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Medical Ethics: Is It Still Relevant to Students and Practicing Physicians?


Medical Ethics: Is It Still Relevant to Students and Practicing Physicians? Nancy W. Dickey, M.D. President, Health Science Center and Vice Chancellor for Health ... – PowerPoint PPT presentation

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Title: Medical Ethics: Is It Still Relevant to Students and Practicing Physicians?

Medical Ethics Is It Still Relevant to Students
and Practicing Physicians?
  • Nancy W. Dickey, M.D.
  • President, Health Science Center and
  • Vice Chancellor for Health Affairs, AM System
  • November 19, 2004

Professionalism, what is it?
  • Principles of professionalism entail not only
    personal commitment to the welfare of the patient
    but also collective effort to improve the health
    care system for welfare of society. Hafferty
  • ABIM defines professionalism as requiring the
    physician to serve the interests of the patient
    above his or her self-interest
  • Broadly speaking, ethics concerns itself with why
    and how one ought to act. Candiles
  • Despite all of this attention, a core
    understanding of what it mean to be a
    professional remains elusive. Hafferty

Professionalism, what is it?
  • For the individual physician professionalism is
    expressed primarily in the clinical transaction.
  • Professionalism is the basis of medicines
    contract with society
  • Establishes standards of competence integrity
  • Essential is public trust in physicians
  • Professional responsibilities of honesty,
    confidentiality, commitment to quality, caring,
    maintaining trust
  • ACP-ASIM defines 3 principles
  • The primacy of patient welfare
  • The principle of patient autonomy
  • The principle of social justice promotion of a
    fair distribution of health care resources

Professionalism ethics, are they different?
  • According to the AMA, ethical principles are a
    body of statements developed to guide physician
    behavior primarily for the benefit of the patient
    and for society
  • They define the essentials of honorable behavior
    for the physician
  • They are standards or guides not laws
  • Having a body of ethical standards developed by
    the profession is one of the things that
    separates professionals from journeymen

AMA Medical Ethics
  • A physician shallprovide
  • competent medical care, with compassion and
  • uphold the standards of professionalism, be
    honest(and) report physicians deficient in
    character or competence
  • respect the law ,
  • respect the rights of patients, colleagues, and
    other health professionals,
  • continue to study, apply, and advance scientific
    knowledge, maintain a commitment to medical
  • recognize a responsibility to participate in
    activities contributing to the improvement of the
  • regard responsibility to the patient as
  • support access to medical care for all people.  

Professionalism Why does it matter? An Emerging
  • AAMC 1998 Initiative on Professionalism created
    in response to growing concern among the public
    and even the profession
  • ABIM/ACP-ASIM 2002 Medical Professionalism
    Project, Changes in the delivery systems
  • threaten the values of professionalism.

Professionalism Why does it matter? An Emerging
  • AMA initiated the STEP program (2003) to fund
    selected medical schools in designing innovative
    methods for educating the next generation of
    physicians in the competencies that constitute

Why the change or the perceived change?
  • Changes in the health care delivery systems in
    countries throughout the industrialized world
    threaten the values of professionalism. Sox
  • Deprofessionalization has been attributed in part
    to specialization, with fragmentation of clinical
    care and loss of an effective single voice for
    the professionthe image of physician
    selflessness has been marred by perceived
    increased emphasis on rewardand impact on
    perceived priorities and trustworthiness of
    physicians with regard to the primacy of the
    patient in the clinical transaction. Barondess

Why the change?
  • A third pressure relates to health care costs and
    their continuing escalation.which will
    ultimately threaten the care of patients through
    a variety of controls, re-entrenchments, erosion
    of clinical qualityadditional efforts might
    address especially a focus on exuberant and not
    infrequently inappropriate use of expensive
    technologies, which are estimated to contribute
    2/3 of annual increases in rising health care
    costs. Barondess

Failure to respond
  • We are not aloneA decade ago Senator Daniel
    Patrick Moynihan warned that the level of deviant
    behavior in our society had surpassed what the
    community could afford to recognize and as a
    result we have been redefining deviancy down so
    that conduct previously stigmatized is now
  • Harvard Business Review 2004

We are not in this alone
  • Peers dont report peers
  • Faculty dont fail learners
  • Administrators cast a blind eye
  • Peer review misused
  • For economic competition
  • Failure to act even in light of problems

Culture is a contributor
  • American culture
  • Taboo on whistle blowing
  • Who am I to judge other peoples values
  • (even today, I am not allowed to judge other
    people values and I have to keep mine neutral so
    I dont offend)

