Lecture 4 Overview on Professionalism in medical practice delivered at Alfarabi medical College in Riyadh, Saudi Arabia (06.10.2016)

1. PROFESSIONALISM IN
MEDICAL PRACTICE
(FMC, 06.10.2016)
Ghaiath Hussein,
MBBS, MHSc. (Bioethics)

2. Outline of the session
■ Professionalism:
– Approaches and Dimensions of professionalism
– clinician’s Professional Relationships and Duties
■ Saudi Code of Ethics for Medical Practitioners
■ Reference:
Citation: Hussein GM, Kasule OH, Al-Kaabba AF. Professionalism and Ethics
Handbook for Residents. Ware J, Kattan T, editors. Riyadh, Saudi Arabia 2015

3. PROFESSIONALISM
clinician’s Professional Duties & Relationships

4. Levels of Behavioural ‘Control’
Morality
(Bio)Ethics
Laws & Regulations
Institutional Policies
Professional standards
Personal beliefs &
preferences
•General unchallenged community value; voluntarily followed
•Inherited as is; not argued
•Not written; changes slowly with time
•Argued; logically established (moral philosophy)
•Voluntarily; not universal
•Inspires codes, policies, & laws
•Binding to everyone
•Legal actions may follow, if not followed
•Binding to those in the institution
•Should be followed; disciplinary action might follow if not
followed
•Binding to those in profession
•Mostly voluntary; disciplinary action might follow if not
followed
•Written as Codes
•Varies individually
•Commits only you (and dependents)

5. Who is a/the ‘good’ doctor?
Thoughts?

7. Clinicians Beyond Hospitals!
COUNTRY/REGION
Policy maker
Planner
Manager
COMMUNITY
Advocate
Researcher
Educator
CLINIC/HOSPITAL
Provider Manager Educator Researcher

8. So your expected roles are…
CanMEDS
(http://www.royalcollege.ca/)
SaudiMEDS
Saudi Meds: A competence specification for Saudi medical graduates
Rania G. Zaini , Khalid A. Bin Abdulrahman , Abdulaziz A. Al-Khotani , Abdol
Monem A. Al-Hayani , Ibrahim A. Al-Alwan , Saddig D. Jastaniah
Medical Teacher , Vol. 33, Iss. 7, 2011

9. SAUDI MEDS
SaudiMED: Competence-Based Frameworks for the Saudi Medical
Colleges

10. SaudiMED
I: Scientific Approach to Practice
The integration and application of basic, clinical, behavioral and social sciences in
clinical practice.
1. Integration of basic and clinical sciences in medical practice
2. Delivery of evidence-based health care
II: Patient care
■ The establishment and maintenance of essential clinical and interpersonal skills to
demonstrate proficient assessment and delivery of patient-centered management
3. Demonstration of the essential clinical skills
4. Demonstration of clinical reasoning, decision making, and problem solving skills
5. Management of life-threatening medical conditions
6. Management of common medical problems
7. Placing patients’ needs and safety at the center of the care process

11. SaudiMED competencies
III: Community oriented practice
■ The ability to practice based on an understanding of the Saudi health care system
and to apply health promotion and advocacy roles for the benefit and wellbeing of
individual patients, communities, and populations.
8. Understand the healthcare system in Saudi Arabia
9. Advocacy of health promotion and disease prevention
9. Advocacy of health promotion and disease prevention
IV: Communication and Collaboration
The ability to communicate effectively with patients and their relatives and to practice
collaborative care by working in partnership within a multi-professional team
10. Effectively communicate with patients, colleagues, and other health
professionals
11. Teamwork and inter-professional collaboration
12. Application of medical informatics in healthcare system

12. SaudiMED competencies
V: Professionalism
■ The commitment to deliver the highest standards of ethical and professional
behavior in all aspects of health practice, and take a responsibility for own
personal and professional development.
13. Adherence to professional attitudes and behaviors of physician
14. Application of Islamic, legal and ethical principles of professional practice
15. Commitment to personal and professional development
VI: Research and scholarship
■ The contribution to the advancement of medical practice with the rigors of
scientific research.
16. Demonstration of basic research skills
17. Demonstration of Scholarly pursuits.

