Delivering Healthcare in America 6th Edition Chapter 2

Chapter Authors: Michael A. Barone, MD, and Joseph Gilhooly, MD

The specific objectives for this chapter are to:

Describe the professional responsibilities of physicians when they provide for their patients.
Provide examples of these professional behaviors as well as lapses in professional conduct in a way that complements The Pediatrics Milestone Project ¹; and
Provide some exercises that can be used in discussions with trainees about the many aspects of professionalism that are involved in everyday clinical care.

Patient care is a core physician competency. Providing patient care with an understanding of professional responsibility and demeanor is at the heart of what society values in a "good doctor." Every medical student, resident, colleague, and patient can provide examples of physicians they admire because of the care they provide and their manner as they provide that care. Individual components of professionalism in clinical care, however, often are not identified. "Bedside manner" — the way a physician identifies with, converses with, and empathizes with the patient's family — is important. But an empathetic, caring relationship is not enough. A physician who is loved by patients but who provides care based on unproven, anecdotal information is not providing professional clinical care. Similarly, the physician whose management decisions are based on the most recent, evidence-based information is not providing professional care if that care is not documented in a timely manner in the electronic health record or if confidentiality of protected health information is not respected.

The following components from the American Board of Internal Medicine Foundation Physician Charter ² relate to professionalism in patient care:

Commitment to professional competence — Achieving and maintaining competence involves a commitment to lifelong learning and maintaining clinical and team skills. Professionalism is one of the domains of competence defined by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS), but it is important to recognize that deficits in any of the other domains (patient care, medical knowledge, practice-based learning, interpersonal and communication skills, and systems-based practice) also reflect a lack of professional commitment.
Commitment to honesty with patients — Honesty with patients and their families requires not only truthfully informing them about their condition (or their child's condition) and the treatment you recommend, but also informing them about potential adverse reactions to treatments and medical errors, whether those errors could result in actual harm.
Commitment to patient confidentiality —Trust and confidence of patients and families depend upon their knowledge that the physician will safeguard patient information. In some situations — adolescent sexual health care for example — confidentiality can be maintained even if the patient is a minor. The physician must be aware of the laws regarding physician–patient confidentiality in their practice area. The electronic health record presents unique challenges to the maintenance of confidentiality, and protocols must be followed to keep access secure. Although confidentiality must sometimes yield to overriding considerations of public welfare (e.g., when harm may come to the patient or others), the patient and/or family should be informed of the intention to divulge clinical findings to appropriate authorities.
Commitment to maintaining appropriate relations with patients — Patients and families are dependent upon the knowledge and decision-making of the physician. Their vulnerability and dependence should not be exploited. Appropriate emotional, physical, and financial boundaries should be maintained between physicians and their patients and their families.
Commitment to improving quality of care — Continuous improvement of care involves not only ongoing, informed review of the medical literature and maintenance of clinical competence, but also working with colleagues, health care systems, and other professionals to improve patient safety. This occurs through providing high-value care, reducing medical errors, improving accessibility and efficiency of care, minimize overutilization and underutilization of medical resources, and improving health outcomes.

The pediatric competencies that are most relevant to this area of professionalism are:

Patient Care
- Organize and prioritize responsibilities to provide patient care that is safe, effective, and efficient.
- Interview patients and families about the particulars of the medical condition for which they seek care, with specific attention to behavioral, psychosocial, environmental, and family-unit correlates of disease.
- Counsel patients and families.
Practice-Based Learning and Improvement
- Identify strengths, deficiencies, and limits in one's own knowledge and expertise.
- Identify and perform appropriate learning activities to guide personal and professional development.
- Participate in the education of patients, families, students, residents, and other health professionals.
Interpersonal and Communication Skills
- Demonstrate the insight and understanding of emotion and human response to emotion that allows one to appropriately develop and manage human interactions.
Professionalism
- Professionalization
- Professional Conduct
- Humanism
- Cultural Competence
Systems-Based Practice and Improvement
- Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate.
- Advocate for quality patient care and patient care systems.
Personal and Professional Development
- Develop the ability to use self-awareness of knowledge, skills, and emotional limitations to engage in appropriate help-seeking behaviors.
- Manage conflict between personal and professional responsibilities.
- Demonstrate trustworthiness that makes colleagues feel secure when one is responsible for the care of patients.
- Demonstrate self-confidence that puts patients, families, and members of the health care team at ease.