Culture is a contributor
Professional issues medical personnel facing
moral dilemmas haveturned to attorney for
guidance, as if to say, If we cannot agree on
what is right, we shall at least adhere to what
the courts prescribe.Trotter There but for the
grace of God go I
Professionalism matters
Professionalism, why does it matter for our
  • Students who received comments about
    unprofessional behavior were twice as likely to
    be disciplined by the medical board when they
    became practicing physicians.
  • Medical students are routinely exposed to a range
    of deleterious influencesand almost 2/3 of the
    study respondents thought their ethical
    principles had eroded because of their clinical

Educating for professionalism
  • To be good is noble to teach others to be good
    is nobler and less trouble.Mark Twain
  • For medical educators, the reverse may be true
  • The challenge of living up to the professional
    standards set for ourselves is great
  • The challenge of setting our students on the path
    to professionalism is even greater.

A tough message
  • Where ignorance is the problem, then education,
    not punishment or discipline, is the answer.
    Where poor ethics is simply misguided, not evil,
    then (ethics) education may be in order. For
    deliberate exploitation of patients for personal
    gain, then responsibility and retribution are
  • Morreim EH. Am I my brothers warden?
    Hastings Center Report,. 1993 23 19-27.

What can medical education do?
  • Institutions do not change on their own
  • Individuals must act and by so doing may change
  • Recognize our obligation to
  • Uphold professional values
  • Accountability
  • Responsibility
  • Intervene in the system
  • Accountability
  • Responsibility

What can we do? You are in the vanguard
  • Becoming a professional takes shape more within
    medicines informal and hidden curriculum than
    within its formally identified modules.
  • Furthermore, and perhaps most disconcerting, the
    norms and value orientations encountered by
    students during their training are not always the
    standards medicine realistically identifies as
    defining medical practice.

What can medical education do?
  • Maintain character
  • An issue of who we admit
  • Mold character
  • An issue of enhancing the qualities of the
    excellent students we admit
  • Transform technical education into
    moral/professional education
  • Either one alone is not enough together they
    are powerful

How do we do that?
  • Provide a role model
  • Albert Schweitzer is credited with saying,
    Example is not the main thing in influencing
    others, it is the only thing.
  • What teachers themselves do with their knowledge
    and lives is educationally and morally

What can medical education do?
  • When concerning behaviors, attitudes, or
    communications occur, do not ignore them but
    directly address them.
  • Consider asking either the leaders in faculty
    development and curriculum/evaluation for
    assistance or ask the medical school to offer
    some training/role playing to practice these
    difficult interchanges
  • Seek a balance between validation and challenge

How do we do that?
  • Discuss negative models
  • Clinical faculty preceptors often offer an
    early opportunity to ask questions, have
  • Listen carefully for the question that may be
    hidden within the question it is tough to
    question a faculty members behavior

What can we do?
  • When you next encounter the unprofessional
    behavior of a learner or colleague, outline what
    steps will you take in responding to him/her?
  • Create a culture that is supportive and
    challenginghelp students and faculty to perform
    better every year
  • Discuss challenges opportunities with academic
    administration and help develop consistent
    processes across the clinical campus

When all else fails.
  • When a student does not attain these skills,
    then the student should not finish medical
  • D. Papadakes

Professionalism matters
Professionalism matters for clinicians
  • Because youweare the examples from which our
    students will learneither as great examples of
    what to do or examples of what not to do.

Professionalism under seige
  • Albert Jonsen illustrates how some feel about the
    current situation, Outrage greets stories of
    the uninsured, injured who are turned away from
    the ED.
  • Stories of the doctor whose golf game or cocktail
    party delays attendance at the patients bed
    arouse angerTrotter
  • Nov, 04 Dallas Morning News article on the effect
    of medical school teaching expectations on
    quality of patient care.

Professionalism, why does it matter for
  • Trust is widely recognized as being central to
    the doctor-patient relationshipresonating with
    both doctors and patients and distinct from
  • In the healthcare marketplace, the absence or
    presence of trust in patient-provider relations
    can have life-changing consequences.
  • A person who trusts his provider is more likely
    to seek care, to comply with treatment
    recommendations, and to return for follow-up care
    than a person who has little trust in a specific
    provider or a health care system. Thom
  • In the words of Galen, one of the founders of
    modern medicine, He cures most in whom most are

Professionalism is
  • Jonsen writes, The ethics of competence, fully
    understood as mastery of the science and skills
    of diagnosis, therapy, and preventionare the
    standard to which all physicians must be held.
    They stand as the modern extension of Hippocratic
    ethics into the age of scientific

