Professionalism and Mental Health Cheryl S Professionalism and Mental Health Cheryl S. Al-Mateen, MD, FAACAP, FAPA Department of Psychiatry VCU School of Medicine Okay. Some of the issues related to professionalism may not apply in our practice and training exactly as seen in this vignette. One of the things I tell students as they come on the Acute Unit at VTCC is that at times we expect a bit of a difference in findings in interviews, based on how the child is interacting with the particular adult. Today our topic is professionalism, and it’s one of a series of talks being given throughout the medical campus by members of the VCU SOM professionalism committee. I’ll tell you more about this committee later.

Professionalism – what is it? Professionalism at MCV Vignettes Overview Professionalism – what is it? Professionalism at MCV Vignettes We will review some concepts of professionalism and how it became an issue at the VCU School of Medicine. Finally, this is an interactive grand rounds. The purpose is to help faculty and learners begin to talk about issues of professionalism. I’ve set aside at least 15-20 minutes for discussion, so be prepared to govern yourself accordingly and discuss some vignettes.

Learned Professions Law Religion Medicine Nursing Occupational Therapy Psychology Recreation Therapy Social Work The definition of professionalism is not an easy one. In some ways, it’s like the definition of pornography used by Supreme Court Justice Potter Stewart in 1964 – “….I know it when I see it.” Dr. Lawrence, in his grand rounds to the Department of Surgery, noted that professionalism is a bit of a “squishy” topic. A Profession, as opposed to an occupation, is a vocation that has a body of knowledge and skills put into service for the good of others. It requires extensive education or specialized training. There is a specialized, complex, and at times uncertain nature of the expertise that goes with the profession, that confers some autonomy on the profession. A profession is expected to regulate itself. Historically, there are 3 professions that are considered “learned,” law, religion and medicine, with medicine considered the profession “par excellence.” (Arnold article) We know that the other specialties in this room -- psychology, nursing, social work, occupational and activities therapies are also learned professions. Professional standards are the skills, competence, and character expected of a member of a highly trained profession (microsoft encarta dictionary) Professionalism in these fields implies commitment, training, and competence in the practice of the field. In each of these professions, the essence of professionalism begins with ethics.

The Oath of Hippocrates I do solemnly swear by that which I hold most sacred That I will be loyal to the profession of medicine and just and generous to its members That I will lead my life and practice my art in uprightness and honor That into whatsoever house I shall enter it shall be for the good of the sick to the utmost of my power, I holding myself aloof from wrong, from corruption, from tempting of others to vice That I will exercise my art solely for the cure of my patients, and will give no drug, perform no operation, for a criminal purpose, even if solicited, far less suggest it That whatsoever I shall see or hear of the lives of men which is not fitting to be spoken, I will keep inviolably secret……. Medical professionalism begins with the Hippocratic Oath, which has the first description of medical ethics and several behaviors that are characteristic and expected of a physician. As I started to put this presentation together, I considered that this department is not only comprised of physicians. The information assembled by the professionalism committee has focused primarily on physicians and students in general. So, I looked to the other professions for their statements regarding professionalism as well. I found that in general, the components of professionalism are communicated through elements, not specific definitions. Each organization directed me to their code of ethics.

The American Psychological Association Psychology General Principles Beneficence and nonmaleficence Fidelity and responsibility Integrity Justice Respect for people’s rights and dignity Ethical standards Resolving ethical issues Competence Human relations Privacy and confidentiality Advertising Record keeping and fees Education and training Research and publication Assessment Therapy The American Psychological Association General Principles – to guide and inspire psychologists for the very highest ethical ideals of the profession. Do not represent obligations. Ethical Standards – specific statements regarding the correct professional conduct in various situations

Social work had similar principles and standards Ethical principles primary goal is to help people in need and to address social problems challenge social injustice respect the inherent dignity and worth of the person recognize the central importance of human relationships behave in a trustworthy manner. practice within their areas of competence and develop and enhance their professional expertise Ethical standards Responsibilities to clients Responsibilities to colleagues Responsibilities in practice settings Responsibilities as professionals To the profession To broader society Social work had similar principles and standards We see beneficence, justice, respect, fidelity and competence