Behavioral Statements

The dimensions of professionalism related to patient care that are listed above provide general goals. In discussions with trainees, it may be helpful to identify specific behaviors or practices that exemplify professionalism in this domain and other behaviors or practices that would represent lapses of professionalism.

Examples of Exemplary Professional Conduct

Demonstrates accountability, responsibility, and respect for patients and families, including appropriate verbal and nonverbal communication
Optimizes comfort and privacy of patients when performing a history and physical exam or a procedure
Maintains comprehensive, timely, medical records and correspondence and protects patient confidentiality
Communicates collaboratively with colleagues, health care providers, patients, and families to provide safe and effective care
Provides culturally competent care for all patients
Recognizes limitations of training and experience and seeks help appropriately
Accesses available information to support clinical decision-making
Responds to constructive feedback and demonstrates commitment to ongoing professional development
Acknowledges errors in medical care; discloses them to colleagues, affected (or potentially affected) patients, and responsible authorities; and takes steps to prevent future errors
Demonstrates appropriate boundaries for patient relationships

Examples of Lapses in Professional Conduct

Provides unsupervised care of an infant, child, or adolescent without previous experience or training in the appropriate skills
Excludes parents or other caretakers from involvement in management of their child's illness when there is no valid reason for doing so
Provides treatment that is inconsistent with best practice or evidence without justification
Documents information that does not accurately describe the patient's condition or the care provided
Willfully misrepresents clinical data in communication with other health care providers
Fails to consult a supervisor or a clinician who is more experienced in caring for the problems being confronted
Provides preferential treatment to certain patients or families to the detriment of others, based upon considerations other than clinical need and available treatment
Fails to recognize and apologize for discourtesy or errors in treatment or judgment
Fails or inappropriately delays to respond to a request by a family or other professionals (nurse, social worker, physician colleague) to provide care for a patient for whom he/she is responsible
Participates in physical or verbal abuse toward colleagues, staff, patients, or family members

Teaching Professionalism

Learning Objectives for Trainees

Identify instances when personal circumstances can be at odds with professional values.
Describe professional responsibilities in regards to patients, families, and colleagues.
Describe how one's behavior can serve as a model for colleagues.
Demonstrate that professionalism involves a wide array of responsibilities to the individual, their colleagues, patients, institution and society.
Demonstrate understanding that a commitment to professional behaviors, and development as professionals, occurs throughout the entirety of one's career.

Reflective Exercises

These reflective exercises can be used for individual reflection on professionalism issues or can be modified and discussed as part of a larger group meeting.

After holding a discussion about the professional responsibilities of physicians, ask your trainees to write, in one page or less, an incident in which they were challenged with a decision that involved professionalism in the care of patients.
Ask your trainees to describe an incident in which they observed exemplary professional conduct on the part of one of their colleagues.
Using any of the vignettes below, ask your trainees to describe a similar real-life situation. Ask them to identify the conflicting values and what they learned from the situation.

Note: Considering the different competencies and milestones for professionalism, discuss the vignettes from the point of view of different training levels across the continuum (students, junior resident, senior resident, attending physician). What would be the expected behaviors of different levels of professional in these vignettes?

Chapter 2 Vignettes — Professionalism in Patient Care

The vignettes that follow were developed for use in a small group setting to help stimulate discussions about issues regarding professionalism. Medical educators are encouraged to expand upon these to reflect local issues and experiences.

Vignette 1 — Trustworthiness

You are on rounds with your attending and one of the medical students is presenting. The student has been working very hard and doing a good job. The attending asks the student about the results of a laboratory test that the student was supposed to have checked. You know that the student did not yet have an opportunity to get the test results, but the student responds by saying that the test was normal.