How does that fit ?
  • More than 50 of patients with diabetes,
    hypertension, tobacco addiction, hyperlipidemia,
    congestive heart failure, asthma, depression and
    chronic atrial fibrillation are currently managed
    inadequately (Institute of Medicine, 2003c)
  • Americans die each year from heart attacks
    because they did not receive preventive
    medications, although they were eligible for them
    (Chassin, 1997 Institute of Medicine, 2003a)
  • Only 55 of patients in a recent random sample of
    adults received recommended care, with little
    difference found between care recommended for
    prevention, to address acute episodes or to treat
    chronic conditions (McGlynn et al., 2003)

How does that fit?
  • Over 1 million American annually suffer medical
  • 44,000 98,000 die annually as a result of error
  • 29 billion annually spent as a result of error
  • One third to one half are considered preventable
  • Harvard Medical Practice Study
  • IOM, To Err Is Human, 1998

The physician-patient relationship cornerstone
of patient trust, satisfaction, and loyalty.
  • As baby boomers reach middle age, they will
    have a dramatic effect on mainstream health care
    services in the United States. They will demand
    to play a greater role in their own care, as well
    as the care of their children and parents. What
    was once thought to be satisfactory care and
    service will be deemed insufficient for
    themselves and their families. Physicians and
    other caregivers who understand and accommodate
    these changing preferences will do well in a
    world where informed patients become the rule and
    not the exception. Montaglione CJ. Manag Care Q.
    1999 Summer7(3)5-21.

However,let us not lose track
  • Scott White Among Nation's 100 Best Hospitals
  • College of Medicine Presents Teaching Award in
  • A member of the AM Health Science Center College
    of Medicine faculty in Temple was recognized with
    an award for outstanding teaching
  • At a White Coat Ceremony 84 entering medical
    students received a white coat signifying the
    beginning of their medical training as the Class
    of 2008 at the College of Medicine. This is the
    largest medical school class in the Colleges
    27-year history. Out of more than 2,300
    applicants, these students represent 40 colleges
    and universities throughout the state and nation.

  • Adams D. Professionalism starts in medical
    school. AMNews. Mar 15 2004.
  • http//
  • Barondess JA. Medicine and professionalism.
    Archives of Internal Medicine. 2003
  • Candiles PJ. Distinguishing law and ethics a
    challenge for the modern practitioner.
    Pychiatric Times XIX no 12 (Dec 2002)1-6.
  • http//
  • Hafferty FW. In search of lost cord. Educating
    for Professionalism. Ed. Wear ED Bickel J.
    University of Iowa Press. 2000.
  • Montaglione CJ. Manag Care Q. 1999
  • OBrien L. How to restore the fiduciary
    relationship. Harvard Business Review. May
    2004 71-78.
  • Reiser, SJ. The moral order of the medical
    school. Educating for Professionalism. Ed. Wear
    ED Bickel J. University of Iowa Press. 2000.

  • Sox, HC. Medical Professionalism in the new
    millenium a physician charter. Annals of
    Internal Medicine. 136no3 Feb 2002243-246.
  • Thom DH, Hall MA, Pawlson LG. Measuring patient
    trust in physicians when assessing quality of
    care. Health Affairs. 2004 23 no3124-132.
  • Trotter G, The Loyal Physician Roycean Ethics
    and the Practice of Medicine. 1997. Vanderbilt
    University Press.

The End
  • Please proceed to post test
  • Download post test
  • Complete post test
  • Return post test to Dr. Sandra Oliver 407i TAMUII

Post test question one
  • ABIM defines professionalism as
  • Interact with consultants respectfully
  • Recognize obstacles to patient care
  • Place the patients interest first
  • Recognize own limitations in learning

Post test question two
  • Which of the following is not identified by
  • ACP-ASIM as a principle of professionalism?
  • The primacy of patient welfare
  • The principle of patient autonomy
  • The principle of social justice
  • The principle of societal beneficence

Post test question three
  • Medical students who received comments about
    unprofessional behavior were
  • Twice as likely to be disciplined by the medical
    board when they became practicing physicians
  • Shown to have no correlation with professional
    behavior as physicians
  • One third as likely to drop out of medical

Post test question four
  • According to Dickey, when you next encounter the
  • unprofessional behavior of a learner or
  • what steps will you avoid in responding to
  • him/her?
  • Report minor incidents that may be in violation
    of the Texas Medical Practice Act
  • Refer students and faculty for help
  • Discuss challenges opportunities with academic
  • Help develop consistent processes across the
    clinical campus