American Psychiatric Nurse’s Association/American Nurse’s Association Provision 1. …practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. Provision 2: ...primary commitment is to the patient, whether an individual, family, group, or community. Provision 3: promotes, advocates for, and strives to protect the health, safety, and rights of the patient. Provision 4: is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care The American Psychiatric Nurses Association, when asked about professionalism, refers one to the expectations for nurses found at the American Nurse’s Association website. These provisions jibe with the principles of altruism, responsibility, advocacy, competence, respect and lifelong learning seen in the other professions. 1= respect 2 = altruism 3= 4 = competence

American Nurses’ Association, cont’d Provision 5: owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. Provision 6: participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action. Provision 7. The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development. Provision 8. The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs. 5 = integrity 6 = justice 7 = scholarship 8 = collaboration

American Therapeutic Recreation Association Beneficence/non-maleficence Autonomy Justice Fidelity Veracity/Informed Consent Confidentiality and Privacy Competence Compliance with Laws and Regulations

Occupational therapy personnel shall…. demonstrate a concern for the well-being of the recipients of their services (beneficence) take reasonable precautions to avoid imposing or inflicting harm upon the recipient of services or to his or her property (nonmaleficence) respect the recipient and/or their surrogates as well as the recipient’s rights (autonomy, privacy, confidentiality) achieve and continually maintain high standards of competence (duties) comply with laws and Association policies guiding the profession of occupational therapy (justice) provide accurate information about occupational therapy services (veracity) treat colleagues and other professionals with fairness, discretion, and integrity (fidelity) Occupational therapy personnel shall….

ACGME Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population And just in case the residents feel they are not included, the Accreditation Council for Graduate Medical Education is the oversight organization for graduate medical education. They note that professionalism includes:

Charter on Medical Professionalism Professionalism is the basis of medicine’s contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession. The charter on medical professionalism was written by the American Board of Internal Medicine, American College of Physicians-American Society of Internal Medicine Foundation and the European Federation of Internal Medicine released the results of the Medical Professionalism Project in 2002. This is the preamble. The document was accepted and adopted by the American Psychiatric Association as a position statement, and as such, is the “definition” of professionalism for psychiatrists.

Charter on Medical Professionalism Commitments Principles Professional competence Honesty with patients Patient confidentiality Maintaining appropriate relations with patients Improving quality of care Improving access to care Just distribution of finite resources Scientific knowledge Maintaining trust by managing conflicts of interest Professional responsibilities Principles Primacy of patient welfare Patient autonomy Social justice Similar to the APA and the NASW, these are the Principles and commitments endorsed by the Charter on Medical Professionalism and Psychiatry. So what I’m seeing is that everyone in this room has the same basic ethical principles. It’s fair, then to continue with the general term professionalism, as we all have the same expectations for behavior. There may be some occasions in which I use the term medical professionalism – that would be a synonym, and is not meant to differentiate expectations for MD’s from others in this room.

Professionalism – what is it? Vignettes Overview Professionalism – what is it? Vignettes Okay, now we’re discussing professionalism at MCV

Professionalism at MCV

The AMA Council on Ethical and Judicial Affairs (1980) A physician shall… be dedicated to providing competent medical service with compassion and respect for human dignity. be honest with patients and colleagues and strive to expose those physicians deficient in character or competence or who engage in fraud or deception. respect the law and a responsibility to seek changes in those requirements that are contrary to the best interests of the patient. respect the rights of patients/colleagues and of other health professionals and shall safeguard patient confidences within the constraints of the law. continue to study, apply and advance scientific knowledge, make relevant information available to patients, colleagues, and the public, obtain consultation and use the talents of other heath professionals when indicated. in the provision of patient care, except in emergencies, be free to choose whom to serve, associate with, and the environment in which to provide medical services. recognize a responsibility to participate in activities contributing to an improved community. The AMA Council on Ethical and Judicial Affairs listed 7 principles of professionalism in way, way back in 1980.

Sources of Concern re: Professionalism Medical student graduation questionnaire AMA AAMC ACGME LCME ABIM Local anecdotes So the question would be, why are we just talking about it now? Each year when medical students graduate, they complete a questionnaire describing their thoughts about the environment at their school of medicine for the AAMC. Responses in 1996 and 1999 showed a concern regarding “being belittled,” particularly in the presence of others. Descriptions of abuse increased in all categories, during this time, including discrimination based on gender, race, ethnicity and sexual orientation. 49% of students reported such abuse in 1999. The numbers at MCV were higher than the national average. In general, this abuse occurred in clinical settings. Clinical faculty perpetrated 28%, housestaff 31% and nurses 22% of the abuse. There is concern about student abuse, particularly medical student abuse. This concern is echoed by the American Medical Association, the American Association of Medical Colleges, and the Liaison Committee on Medical Education (which oversees undergraduate medical education in the US). The American Board of Internal Medicine has a “Project Professionalism” which talked about altruism, accountability, excellence, duty, honor, integrity and respect for others. We already talked about that a bit. These groups have all verbalized the need for developing an awareness of these issues in medical schools and called for the development of policies and procedures to correct any existing problems.