13. The round with Mr. Butcher (MD, MRCS)
■ On his round, the well-known surgeon Mr. Butcher was always keen to have all the
residents and interns on his unit in attendance, in addition to other health care
team members (dietician, physiotherapist, nurses, and others) to whom he always
referred as the “paramedics.”
■ During the round, he asked one of his unit’s female interns to examine a 65-year-
old male patient who had had his prostate removed two days before. He asked her
in a loud voice.
■ Both the intern and the patient felt embarrassed. The surgeon stopped her when
she tried to pull the curtains, as there were few other patients next to this patient
who would see him being examined if the curtains were not pulled. He said,
“Nothing to be ashamed of. He is a patient in a teaching hospital so he expects
that you will all examine him,” then, “isn’t that right Mr. X?” talking to the patient.
■ The intern asked the patient’s permission then examined him, and the operation
site. The surgeon then asked her and the other “doctors” some questions. As usual
in his round, the wrong answers were ridiculed, and the “paramedics” were never
given a chance to answer.
“Paramedics are to take the instructions doctors give them,” he would always say.

14. OVERVIEW ON
PROFESSIONALISM

15. Professionalism (Definitions)
“constituting those attitudes and behaviors that serve
to maintain patient interest above physician self-
interest.”
American Board of Internal Medicine
Professional competence is the habitual and judicious
use of communication, knowledge, technical skills,
clinical reasoning, emotions, values, and reflection in
daily practice for the benefit of the individual and
community being served.
Epstein and Hundert

16. Professionalism (WMA)
“Medical professionalism describes the skills, attitudes,
values and behaviours common to those undertaking the
practice of medicine.
 It includes concepts such as:
 the maintenance of competence for a unique body of
knowledge and skill set, personal integrity, altruism,
adherence to ethical codes of conduct, accountability, a
dedication to self-regulation, and the exercise of
discretionary judgment.

17. Professionalism (WMA)
Professionalism is also:
 the moral understanding among medical practitioners that
gives reality to what is commonly referred to as the social
contract between medicine and society.
 This contract in return grants the medical profession a
monopoly over the use of its knowledge base, the right to
considerable autonomy in practice and the privilege of self-
regulation. ”
(Blackmer, Canadian Medical Association, July 2007)

18. What is professionalism about?
Undesirable conductDesirable Behaviors
Abuse of power
Bias
(Sexual) harassment
Breach of confidentiality
Arrogance
Greed
Misrepresentation
Impairment
Lack of conscientiousness
and
Conflicts of interest
Altruism
Accountability
Excellence
Duty
Honor
Integrity
Respect for others, and
A commitment to lifelong
learning
Source:http://www.med.uottawa.ca/students/md/professionalism/eng/what_is_professionalism.html

19. Source: https://www.cma.ca/En/Pages/medical-professionalism.aspx

20. Professionalism = clinical ethics or bioethics?
■ The term "ethics" simply refers to a system of moral principles or standards
governing conduct (9).
■ Bioethics is essentially an umbrella term for moral conduct in the broad area of life
sciences and medicine (12). It also encompasses the following subject areas:
philosophy of science, biotechnology, politics, law, medicine, and theology.
■ Clinical ethics tackles patient-based ethical decision making. This area of ethics
considers different judgments as they apply to the clinical practice of medicine.
Thus, clinical ethics is a system of principles governing medical conduct with
respect to patients and their families.
■ The ethics of professionalism in medicine is more concerned with the
characteristics and behaviours of physicians in the context of medicine as a
profession. Specifically, it examines desirable and undesirable attributes of
physicians (4). The ethics pertaining to professionalism not only motivate patient-
physician interaction, but also outline expected behaviour with other physicians,
health care workers, medical students, and preceptors.
SOURCE:
http://www.med.uottawa.ca/students/md/professionalism/eng/what_is_professionalism.html

21. SAUDI CODE OF
ETHICS FOR
HEALTHCARE
PRACTITIONERS
http://www.scfhs.org.sa/Reglations/CR/Documents/%D8%A3%D8%AE%D9%84%D8%A7%D9%82%D9%8A%D8%A7%D8%AA
%20%D8%A7%D9%84%D9%85%D9%85%D8%A7%D8%B1%D8%B3%20%D8%A7%D9%84%D8%B5%D8%AD%D9%8A.pdf

