MEDICAL PROFESSION (MED131) Lecture Notes PDF

MEDICAL PROFESSION MED131 Abstract An overview of what it means to be a professional, who is considered a medical professional,...

MEDICAL PROFESSION MED131 Abstract An overview of what it means to be a professional, who is considered a medical professional, how to think critically, the foundations of medical ethics, and how to conduct oneself to the best interest of the patient and medical profession. Dr Ahmed Elsheshai, MD MRCPsych [email protected] Contents Introduction & overview of professionalism 2 Critical thinking 7 Attributes of a physician 9 Doctor-patient relationship 10 Maintaining a professional boundary 11 Overview of medical ethics 12 1 Introduction & Overview of Professionalism Part 1: What is professionalism The competences expected of a professional Competence = skill + knowledge + experience Thinking about your studies in medical school, reflect on how you are working to gain knowledge, skill, and experience to become a medical professional According to the American board of internal medicine, the competencies expected of a physician are: “Aspiring toward altruism, accountability, excellence, duty, service, honor, integrity, and respect for others.” Altruism (:)‫ اإليثار‬The only productive outcome of our work as physicians is improving patients’ quality of life. Therefore, this should be our prime target, and we should aim to achieve everything else only through the patient's benefit and never despite it. Accountability (‫)المساءلة‬: Whether before he makes them, while he makes them, or after he makes them, a physician should always be ready and willing to be held accountable for his decisions. A physician’s will and acceptance of accountability at all stages of decision making signifies that all his decisions have only the best interest of the patient at heart and the best available evidence on his mind. Excellence (‫)التميز‬: When have you ever heard of a patient settling for a mediocre doctor? In our time of weakness, we always seek the most excellent medical service we can have. It is essential that doctors provide a minimum level of excellence that assures that no matter where a patient might end up, they will have a satisfactory service provided to them. Duty (‫)الواجب‬: The medical profession is not one that is bound by the rules of working hours or fees for service. Instead, medical professionals should be motivated in the first place by their sense of duty and responsibility towards their patients. Service (‫)الخدمة‬: Medical professionals work in the service of their patients. All actions that a physician makes in his career should be geared towards this prime and only target. 2 Honour (‫)الشرف‬: A physician’s actions should always be honorable. Meaning that he/she should always be doing what he/she knows and believes to be the morally correct action. Integrity (‫)النزاهة‬: While “honour” means knowing and intending to do well, “integrity” means actually doing the honourable action, being honest about it, and having a clear, constant, and honourable direction for their actions. Respect for others (‫)احترام اآلخرين‬: The medical profession is a very busy one. While in other professions one may deal with only his client and maybe a few colleagues, physicians deal with so many stakeholders every single day. Patients, relatives, caregivers, colleagues, managers, seniors, and junior doctors just to name a few. In dealing with all these people, doctors should have respect for the diversity of their views, backgrounds, and intentions. Of course, and above all, respect for patients reign supreme. Part 2: The social contract The relation of the medical field with society is an especially complicated one. Doctors usually view treating patients and dealing with the hardships of a disease in a very practical way as their everyday job. Patients suffering from this disease regard this matter with more emotionality and sensitivity. To achieve a balance between these two contradicting views, a social contract was outlined to describe what society should expect from doctors and vice versa. Society’s expectations from medicine The service of a healer: society expects doctors to understand that the primary target for all their actions is healing patients. Assured competence: Either because it is too difficult or impractical, patients cannot test their doctors’ knowledge and skill before accepting their services. Therefore, it is the duty of the 3 medical community to assure that those working in this profession have the necessary and essential set of skills and knowledge to carry their jobs properly. Altruistic service: As mentioned earlier, doctors should only seek success through their patients’ well-being. A patient giving himself in to his doctor should trust that the doctor only has his best interest at heart. Morality and integrity: patients need to trust that doctors are acting according to the best-known standards and that what doctors do to them is the same as what would be done to the doctors if they were in their shoes. Accountability: Again, as patients’ do not usually have medical education, it is their right to be able to hold physicians accountable for their actions. This is not a thing that physicians should shy from, instead a physician should always be ready to defend his/her decisions and actions. Transparency: Physicians should be clear about all forces influencing their decisions. Whether there is a conflict of interest or whether there is something a patient may object to, it is not a physician’s right to hide anything