VCU SOM Professionalism Task Force Report - 2001 Reviewed definitions Assess MCV campus environment Develop goals for enhancing MCV environment Assist Dean’s office in maintaining professionalism In the year 2000, Dean Newsome recognized the need to actively promote the concepts inherent in professionalism on the Medical School Campus. He appointed a task force, with representatives from several departments as well as the Dean’s Office, to study the matter. Dr. Levinson was also on this committee. The committee was charged to 1) review definitions and standards regarding professionalism in a medical school environment, 2) assess whether the environment at MCV enhanced or undermined standards of professionalism, 3) develop short and long term goals for enhancing professionalism at MCV and 4) assist the Dean’s Office in maintaining professionalism on campus.

VCU SOM Professionalism Task Force Conclusions and Tasks All unprofessional behavior is unacceptable….corrective actions will be necessary Enhancing professionalism among the faculty, who serve as role models for others, will have a beneficial effect on these groups There is limited evaluation of individual faculty members and students of professionalism in our school. A new series of evaluation processes is necessary We need specific policies to deal with transgressions in professionalism We need coursework on professionalism A program to increase the awareness of medical professionalism in the entire community of VCU SOM The conclusion was a report which was presented in September 2001. The task force concluded that there are concerns about professionalism at MCV. First, there should be an increase in the awareness of issues related to professionalism. There is a clear need for education about what professionalism is, AND for our performance evaluations to assess not only on our technical proficiency in the practice of medicine and therapy, but also our level of professionalism. It was recommended that the focus start with faculty, who would then model the most appropriate behavior for housestaff, professional, graduate and undergraduate students.

Components of Medical Professionalism Altruism Accountability Excellence Respect for others Personal commitment to life-long learning Duty Honor and integrity (KUMC definition) VCU School of medicine has adopted the Kansas University Medical Center components of professionalism: (see slide). This is the VCU School of Medicine definition of professionalism.

Challenges to Professionalism Abuse of power Discrimination Bias Breach of confidentiality Arrogance Greed Misrepresentation Impairment Lack of conscientiousness Conflict of interest (KUMC definition) Okay, we’ve defined professionalism in general, as it is noted by our respective professions, and specifically what is expected at VCU SOM. What do we see if someone is not professional? These are examples of challenges to professionalism as defined by the Kansas University Medical Center….

Unprofessional Behavior Unmet professional responsibility Lack of effort toward self-improvement and adaptability Poor interaction with patients and families Inappropriate relationships with health care professionals In short, when someone is not professional, we will see behaviors such as poor patient care, and hostility towards colleagues and students. This hostility may be overt or covert.

Teacher-learner relationship Mutual trust Respect Responsibility Professional manner Focus on education High quality patient care Ethical conduct. The AMA Council on Medical Education has stated that the teacher-learner relationship should be based on mutual trust, respect and responsibility. This relationship should be carried out in a professional manner and in a learning environment that places strong focus on education, high quality patient care and ethical conduct. Ultimately, it was felt that the unprofessional behavior of a few faculty and housestaff has a negative effect on students’ development of professional attitudes. It was felt most important to start with officially evaluating faculty for professional behavior. The process for housestaff was already underway. As all of you are aware who work with M-3 and M-4 students, assessment of their professionalism is now included in their evaluations as well.

Vignettes

A patient witnesses her kitten being mauled and killed by a pit bull A patient witnesses her kitten being mauled and killed by a pit bull. She is in significant distress. She has taken a picture of the cat for legal purposes. She has come to you for treatment of anxiety symptoms. She wants to show you the pictures, indicating that she feels you cannot understand the depth of her grief without seeing the pictures. Do you look at the pictures? What if you don’t want to look at the pictures?

Tape Vignettes How could this situation present in mental health training? How should it be handled?