22. Overview on the Saudi Code of Ethics (1)
■ Introduction
(A) Medical Profession Ethics and
Regulations
(B) Honour of the Healthcare Professions
(C) Sources of Healthcare Professional
Ethics
(D) Healthcare Profession Honour
(E) Role of Role-Models
■ Healthcare Practitioner Ethics
(A) Devotion and Feeling the Worship of
Allah (SWT)
(B) Demonstration of the Best of
Manners
(C) Self-accountability
(D) Avoidance of Trivialities and Pettiness
■ Healthcare Practitioner’s Duties Towards
Patients
(A) Good Treatment of Patient
(B) Achieving Patient’s Interest and Guarding
His/Her Right
(C) Patient’s Consent
(D) Reassurance of Patient
(E) Maintaining Patient’s Secrets - Confidentiality
(F) Photographing Patients and Recording Their
Voices
(G) Dealing with Patients Who Refuse a Medical
Procedure
(H) Conscientious Objection to Refrain from
Treating a Patient
■ Healthcare Practitioner’s Duties Towards
Community
■ Healthcare Practitioner’s Duties Towards
Professional Colleagues
■ Healthcare Practitioner’s Duties Towards
Him/Herself

23. Overview on the Saudi Code of Ethics (2)
■ Healthcare Practitioners’ Duties
Towards His/Her Profession
■ Observance of Religious Rulings
(A) Ruling on Exposing Private Parts of
the Body (Awra)
(B) Rulings in Abortion
(C) Relation Between the Opposite
Sexes
(D) Healthcare Practitioner’s Relations
Outside the Limits of the Profession
(E) Religiously Forbidden Procedures
and Treatment Methods
■ Ethics of Teaching and Learning on
Patients
■ Ethics of Documentation and
Authentication
(A) Medical Record
(B) Certificates and Reports
(C) Medical Prescriptions
■ Ethics of Financial Affairs in the
Healthcare Field
(A) Healthcare Practitioner’s Fee
(B) Practicing in Private Sector
(C) Advertisements and Publicity .
(D) Participation in the Media
(E) Gifts and Benefits
(F) Relationships with Pharmaceutical and
Medical Equipment Companies
(G) Insurance

24. Overview on the Saudi Code of Ethics (3)
■ Ethics of Conducting Biomedical
Research
(A) Conducting Biomedical Research
on Humans
(B) Conducting Research and
Experiments on Animals
(C) Regulations for Accepting Scientific
Research Grants
(D) Regulations for Innovative
Interventional Procedures
■ Ethics of Dealing with
Communicable Diseases
■ Ethics of Dealing with the
Developments in Healthcare
Practices
■ Ethics of Dealing with Emergency
Situations
■ Ethics of Dealing with Life-
threatening and Incurable Diseases
(A) Does the Patient Have the Right to
Refuse Treatment in Incurable
Conditions?
(B) Should Medical Treatment Be
Stopped?
(C) Cardiopulmonary Resuscitation
(D) Conditions of Prolonged or
Terminal Coma due to Cerebral
Cortical Damage

25. Muslim Doctors’ Duties Towards Patients
 Respect for Patient ‫المريض‬ ‫احترام‬
 Respect for Privacy ‫المريض‬ ‫خصوصية‬ ‫ضمان‬
 Comprehensive care ‫للمريض‬ ‫الشاملة‬ ‫الرعاية‬
 Respect for patient’s autonomy ‫المريض‬ ‫استقاللية‬ ‫احترام‬
 Inform the patient about his/her condition ‫المريض‬ ‫تبصير‬
‫مرضه‬ ‫بطبيعة‬
 Protect patient's interests ‫المريض‬ ‫مصلحة‬ ‫حماية‬
 Keep the patients’ secrets (confidentiality) ‫المريض‬ ‫سر‬ ‫كتمان‬
Source: Islamic Code of Medical & Health Ethics

26. Physician's Duties Towards Colleagues
 To deal with, and act towards his colleagues in a good
manner and in the same way he would prefer to be treated
 To avoid direct criticism to his colleague in front of patients
 Not to indulge in defaming the honor of his colleagues
 To exert every possible effort to educate the colleagues
 Respect the differences with colleagues (sex, culture,
belief…).
 The physician should respect other non-physician medical
profession colleagues, and appreciate their roles in
healthcare of the patient
 She/he must report the incidence in which a colleague could
be dangerous to the authority concerned

27. clinician’s Duties Towards his/her Profession
 Respect the honour of the profession;
 Develop him/herself to develop the profession through
CME, research, and publications;
 Adhere to the standards of practice (GCP, EBM,
guidelines, etc.)
 Abstain from any behaviour/action that would question
his/her credibility, or establish dishonest affairs with
patients or their families;
 Avoid the request of fame on the account of the
professional ethics and standards
 To provide role model for his colleagues and patients
Source: Islamic Code of Medical & Health Ethics

28. clinician’s Duties Towards his/her Profession
Reflect sincere devotion and dedication to the
medical profession.
To avoid any action that could lead to contempt of the
medical profession and to maintain the standards of
medical profession
To contribute in the development of the profession
through research and continuous learning.
The physician should not take advantage of his
profession position for obtaining any material or
moral gains, which are not in conformity with or
violate the laws and tradition.