from their patient. Objective advice: while many patients value their doctors’ personal opinions, it is imperative that physicians provide impartial and objective advise based of the best known evidence. Moreover, when expressing their opinion, physicians should point this out clearly, explaining the difference between evidence and choice. Promotion of the public good: finally, physicians are expected to not only promote their individual patient’s health, but also the public good of all society and the prevention of all disease and suffering. Medical profession’s expectations from society Trust: While it is a patient’s right to know and understand everything he is going through, it is not always practical to explain every little detail about their illness and treatment. Therefore, doctors need society to trust them that they are doing what is best for their patients. Autonomy: in practicing medicine, doctors need to have autonomy and not to be forced to take any actions they believe is not in the best interest of their patients. Self-regulation: The medical profession is a complicated one, where many professionals work together and where the slightest margin of error can prove fatal. Therefore, regulating this delicate workplace should be left to those carrying this responsibility and who best understand it. A health care system that is value-driven and adequately funded: imagine a patient who has a problem in the arteries of his lower limbs (a condition called ischemia), he cannot walk properly and has started using a wheelchair. Which is a more proper target to describe this patient’s need: to be able to walk freely again (value), or to perform an operation on his arteries (service)? 4 Sometimes just performing a service such as surgery, writing a prescription, or doing physiotherapy is not enough on its own to achieve the value that the patient needs. In a service- oriented healthcare system, patients provide fees and doctors provide service. However, in a value-based healthcare system, patients and doctors decide on a specific target value they want to achieve, then the doctors work with their teams and with the patient to achieve that target regardless of how many services will or will not be included. Both doctors and patients stand to have great benefit from having a value-based and well-funded healthcare system. Participation in public policy: A doctor’s role is not only sitting in their clinic with their patients, but in order to promote public good, doctors need to be involved in public policy. This also reflects on their work directly as poor policy will lead to more sick people which in turn will lead to more healthcare burden. A very recent and live example was the “stay home” campaign that took place during the early days of COVID-19 pandemic. Not staying home meant higher infection rate, which meant more patients at hospitals, leading to exhaustion of resources and higher risk to medical teams. Shared responsibility for health: health and healing is not the sole responsibility of doctors. Patients, relatives, caregivers, religious leaders, political figures, business owners, and the whole society share in the common responsibility of preserving and promoting health. A monopoly: in order to maintain the integrity of the medical profession, doctors need to make sure that all those who enter their profession are certified and qualified to practice medicine, and that all those who are not are prevented from claiming false healing effects. Both non-financial and financial rewards: as any professionals, doctors seek proper compensation for their efforts. According to maslow’s “hierarchy of needs” theory, one cannot have the best interest of others at heart if one’s own interests are not fulfilled. Part 3: Reality vs appearance It is not enough for physicians to only have the competencies or to fulfil the duties decreed by the social contract detailed above, but it is also essential that physicians make sure this is communicated clearly to society. This involves several challenges, among which are: Information abundance: information is all around us and patients may easily think they do not really need doctors (the internet has videos that describe how to perform operations for yourself at home). unless they understand the complexity of the medical profession and have trust in their doctors, this phenomenon will only become worse. Info-demic: Many doctors are opposed to patients seeking verification for their symptoms and treatments from other sources (most commonly the internet). The real problem is not that patients seek knowledge elsewhere but rather that this “knowledge” is usually nonsense that is either put on the internet by mistake (misinformation) or intentionally to promote a product or a certain view (disinformation). The way to fight this is by leaving patients with no need to look 5 further or at least encouraging and directing them on where to look and where to get their information. Public sentiment: The abundance of social media in people’s lives today means that the negative sentiment experienced by one person towards the medical field can be like a spark that can set the whole society on fire. It is important that doctors and medical professionals make sure this spark does not find a flammable environment to grow in by ensuring that, to the best of their abilities, the expectations of society detailed above are thoroughly met. A society that trusts their doctors as having integrity, transparency, altruism, accountability, and assured competence, is more likely to consider one of its members bad experience with a medical professional as an individual incident. Alternately, a society that believes that doctors are hiding information, acting in their own best interest, and having “flexibility” in their moral code, will probably interact with any individual complaint as a phenomenon. Advocacy: doctors need to advocate their own profession. Advocacy does not mean covering up mistakes or lying about shortcomings. Instead, advocacy means doing our best to defend our profession against slander and clarify its burdens and duties. 