Okay, so let’s talk more about what professionalism means here at VCU SOM. You all should have received a copy of the professionalism initiative requesting your signature to confirm your understanding of the Initiative. (only 42 of Department of Psychiatry faculty have turned in their forms!! Out of 82 faculty) The standards have also been propagated through SOM Faculty Development workshops, through departmental grand rounds, and through the SOM Professionalism website. Initially, the committee came up with one set of criteria for faculty, and a different one for housestaff and students, even thinking in terms of separating out graduate and medical students. However, upon further examination, it was realized that one set of criteria was appropriate for all individuals in the School of Medicine.

VCU School of Medicine Standards of Professional Behavior These standards describe behaviors expected from faculty, housestaff, and students in the School of Medicine: Recognize their positions as role models for other members of the health care team. Carry out academic, clinical and research responsibilities in a conscientious manner, make every effort to exceed expectations and make a commitment to life-long learning. Since this list is imperative for us in the MCV Community, I will review each standard

Treat patients, faculty, housestaff and students with humanism and sensitivity to the value of cultural, social, age, gender, disability and economic diversity without discrimination, bias, or harassment. Maintain patient confidentiality. Be respectful of the privacy of all members of the medical campus community and avoid promoting gossip and rumor. Interact with all other members of the health care team in a helpful and supportive fashion without arrogance and with respect and recognition of the roles played by each individual.

Provide help or seek assistance for any member of the health care team who is recognized as impaired in his/her ability to perform his/her professional obligations. Be mindful the limits of one’s knowledge and abilities and seek help from others whenever appropriate. Abide by accepted ethical standards in the scholarship, research and standards of patient care. Abide by the guidelines of the VCU Honor System.

“Bottom Line” Medical Professionalism is an expected behavior in all interactions Faculty Housestaff Support staff Students

This is the medical student professionalism rating scale – way too hard to read

A bit easier to read – point out elements

DEPARTMENT OF PSYCHIATRY EVALUATION OF RESIDENT'S PERFORMANCE PROFESSIONALISM 1 2 3 4 5 6 7 Respect/Compassion Ethics/Integrity Cultural/Ethnic Sensitivity Demeanor/Bearing/Appearance Punctuality/Attendance This is the residency form for assessing professionalism

Faculty Evaluation for Professionalism ? We have yet to develop the format in our Department in which faculty professionalism will be assessed.

Although there are clearly official “formal” channels in place for addressing professionalism, such as reporting to division and department heads, there is the possibility that an individual will not feel comfortable enough to do so. The professionalism contact committee has several members throughout the school of medicine that serve as informal contacts. The member of the professionalism committee can serve as a resource to connect to other systems already in place (such as the EEO/AA office or sexual harassment policies), perhaps pulling together a small committee who can review the problem and make recommendations for appropriate resolution.

Professionalism Committee Process Discuss/guidance Modified Informal Complaint Refer Student Housestaff Faculty Professionalism Committee This is a confidential process in which a learner of any kind (student or housestaff) may discuss perceived unprofessional behavior on the part of the teacher (housestaff or faculty). The member of the committee may guide the student toward another resource, such as the sexual harassment policy, or participate in a modification of the Informal Complaint Option that is already in the VCU resource guide. In this process, the member of the comimttee serves as an ombudsperson for the student. Other members of the professionalism committee may be included in the review process if this is felt appropriate. If the process is not successful in resolving the situation, the department chair and the Dean may be involved in a more formal process. In one instance, there was concern about professionalism in a student that could not be specifically identified because of the nature of the complaint. The concern was “referred” to curriculum and to the student body as a whole, as more education was felt the most appropriate way to handle the situation.

School of medicine professionalism contact committee Dr. Karen Sanders (Chair), VAMC Dr. Cheryl Al-Mateen, Psychiatry Dr. Diane Biskobing, Internal Medicine Dr. Melissa Bradner, Family Medicine Dr. Jan Chlebowski, Graduate Education Dr. Ron Clark, Internal Medicine Dr. Ray Colello, Anatomy Dr. Philippe Girerd, OB/GYN Carol Hampton, Faculty and Instructional Development Dr. Walter Lawrence, Surgery Dr. Joyce Lloyd, Human Genetics Dr. James Messmer, Undergraduate Medical Education Dr. Mary Alice O’Donnell, Graduate Medical Education Dr. Andrea Pozez, Surgery Dr. Elizabeth Waterhouse, Neurology

SOM Professionalism Website http://www.medschool.vcu.edu/professionalism/