READ: A young doctor’s fear of raising questions causes a mistake

This article was written by a medical student (who is now faculty in the Department of Medicine at UW) who describes feeling uncomfortable with a patient care task he was asked to perform. He felt silenced by the medical hierarchy and didn’t speak up at the time due to fear. He emphasizes the importance of changing the culture of medicine to one that respects open communication and respectful advocacy to promote safety in the learning environment and patient care.

Evolution of Professionalism

Why Does Professionalism Matter?: Perspectives

Watch this video.

Curiosity and What Empathy Really Means by Atul Gwande

Read this article (pdf).

  • This article (also available online at: https://www.newyorker.com/news/news-desk/curiosity-and-the-prisoner) explores the foundational principle of medicine that all lives are created equal and how in modern day applying these principle requires a willingness see the humanity in all people even those different from you and to try to understand what it is like to be them.  It requires a curiosity and openness and level of respect and through a respect of the humanity of others you “will be given trust ot see human beings at their most vulnerable and serve them.”

ABIM Medical Professionalism: A Physician Charter

Review this document (pdf, optional).

  • 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.

Physician Accountability After Critical Events

Molly Jackson, Elizabeth Kaplan

1) Read Article

Read the Medical error: the second victim. The doctor who makes the mistake needs help too (Wu, AW., 2000)

GOAL: Appreciate the idea of aftermath of medical error and idea of provider as second victim..

Context and Instructions: Read article to begin to appreciate medical errors can have on providers and get introduced to a way of thinking of how to support ourselves and colleagues who experience the aftermath of a medical error.

2) Read Article

Read Patient Safety Primer – Debriefing for clinical learning (as a pdf).

GOAL: Gain more familiarity with tool of debriefing especially as it might pertain to the aftermath of an adverse clinical event.

Context and Instructions: Read article to learn about the definition of debriefing, the components of debriefing, and special considerations.

Conflict of Interest in Patient/Physician Interactions

 

Required:

Optional:

Trustworthiness and Relational Autonomy

In this session, we will be focusing on the Ethical Framework of Rules/Obligations (see Ethics Case Analysis Tool). We will investigate one of the primary obligations of clinicians: respect for patient autonomy, and consider what this might mean in more complex clinical cases. We will also explore another primary obligation of clinicians: the obligation to build trusting relationships with patients. This second obligation is often required for fulfilling the first, and these cases help us to see why.

(1) Review these key ethics concepts:

  1. Autonomy and Relational Autonomy
  2. Trust and Trustworthiness

**Keep in mind that this session will focus on cases that are meant to draw out population level biases and ethical concerns in particular clinical interactions. We will be addressing more societal, systematic, and broader justice issues in other sessions (see Justice in Healthcare). Likewise, we will come back to system level methods of advocacy (including advocacy for clinicians with underrepresented minority identities) in other sessions. Here, our intention is to start thinking creatively about how to be in relationship with particular patients in complex contexts.**

(2) Then READ:

Stonington SD. Whose Autonomy? JAMA. 2014;312(11):1099-1100. 

As you read CONSIDER… Autonomy is a complicated concept. While in the US it is often understood as the capacity of an individual to make independent choices, this isn’t the reality of choice and this article helps us to see why. Our choices are always enmeshed in complicated interpersonal (e.g. family) and structural (e.g. cultural norms) social relations. 

How do you think building trust and being trustworthy relates to respecting patient autonomy?

(3) APPLY what you have learned so as you READ and REFLECT on CASE 1 (you should remember this case from your IPE Session Teamwork and Values)

As you read CONSIDER…

  • What are Doris’ goals and those of the care team? How do they align and how they conflict?
  • How does trustworthiness factor into this case? Might it guide clinicians in some particular way? How so?
  • What does it mean to respect a patient’s autonomy in this case?

CASE 1 – DORIS

Doris at hospital admission  

Doris Carlson is a 72-year-old woman who was brought to the ED by medics shortly after collapsing at home with shortness of breath and leg weakness.  She was in her usual state of health, able to walk a couple of blocks and care for herself, until a week prior to admission, when she noticed that she was even more short of breath than usual and her legs were swelling.  She thought maybe it was the heat, but four days ago she couldn’t lay flat to sleep.  Finally her legs were so weak that she fell in her hallway this morning.  She was able to crawl to the phone to call the medics, who had a tough time getting her out of her apartment because the rooms were stacked with books and periodicals.

