In every state there is a public regulatory entity, the function of which is to ensure the quality of medical care. Medical boards respond to complaints against physicians and are empowered by law to ensure physician behavior meets professional standards. This is an awesome responsibility for members of boards, who are usually a mix of physicians and public members and, in some cases, have no training in medical ethics or relevant laws. Matt Weinberg, M.B., has written about a pressing need to develop a better understanding of the concepts of professionalism, its philosophical roots and the development of codes of ethics by which standards are defined. It is important to develop an understanding of available tools used by boards to make decisions, and to develop methods for disseminating such seminal and necessary concepts as professionalism to medical students and resident training programs.
The defining aspects of professionalism go far beyond dictionary descriptions that often characterize it as a high level of training and proficiency. Webster’s Dictionary further asserts professionalism entails “... conforming to the technical or ethical standards of a profession or an occupation.” Another frequently cited definition is this one by the late Dean Roscoe Pound of Harvard Law School: “The term refers to a group ... pursuing a learned art as a common calling in the spirit of public service.” Noted author Herbert M. Swick, M.D., opined professionalism consists of certain behavior demostrating the worthiness of trust that is engendered by patients and the public.
Philosophy was a key element in the ancient world, and inquiry often led to the formulation of principles that would withstand the test of time. In medicine, the Hippocratic Oath was developed, proposing a set of principles governing the relationship between the physician, society and the patient. Although there are detractors to the content of the oath, with some claiming that it is outdated and morally wrong, closer examination reveals the core principles and standards of behavior the Oath requires of physicians are still relevant today. The specific prescriptions of the oath can be grouped under three principles: beneficence, justice and respect for persons. There is an interdependence of the principles of beneficence and non-malfeasance, which are the positive and negative formulations of the same principle. The Oath calls for fairness to all without discrimination. There are specific references to non-exploitation of the vulnerable, especially regarding sexual abuse. The Oath recognizes the right of privacy, the duty to maintain confidentiality and respect for the dignity of the patient. Honesty and truth telling essential to development of trust demonstrates the respect for patients’ right to know about their conditions. Respecting the autonomy of patients, who often lose their independence during the course of illness, is considered good professional behavior.
The Oath was modified over time and reinterpreted and exploited for many reasons, but can still exist as a framework of our understanding of the elements of medical professionalism as we perceive them today. The basic purpose of establishing standards of professional integrity can help to define the values boards use in their decision processes. Unprofessional conduct has two components, the legal and the ethical. The ethical component is more difficult to codify. Statutes tend, therefore, to stress rights more than responsibilities. Understanding such standards and values is not only helpful for board education, but will help promulgate the expectations required of licensees. Boards should serve as an outreach resource for medical students and residents training in their communities. A simple alphabetical listing of standards related to professionalism could provide board members with a simplified schema to help them systemize their approach their tasks, as well as serve as an uncomplicated model to instruct medical students and residents. Based on traditional concepts, four areas have been designated as encompassing professionalism: A would include altruism and accountability; B would examine the tools created by bioethicists to assist with decision making; C explores the contract between physician and patient, with emphasis on establishing and severing a relationship, the nature of informed consent and contact with society; D delineates the duties of the physician to the patient, as well as the failure by dereliction of duty and its consequences.
ALTRUISM AND ACCOUNTABILITY
Altruism has long been thought of as a basic motivator for medical practice. The fact it may be a means of livelihood does not abrogate the responsibilities of the physician to the patient or society. Altruism requires physicians to be devoted at all times to the best interests of patients. One form of conflict arises in the health maintenance organization (HMO) setting when a physician is subservient to the wishes of the HMO and prioritizes the patient’s interests secondary to those of the HMO. Autonomy has become one of the basic principles to be respected in the physician-patient relationship. A major criticism of the Hippocratic Oath is the failure to assign the importance of the patient as an independent moral agent. By respecting patient autonomy, physicians must be honest in their dealings with patients and empower patients to make informed decisions with regard to treatment. The patient is at a significant disadvantage compared to the physician, who possesses more knowledge and experience. The physician is required to provide sufficient information to allow a patient to make an informed judgment.
