Medical Professionalism, Critical for Good Practice and Clinician Wellbeing
D. Slattery 1,2,3
1. Faculty of Medicine, Royal College of Surgeons in Ireland, Dublin
2. Bon Secours Health System
3. Children’s Health Ireland at Temple St. Dublin
Professionalism is a key component of good patient care. Research has shown that professionalism improves patient safety, patient experience, staff morale, recruitment and retention, healthcare institution reputation and health system productivity. In parallel it reduces clinical incidents, claims and costs. It must be inculcated in our medical students and doctors to ensure patient centred care is provided.
The spotlight has been shone on professionalism, both individual and organisational with recent high profile cases including that of Hadiza Barwa Garba, a paediatric registrar, who made mistakes but was convicted of gross negligence manslaughter for her involvement in the tragic death of a six year old boy, despite significant system failures at the hospital. This demonstrated a blame and shame culture rather than a “just and learning culture”. She subsequently won her appeal to be allowed to practice again 1. The case of the National Cervical Screening Programme where patients being treated for cancer were not informed that their previous smears were misinterpreted, highlighted the failure of open disclosure to be implemented 2. Meanwhile Tokyo Medical University, one of Japan’s most prestigious medical schools, recently admitted deliberately altering entrance exam scores of female students for more than a decade, to restrict the number of female students and ensure more men became doctors 3.
The recent publication by the Royal College of Physicians (London), Advancing Medical Professionalism is timely and welcomed 4. It identifies that “there is increasingly a gap between what doctors are trained to do and the realities of modern practice”. The report quotes the research documenting the benefits of professionalism to patient care, clinician wellbeing and productivity of health systems. It highlights the shifting context in medicine of increasing multi-morbidity in an aging population, a rise in burnout, more complex information technology, a changing doctor-patient relationship and new non-clinical roles.
The report is practical and outlines the values, behaviours and relationships that characterise a doctor today. It identifies seven key aspects of professional practice: doctor as healer, patient partner, team worker, manager and leader, teacher and learner, advocate and innovator. It provides specific guidance and exercises for individual doctors to improve their competence in each of these seven roles, in addition to advice to organisations and educators.
It explains that the doctor as healer is important even in a time of technological and scientific advancements because the majority of suffering needs to be healed, because often there is “no cure”. The latter is particularly true regarding end of life care where a difficult conversation can heal what a procedure or pill cannot. We are reminded that being a healer involves active listening, emotional intelligence and self-care.
Shared decision making, the report identifies, ensures the balance of power is shifting and equilibrium is being achieved in the doctor patient relationship. The doctor is a patient partner. Integrity, respect and compassion help this balance while doctors remain cognisant of patient autonomy and vulnerability.
The authors emphasise that twenty first century doctors must have the skill to work collaboratively in multiple complex teams. Team culture, team communication and team reflexivity (the ability to reflect on events and learn from them) are critical to improve the effectiveness of team work.
Good clinical leadership can improve patient outcomes. The report outlines that a doctor must function as both a leader and follower and that collaborative clinical leadership is important.
Less well taught and perhaps less liked is the concept that doctors must become skilled in managing resources and see the critical importance of this when working in complex healthcare systems.
Another role identified is doctor as learner and teacher. As life-long learners doctors must maintain high standards regarding their knowledge, skills and attitudes in an ever-changing world of new diagnostics, treatments, techniques and relationships with patients, colleagues and society.
The report reminds us that doctors must be advocates for patients and particularly for patient safety. It highlights the importance of implementing open disclosure, peer support after an adverse event and a just culture (where healthcare professionals are not punished for human mistakes but are held accountable for unprofessional conduct). This environment of trust is critical for patient safety. We are remined that doctors should advocate for other more global issues such as alleviation of poverty, inequality and climate change: the latter being the most significant threat to global health.
Doctors, the authors tell us must be innovators as their role changes in an era of automated systems. Collaboration between doctors and machines is key because the latter may soon be more efficient and accurate at diagnosing certain diseases than the former.
The report calls on the Academy of Medical Royal Colleges, (of which the Royal College of Surgeons in Ireland and the Royal College of Physicians of Ireland are members), to implement a plan for advancing professionalism, which the report identifies as key to a better health system and more satisfied doctors.
Much work is currently underway in Ireland in this area. As an example, we are implementing a unique programme in professionalism. This involves clinical and non-clinical staff because to improve a culture of professionalism across an organisation one needs to involve everyone.
The Professionalism in Healthcare Programme is being implemented across the continuum of undergraduate and post graduate education and continuous professional development. A new explicit, integrated and case-based curriculum in professionalism is being implemented this year in undergraduate medicine. At post graduate level there are multiple components to the programme including an annual conference in professionalism with international and national expert speakers; a work place behaviour questionnaire to all healthcare workers identifying opportunities for improvement and a baseline against which the impact of interventions can be measured; practical professionalism teaching sessions using case scenarios in each of six healthcare settings, an inter-professional post graduate professionalism course, analysis of a decade of clinical claims for lessons learned and research in undergraduate and post graduate aspects of professionalism.
In an increasingly complex clinical workplace environment, with rising clinician burnout and unacceptably high levels of preventable medical errors, improving medical professionalism may offer some solutions.
Prof. Dubhfeasa Slattery
Chair of Medical Professionalism
Department of Medical Professionalism, RCSI 123 St Stephen’s Green Dublin D02 YN77
Bon Secours Health System, Dublin
Temple St., Children’s University Hospital, Dublin
1. Dyer C. Hadiza Bawa-Garba wins right to practise again. BMJ 2018; 362: k3510.
2. Dyer C Ireland’s cervical cancer screening system was “doomed to fail” inquiry finds. BMJ
3. Toyko medical school “changed test scores to keep women out”. The Guardian, August 2018.
4. Advancing medical professionalism, Royal College of Physicians London, December 2018