Doris lives alone and says she likes it that way.   When she retired 4 years ago from her job as a librarian, she moved into a second floor apartment with an elevator.  Doris is obese and was diagnosed with type 2 diabetes and hypertension almost 15 years ago, but hasn’t actually seen a doctor in years and takes no prescription medications.  She does take Vitamin D because she read about the low levels among Seattleites. At baseline, she can walk a couple of blocks before feeling out of breath, and is able to get to the grocery store and other key places on foot.  In the week before collapsing though, she hadn’t been able to get to the store, and had no one she could call on for help.

Doris at Hospital Day 19 

Doris refused most recommendations and therapies, yet she loved to have long conversations with everyone on the team.  The Cardiology team spent hours teaching about her cardiac disease, and trying to negotiate a mutually acceptable plan.  The pharmacy team spent hours providing drug education.  The team eventually resorted to only sending one person into the room during morning rounds to avoid delaying their rounds.  The dietitian had prolonged conversations about better diet choices for diabetes, as well as a low sodium diet (and also tried to help out with the avocado situation). Hospital dentistry evaluated Doris given her lack of dental care, diabetes, and left lower jaw tenderness while in the hospital, but she refused to go down to the clinic for a full exam or x-rays.  The team social worker spent hours first trying to identify community supports, and then skilled nursing facility placement, only to have Doris refuse all options.  Doris even refused to be discharged home by cabulance insisting she would take a taxi.

While most patients on the medical floor have a primary nurse, no one would volunteer to take Doris.  Eventually, a plan was developed for rotating care of Doris daily among the nursing team to diminish frustration. Doris would often complain that she didn’t like someone on her care team, often trying to engage the person currently with her to “help” with some problem.  The physical therapist and occupational therapist also spent hours with Doris but had a different experience. While Doris was fairly passive receiving OT and PT therapy, she was appreciative of their attention and efforts.

Because of her unwillingness to take most oral medications, Doris remained quite hypoxic on room air, and was thus not ready for discharge.  She declined home oxygen, though she wore it in the hospital.  Doris’ hospitalization dragged on for weeks during a time when the hospital was full and other patients were being diverted.

The Cardiology team requested a Psychiatry consult to assess Doris’ decision-making capacity.  Doris refused to talk to Psychiatry but after discussing with other team members, the psychiatrist (and cardiologists) felt Doris was indeed able to make decisions for herself.

By hospital day 19, the Cardiology team decided to discharge Doris with or without home oxygen, medications, dental follow-up, assistive equipment or any other social services.  They had offered ample recommendations but she was unwilling to accept any.  Other team members were uncomfortable with this plan, given that her room air oxygen saturation remained in the low 80s.  Her nurse asked if she was supposed to just remove the oxygen at the curb and wish her “good luck” as she got in the cab?

One team member eventually was so uncomfortable, discharge was delayed and an ethics consultation was requested.

 

SHIFTING GEARS A LITTLE… We’re going to look at the intersection of the values of autonomy and trustworthiness in the more complicated context of IV drug use and addiction. This reading will be directly relevant to an in-class exercise in which students will be expected to participate in a mock family meeting.

(4) READ this publication by Dr. Kirkpatrick (Cardiologist and Ethics Consultant at UWMC): 

“Infective Endocarditis in the Intravenous Drug User” in AMA Journal of Ethics. 2010;12(10):778-781.

Dr. Kirkpatrick uses a case and casuistic comparisons to critically reflect on the meaning of the term ‘futility’ in contexts where a patient’s addiction to IV drugs might be taken as a reason against pursuing a particular medical intervention.

As you read HIGHLIGHT the central ethics rules/obligations that Dr. Kirkpatrick applies in his discussion.

 


For further investigation on addiction, see…

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.


Individual Responsibility to the Profession

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.

Physicians and patients alike will agree that empathy is integral to patient care. But it is not as easy as we might think. Empathy is not unlike other clinical skills and practices. Take learning to listen to a heart. We begin with simple instructions about how to use a stethoscope and then slowly build more precise attunement to any irregularities in heartbeat. In empathy, we begin with simple questions like “how do you feel today?”, but experience, practice, and knowledge will create greater attunement to the feelings of others. This article by Dr. Shapiro is just one step in the direction of building the knowledge necessary to becoming an excellently empathically attuned physician. 

WATCH: Examined Life – Judith Butler & Sunaura Taylor

The conversation in this video is an excellent example of what it means to be curious, humble and empathic in conversation with others and across sameness/difference. Sunaura Taylor is an artist and writer, she articulates the social model of disability and demonstrates its effect on her life excellently. Taylor and Butler call on us to think about how what our bodies can do in the world depends on what the world allows physically and through social norms. Most importantly, Taylor and Butler show us how important it is to know about the experiences of others by talking with them and privileging their perspective by always remaining curious and open.  

Review these Key Ethics Terms:


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