6 Critical thinking Definition The objective analysis and evaluation of an issue in order to form a judgement. History First used as a formal educational method by Socrates. His tool was “Socratic questions” which were a series of thoughtful questions posed against an argument to elaborate, examine, and determine the validity of said argument. In the 1930s, American philosopher John dewey formalized the term critical thinking in academia and for educational purposes by proposing the definition that critical thinking is “Active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it, and the further conclusions to which it tends.” Dewey’s concept of critical thinking Dewey described the process of critical thinking as consisting of 5 stages: Brainstorming Formulation Using one suggestion Reasoning Implementing the after another to solution Looking into a initiate and guide Deciding on which problem from all further observation hypothesis is best sides and gaining and collection of data suited for solving the various perspectives problem Suggestion Hypothesis Testing He then went on to describe several components that are related loosely to these stages 1. Noticing a difficulty 2. Defining the problem 3. Dividing the problem into sub-problems 4. Formulating a variety of possible solutions 5. Gathering information 6. Judging the credibility of information 7. Drawing conclusions from information 8. Determining what evidence is relevant 9. Systematic observation or experiment 7 Accepting a solution that the evidence adequately supportsBeing a critical thinker requires various skills, among the most commonly cited such skills are Attentiveness Open-mindedness Habit of inquiry Willingness to suspend judgenent Self-confidence Trust in reason Courage Seeking the truth Rational fallacies and bias A systematic error of thinking. An error that is a result of a wrong understanding of the situation based on one’s attitudes and thoughts and not for example on lack of knowledge, negligence, or mal-intention. Actor observer bias: if I see someone bumped their car I immediately think “what did that person do wrong and why couldn’t he avoid this accident?”. If I bump my car I immediately think “what did the other person do wrong and why couldn’t HE avoid my car?” Self-serving bias: our failures are situational, but our successes are our responsibility Anchoring Apophenia Availability heuristic: I makes decisions based on the information available to me at the time. E.g. I want to book a flight → (brain remembers plane crashes) → I cancel trip False consensus: assuming everyone must share my same views Halo effect: one specific trait of a person is used to make an overall judgement of that person. 8 Attributes of a Physician Definitions Personality traits: genetically and developmentally determined features of the personality that are constant, stable, and very difficult to change. While they are very important in defining a person’s career, yet there may be a place for every type of personality in medicine. This is largely due to the very diverse nature of the medical profession. Famous theories describing personality traits are: Big five personality traits theory (OCEAN): o Openness to experience o Conscientiousness o Extraversion o Agreeableness o Neuroticism Myers Brigs Type Indicators o Extrovert-Introvert Try yourself at o Sensing-Intuition www.16personalities.com o Thinking-Feeling o Judging-Perceiving Attributes: Personal features that are amenable to learning and acquisition. Some of them are essential for the definition of a physician (competencies), while others can be considered bonus features. The presence of these bonus attributes makes for a better doctor, but their absence do not Attributes of a physician Optimism Compassion Communication Confidence Organization Humility Meticulous Passion Curiosity Mentorship Collaboration Courage Persistence Humanity 9 The Doctor-Patient Relationship (DPR) What is the nature of the relation between a doctor and his patient? A consensual relationship in which the patient knowingly seeks the physician’s assistance and in which the physician knowingly accepts the person as a patient. Key concept Health values Patient values Models of DPR Paternalistic Deliberative Informative Interpretive (Authoritarian) (Authoritative) Patient values Only concern is Open to Defined fixed and Require health, shared by development and known to the clarification and physician & revision patient. agreement patient Physician’s Patient well-being Persuading the Provide factual Clarify patient’s obligation independent of patient of the information… personal values… their preference best path… and implement and implement and implement patient’s choice. their choice. their choice. Autonomy Assenting to Developed Control over Developed objective health through medical care through values understanding of understanding of health values own values Physician role Guardian Friend/Teacher Technical expert Counselor or advisor Examples Doctors treating Most common