29. clinician’s Duties Towards his/her Profession
To take the appropriate procedure when he comes
to know that one of the members of the health
team is sick, ignorant or negligent of his duties; in
furtherance of protecting the patient in the first
place and the medical profession next.
The physician should refrain, when dealing with the
patient, from any act or conduct that would infringe
his honesty and integrity.
To avoid seeking fame at the expense of the
profession ethics and principles.

30. clinician’s Role Towards Community
 Positive interaction with the community’s affairs
 Protect the community by reporting
reportable/epidemic diseases
 Improve health in the community through advocacy
and health education, and involvement in community
health activities
 Rational use of the healthcare institutions’ resources
 Effective contribution to the development of policies
and health systems that respond to the community
needs and facilitates easier access to health care.
Source: Islamic Code of Medical & Health Ethics

31. clinician’s Role Towards Community
 To be as a role model in his/her attitude and religion
 Promotion of health equity among the society
members
 Maintenance of health resources and the ideal
utilization of such resources.
 Use his skills, knowledge and expertise to improve
the standards and quality of health services rendered
to the society.

32. Lack of Professionalism
Signs of lack of professionalism (ABIM, 2001)
1. Abuse of power:
– Abuse while interacting with patients and colleagues;
– Bias and sexual harassment; and
– Breach of confidentiality
2. Arrogance (offensive display of superiority and self-importance);
3. Greed (when money becomes the driving force);
4. Misrepresentation (lying, which is consciously failing to tell the truth; and
fraud, which is conscious misrepresentation of material fact with the
intent to mislead);
5. Impairment (any disability that may prevent the physician from
discharging his/her duties);
6. Lack of conscientiousness (failure to fulfill responsibilities);
7. Conflicts in interests (self-promotion/ advertising or unethical
collaboration with industry; acceptance of gifts; and misuse of services
– overcharging, inappropriate treatment or prolonging contact with
patients).

33. Discussion of Mr. Butcher’s Case
■ On his round, the well-known surgeon Mr. Butcher was always keen to have all the
residents and interns on his unit in attendance, in addition to other health care
team members (dietician, physiotherapist, nurses, and others) to whom he always
referred as the “paramedics.”
■ During the round, he asked one of his unit’s female interns to examine a 65-year-
old male patient who had had his prostate removed two days before. He asked her
in a loud voice.
■ Both the intern and the patient felt embarrassed. The surgeon stopped her when
she tried to pull the curtains, as there were few other patients next to this patient
who would see him being examined if the curtains were not pulled. He said,
“Nothing to be ashamed of. He is a patient in a teaching hospital so he expects
that you will all examine him,” then, “isn’t that right Mr. X?” talking to the patient.
■ The intern asked the patient’s permission then examined him, and the operation
site. The surgeon then asked her and the other “doctors” some questions. As usual
in his round, the wrong answers were ridiculed, and the “paramedics” were never
given a chance to answer.
“Paramedics are to take the instructions doctors give them,” he would always say.

34. Discussion of Mr. Butcher’s Case: Summary Points
■ Referring to non-doctor health care providers as paramedics is not acceptable,
at least in the way he uses the term. It is more respectful to your colleagues to
call them by their job titles.
■ An old male patient feels quite depressed-if not abused-to be put in a situation
where a female of his daughter’s age examines his private areas.
■ By not pulling the curtains, the doctor deprives his/her patient of his/her least
level of privacy.
■ Not asking for the permission of the patient to be examined is never
acceptable, unless it is an emergency or the patient is unable to give
permission. This is applicable even in teaching university hospitals.
■ Humiliating your colleagues, especially the junior ones, is completely unethical.
It is abusive, and totally inappropriate as a role model for junior practitioners.
■ All health care team members are of equal value and should be given the
chance to share the knowledge they have. You can learn a lot from them, as
much from your physician colleagues.

35. Summary points
■ Being a clinician is about being part of a team. You have rights and
duties as part of this team.
■ Central to your care is your patient (not your ego and not your bank
account).
■ Many of the positive attitudes and skills can be developed through
training, and self-development.
■ Developing and adhering to these standards develops you, improves
health care, and enhances public trust in the health system.
■ By respecting your patients, colleagues, and the community in
general, you build better relations and a better reputation for being a
faithful model clinician