An excellent way to demonstrate actions and accepted accountability by physicians are written records. Illegible records can create bad inferences that can lead to board actions and catastrophe in a courtroom. It is not acceptable to alter a prior record unless it is necessary to protect the patient or to correct an obvious error, nor should physicians make changes in records after they have reason to believe the records may become evidence in a lawsuit. Acceptable alternate procedures include dating deletions or additions to a patient record, or creating a new note explaining any changes. Board investigation committees in studying records with sub-optimal record documentation will have to determine how substantive any deviation is from the standard of practice, and how this effects the clinical decision process and the outcome. Any combination of these factors may be considered unprofessional conduct.
BIOETHICS
In “Bioethics: The Birth of Bioethics” by Albert R. Jonsen, published in the March 3, 1999, issue of JAMA, Jonsen describes bioethics as a “minor form of moral philosophy practiced within medicine.” Ethical issues have been integral to medical practice since the time of Hippocrates, and rapid technological advances can cause moral dilemmas to increase in number. The shift in emphases with the ascendancy of the patient as a moral agent has led to a modern medical bioethics. Such horrific examples as the Nuremberg Trials in 1945, which revealed Nazi human experimentation, and the Tuskegee Syphilis Experiment show that scientific research had to have safeguards to protect the rights and welfare of human subjects. The U.S. Congress established the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research to recommend policies to guide researchers in the design of ethical research. This was published in 1979 as the Belmont Report.
CONTRACTS BETWEEN PHYSICIAN AND PATIENTS
There is an ethical contract between the physician and patient. With the patient’s consent, the physician can delve into personal areas of the patient’s lives, and may explore the patient’s body, externally or internally. There is also a contract between physicians and society. The physician should be an advocate for the fair distribution of health care resources and respect the need for cost effectiveness. Paul Root Wolpe, Ph.D., has written about informed consent as the “modern clinical ritual of trust.” This trust involves the physician trusting the patient with such professional information as risks, procedures, diagnoses, and the patient returning the trust by allowing the physician to perform procedures despite knowledge of the risks. Another aspect of trust is the physician is expected to be honest with the patient and act in accordance with acceptable standards of information disclosure. Respecting the patient’s autonomy, one would expect that the information would be what a reasonable person would want, although this may be too simplistic in many cases.
One of the most important areas of truth telling is related to divulging medical errors. Errors are reported to boards either directly from patient’s complaints, hospital committees or from malpractice insurance carriers. It is often the public’s assumption that all medical errors are the result of negligence and involve harm to the patient. It is the task of the board to determine the applicable standard of care and if the error resulted from a physician performance defect (for example, during diagnosis or during administration of medication) or a system failure. In the case of a medical misadventure there is a requirement that patients have the right know about their conditions. The best reason for disclosure may well be the effect it has on the physician-patient relationship. Often there is a positive effect, by defusing anger toward the physician. When a physician is not forthcoming because of the fear of lawsuits or pressure to remain silent from other caregivers or an organization, and corrective action is not taken to avoid an adverse outcome, this failure would be considered unprofessional behavior.
DUTY
Duty is defined as behavior expected from a professional by force of moral obligation. Ethical codes include the fact that physicians have a duty to serve patients needs to the best of their abilities. Once a physician-patient relationship is formed by mutual agreement there is the obligation to provide care. Dereliction of duty is a breach of trust. In extreme cases, there can be negligent misconduct through incompetence, willful misconduct or failure to conform to minimal standards of care. Medical boards are obligated to review the outcomes of such actions and determine if there was any unprofessional conduct on the part of the physician. Another duty required by a physician involves conduct within the health care team. There should be a harmonious relationship that will enhance patient welfare. Physicians are expected to participate in peer review and have the responsibility to recognize and expose incompetence or unethical behavior in peers and other health care professionals. This also applies to the responsibility of physicians to protect patients from impaired physicians. Boards are not necessarily punitive in their interest, but are interested in rehabilitating physicians who have problems by encouraging or requiring them to seek help. Physicians should be willing to render expert advice to board investigating committees, keeping in mind they enjoy the same privileged protection as when they serve on a peer review committee. They have a responsibility, if necessary, to provide expert medical testimony.
I hope by utilizing a more proactive approach, aided by uncomplicated, effective tools, medical boards can reach out to the community and become more involved with medical student and resident training programs in the noble pursuit of teaching medical professionalism.
