1. Richard Cruess OC, MD, FRCSC
PROFESSIONALISM
Richard Cruess OC, MD, FRCSC
Sylvia Cruess MD, CPSQ
McGill University
How to reference this document:
Cruess R., Cruess S., Professionalism. CanMEDS Train-the-Trainer Program on Professionalism. 2009

2. Definition Before Diagnosis
PROFESSIONALISM
What Is It?
Definition Before Diagnosis

3. TAKE AWAY MESSAGES
Professionalism has a cognitive base which includes definable attributes
Professionalism is the basis of medicine’s social contract with society
Both medicine and society have legitimate expectations- “each of the other”
Medicine’s obligations arise from societal expectations
There are consequences if these expectations are not met
Linking professionalism to the social contract is beneficial to the teaching of professionalism

4. VIGNETTE Think about what aspects of professionalism
Your daughter is scheduled to graduate from high school this afternoon. As you are preparing to sign out to a colleague, one of your long time patients present in the ER with chest pain. You enter the ER and a partner in your group practice is already there to evaluate the situation. As you know that he is competent and conscientious, you go to reassure your patient. He pleads with you to stay.
Think about what aspects of professionalism
are demonstrated by this situation

5. Professional Status is Not an Inherent Right IT IS GRANTED BY SOCIETY

6. It Must Be Constantly Earned by Meeting the Obligations Expected of a Professional

7. IF MEDICINE FAILS TO MEET ITS OBLIGATIONS SOCIETY WILL CHANGE ITS STATUS

8. PROFESSIONAL STATUS IS IMPORTANT TO MEDICINE
IT CONFERS
Prestige and Respect
Trust
Autonomy in Practice
Physician-Led Regulation
Financial Rewards

9. PROFESSIONALISM ALSO BENEFITS SOCIETY
“ Neither economic incentives, nor technology, nor administrative control has proved an effective surrogate for the commitment to integrity evoked in the ideal of professionalism ”
Sullivan, 1995

10. PROFESSIONALISM IS THREATENED
A questioning society
A complex health care system
The commodification of health
Failure of the professions to meet their obligations

11. WHAT IS A PROFESSIONAL?

12. DEFINITIONS-PROFESS(ION)
PROFESSIONAL
PROFESSIONALISM

13. PHYSICIANS HAVE TWO ROLES
Healer
Professional
Served simultaneously
Analyzed separately
Professionalism as the word is used generally includes both roles

14. HEALING AND PROFESSIONALISM
THE HEALER
THE PROFESSIONAL
Antiquity
technology
“curing”
Middle ages
“Learned professions”
clergy, law, medicine
1850:Legislation monopoly
1900:University linkage
Asclepius
Hippocrates
Code of
Ethics
Science
THE PRESENT

15. ATTRIBUTES Professional Healer Autonomy MD-led regulation
associations
institutions
Responsibility
to society
Team work
Competence
Commitment
Confidentiality
Altruism
Trustworthy
Integrity/Honesty
code of ethics
Morality/Ethical Behavior
Responsibility to profession
Caring/ compassion
listening
Insight
Openness
Respect for the
healing function
Respect patient
dignity/
autonomy
Presence/Accompany
Professional
Healer
Based on the Literature 15

16. DEFINITION AND DESCRIPTION PROFESSIONAL
Definition: As professionals, physicians are committed to the health and well-being of individuals and society through ethical practice, professional-led regulation, and high personal standards of behavior
-RCPSC, 2005 16

17. DEFINITION AND DESCRIPTION PROFESSIONAL
Physicians have a unique societal role as professionals who are dedicated to the health and caring of others. Their work requires the mastery of a complex body of knowledge and skills, as well as the art of medicine. As such, the professional role is guided by codes of ethics and a commitment to clinical competence, the embracing of appropriate attitudes and behaviors, integrity, altruism, personal well-being, and the promotion of the public good within their domain.
These commitments form the basis of a social contract between a physician and society. Society in return grants physicians the privilege of profession-led regulation with the understanding that they are accountable to those served, to the profession, and to society.
-after RCPSC, 2005 17

18. OTHER DEFINITIONS Cruess, Johnston, & Cruess Swick
Royal College/CMA/ABIM/ ACGME
The International Charter
Self-generated: must be based on the literature
ALL ARE ACCEPTABLE

19. CORE OF PROFESSIONALISM
Specialized knowledge
Science
Art
Service to others
Morality

20. The Primary Role is that of the Healer

21. “The Professional Model”
Society uses the concept of the profession as a means of organizing the delivery of complex services which it requires, including that of the healer.
“The Professional Model”

22. > OTHER MODELS ARE AVAILABLE Bureaucratic Free Market none pure
Neither Share the Values of the Healer
>
none pure

23. The Social Contract in health care hinges on professionalism.
It serves as the basis for the expectations of medicine and society.

24. -Gough, “The Social Contract”, 1957
“The rights and duties of the state and its citizens are reciprocal and the recognition of this reciprocity constitutes a relationship which by analogy can be called a social contract”
-Gough, “The Social Contract”, 1957

25. THE SOCIAL CONTRACT
PROPOSES RIGHTS, PRIVILEGES, AND OBLIGATIONS ON BOTH SIDES
“BARGAIN” (Klein)
Professions are given prestige, autonomy, the privilege of physician-led regulation, and rewards on the understanding that they will be altruistic, regulate well , be trustworthy, and address the concerns of society

26. THE SOCIAL CONTRACT A Mix of: • The explicit and the implicit
• The written and the unwritten
licensing laws
certification standards
health care legislation codes of ethics
• Legal and moral obligations
• The universal and the local