Chronic disease, Nutritionists, incapacitated clinic model Elective Addiction patients procedures specialists (aesthetic procedures) 10 Maintaining a professional boundary Treating relatives and friends Keep it professional o Time and space boundaries o Financial boundaries o Patient autonomy Avoid high-risk situations Encourage second opinion Involve a colleague You will ALWAYS run into that relative again The worst kind of bad reference is that of someone close to you personally Developing friendship with friends Tests professional boundaries o Time o Space o Autonomy o Finances Heightened expectations Romantic relations with current patients NEVER enter a romantic relation with a current patient. If the patient pursues a romantic relation with you: o Politely and considerately re-establish the professional boundary o If not possible then terminate relation with the patient according to guidance You must not use professional relationship to pursue romantic relations with someone close to the patient You must not end the professional relation with a patient solely to pursue a romantic relationship with them Romantic relations with former patients Time since the professional relationship ended The nature of the previous professional relationship Level of vulnerability Whether you will be caring for other members of the patient’s family. 11 Overview & Development of Medical Ethics Part 1: definitions Moral philosophy: is a “branch of philosophy that involves systematizing, defending, and recommending concepts of right and wrong behavior”. It is debatable and there are always many sides to the argument of what is “right”. Bioethics: Bioethical questions often involve overlapping concerns from different fields of study including life sciences, biotechnology, public health, medicine, public policy, law, philosophy and religion. Bioethicists debate all factors concerned with different medical situations and decide on the Clinical Ethics: the set of rules that are outlined to help manage the delicate complexities of clinical situations. Moral philosophy Bioethics Clinical ethics An ongoing debate: Taking philosophy, medicine, public Rules to follow: view, and law into consideration: What is the meaning of it is not allowed to Life support should not be “death” and whether death discontinue life support to a disconnected to any patient of the brain is considered the brain-dead person. unless the heart stops to same as death of an function irrespective of his individual? brain activity. When is a fetus considered to A fetus is considered to have Abortion is prohibited after have a life of its own? After a life of its own after implantation (sparing fertilization? after implantation. However, a contraception). If there is implantation? after having a chance is given to examine severe deformity, abortion heartbeat? after making the the fetus for deformities and may be performed before 24 first voluntary action? severe congenital disease weeks. Afterwards it is before it reaches 24 weeks of prohibited unless pregnancy gestation. poses a risk to the mother. Is a person free to choose People have the right to Organ donation is allowed what to do with his organs? donate organs, but they do after making sure it will not not have the right to harm harm the donor’s health of themselves or end their or risk his/her life. anyone else’s lives. Is someone free to end their it is not the right of any It is completely prohibited to own life? Are doctors person to actively take any assist a person or a patient to allowed to help life even their own end their life regardless of people/patients end their any suffering or prognosis of lives? their condition. This, however, does not include refusing to seek treatment. 12 Part 2: History of medical ethics The first mention of ethical rules in medicine comes from the medical papyri of ancient Egypt such as the Edwin smith papyrus which mentions that resources should be saved to cases that can respond to treatment. Only in cases where resources are plenty that a doctor may perform palliative treatment to terminal cases. The first law concerning medical ethics was the Hippocratic oath which included many parts such as confidentiality, beneficence, non-maleficence, confidentiality, honoring teachers, and honorably representing the profession of medicine. The first detailing of the pillars of medical ethics that are universally central to almost all bio- ethical doctrines today was laid out by English physician Thomas Percival in his book “Medical Ethics” in 1794 AD Part 3: The four pillars of medical ethics Beneficence: everything a physician does should be aimed at the benefit of the patient Non-maleficence: the physician should not do anything that would harm his patient, unless the benefit of doing the procedure clearly outweighs the harm. Autonomy: a patient has the right to think freely of all the choices he has, to be free to favor any of the options without pressure, coercion, or deceit act in the way he choses to manage his case without being forced to any choice against their will Justice: The idea that the burdens and benefits of treatments must be distributed equally among all groups in society. Keeping in mind that exceptions can be made in order to: Have fair distribution of scarce resources e.g., ICU beds in COVID-19 pandemic Competing needs of certain populations e.g., pregnant women and the elderly Rights and obligations e.g., healthcare staff in the COVID-19 pandemic Potential conflicts with established legislation e.g., organ harvesting from brain-dead patients 13