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

Definition Before Diagnosis PROFESSIONALISM What Is It? Definition Before Diagnosis

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

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

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

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

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

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

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

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

WHAT IS A PROFESSIONAL?

DEFINITIONS-PROFESS(ION) PROFESSIONAL PROFESSIONALISM

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

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

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

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

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

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

CORE OF PROFESSIONALISM Specialized knowledge Science Art Service to others Morality

The Primary Role is that of the Healer

“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”

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

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

-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

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

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

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

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

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

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

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

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

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

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

THE EVOLUTION OF PROFESSIONAL STATUS 1850-1960: PROFESSIONS DOMINANT “NOSTALGIC PROFESSIONALISM” Solo Practitioner-Single Payer Modest Income Accountable to Patient Altruism-Indigent High Trust & Influence

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

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

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

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

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 ??

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

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

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

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

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!

“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

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