27. Perspectives in Biol & Med. 2008
THE SOCIAL CONTRACT
SOCIETY
THE MEDICAL
PROFESSION
Patients
PROFESSIONALISM P O L I T C A
General
Medicine’s
Public
Expectations
Obligations
Institutions
Government
Individual
Physicians
Politicians
Civil Servants
Managers
PROFESSIONALISM
Cruess & Cruess
Perspectives in Biol & Med. 2008 27

28. MEDIATORS OF THE SOCIAL CONTRACT
1. Health Care System
2. Regulatory Framework
3. The Commercial Sector
4. Other Stakeholders
5. The Media
after Rosen & Dewar, 2004

29. THE SOCIAL CONTRACT Society’s Expectations of Medicine
to fulfill the role of the healer
assured competence
timely access to care
respect for patient autonomy
altruistic service
morality, integrity, & honesty
accountability and transparency
team health care
source of objective advice
promotion of the public good
Medicine’s Expectations of Society
trust
autonomy
MD-led regulation
reasonable lifestyle
health care system
-value-laden
-adequately funded & staffed
- reasonable freedom
role in public policy
monopoly
rewards
- financial
- non-financial
• respect
• status

30. NOTE Linking professionalism with the social contract provides a rational basis for medicine’s obligations, both individual & collective It seems empowering to students and residents. The concept implies that medicine can negotiate the terms of the contract

31. LICENSING BODIES AND PROFESSIONAL ASSOCIATIONS
Mandate
state sanctioned authority
Collegiality
major regulatory role
set and maintain standards
discipline
advise public
They Must
demonstrate morality and virtue
assure competence
be open and transparent
be governed by an institutional code

32. POTENTIAL TO PROMOTE OR SUBVERT THE IMAGE OF MEDICINE
LICENSING BODIES AND PROFESSIONAL ASSOCIATIONS
MUST MANAGE CONFLICT OF ROLES
altruism vs self-interest
public good vs union function
POTENTIAL TO PROMOTE OR SUBVERT THE IMAGE OF MEDICINE

33. Self-Regulation Obligation (individual) Obligation (collective)
maintain competence
participate in and submit to the process of self regulation
support professional associations and regulatory bodies
ensure their integrity
Obligation (collective)
demonstrate morality and virtue
assure competence
be open and transparent
be governed by an institutional code

34. THEORY OF COUNTERVAILING
THE EVOLUTION OF PROFESSIONAL STATUS
THEORY OF COUNTERVAILING
FORCES
PROFESSIONS
CORPORATE SECTOR
STATE

35. THE EVOLUTION OF PROFESSIONAL STATUS
: PROFESSIONS DOMINANT “NOSTALGIC PROFESSIONALISM” Solo Practitioner-Single Payer Modest Income Accountable to Patient Altruism-Indigent High Trust & Influence

36. THE EVOLUTION OF PROFESSIONAL STATUS
1960- Present: STATE/CORPORATE
SECTOR DOMINANT
PROFESSIONALISM HAD TO EVOLVE

37. THE EVOLUTION OF PROFESSIONAL STATUS
THE NEW PROFESSIONALISM
Accountability Autonomy
Patient Autonomy
Transparency
Financial rewards/conflicts of interest
Team Health Care
Altered Expectations (society & professionals)
A NEW SOCIAL CONTRACT
Must Preserve Core Values of the HEALER

38. THE SOCIAL CONTRACT
THERE ARE CONSEQUENCES WHEN EXPECTATIONS ARE NOT MET
BREACHES IN THE CONTRACT

39. MEDICINE FAILS TO MEET SOCIETAL EXPECTATIONS
BREACHING THE SOCIAL CONTRACT
MEDICINE FAILS TO MEET SOCIETAL EXPECTATIONS
THE RESULT- A CHANGE IN THE CONTRACT
public trust in the “system” (contract)
trust in physician/profession
medical influence on public policy
self-regulation external regulation
autonomy

40. MEDICINE’S PERCEIVED FAILURES
Altruism
individual -lifestyle
financial gain
collective -union
Flawed MD-led regulation
Badly managed conflicts of interest
Lack of attention to social justice
BREACH ??

41. BREACHING THE SOCIAL CONTRACT
Society Fails to Meet Medicine’s Expectations
Trust in the
“system”
(contract)
Cooperation
Withdrawal
Job vs Calling
Satisfaction
OPTIMISM
PESSIMISM
Involvement
community
associations
stakeholders
Negotiation
? Satisfaction
Medicine’s Response-Two Poles

42. CANADA 2009 Trust in the system Funding of the System Personnel
Personal Freedom
MAJOR CHANGE IN THE CONTRACT
?? BREACH
Trust in the system

43. WHAT SHOULD MEDICINE DO?
These issues are here to stay
Linked to societal changes
MEDICINE:
Must address issues within its control
Must negotiate issues which it cannot control

44. MEDICINE MUST ADDRESS ITS FAILURES
THIS IS IN PART
AN EDUCATIONAL ISSUE

45. However- MEDICINE’S STRENGTH IS SOCIETY’S
WHAT SHOULD MEDICINE DO?
Negotiate a Social Contract which Supports the Healer and Professional Roles
Negotiations must:-Preserve Trust Satisfy both sides
Negotiations not Symmetrical- Society (through government has more power
However- MEDICINE’S STRENGTH IS SOCIETY’S
NEED FOR THE HEALER!

46. “Since time immemorial, a part of human culture has been man’s care for himself, for the body in which the spirit resides - that is for his own health. The culture of healing may be a less visible aspect of life, yet it is perhaps the most important indicator of the humanity of any society”
Vaclav Havel, Summer Meditations, 1993

47. ACTION PLAN
Take a few minutes to reflect on this half-day, and complete the relevant section of the action plan