Exemplary family physicians and consultants: empirical definition of contemporary medical practice.

To identify the characteristics of exemplary family physicians and consultants, we interviewed 25 family physicians and 25 consultants (5 each in the specialties of internal medicine, obstetrics and gynecology, pediatrics, psychiatry and surgery) selected by their peers as being exemplary in their own practice setting. The results indicated that the participants had well-formulated concepts of exemplary practitioners, defining five main categories of performance: clinical competence, relationship with patients, availability, family physician-consultant relationship and a fifth category that included organizational ability and personality attributes. The family physicians and the consultants placed different values on these categories and indicated that these values might change under different clinical circumstances. Their concepts appear to be compatible with, but not restricted to, a model of contemporary medical practice based on an ethic specific to medicine.     

Medical professionalism and the doctor-patient relationship

The practice of medicine increasingly poses obstacles to the cultivation of strong relationships between physicians and their patients. The current discussion of medical professionalism aims to identify some of these obstacles and to improve both the doctor-patient relationship and the quality of medical care. In this essay, we explore professionalism within the context of the relationship between physician and patient and examine the concrete actions, behaviors, and qualities that medical professionalism requires of physicians in today's challenging environment.     

Alberta's Rural Physician Action Plan: an integrated approach to education,recruitment and retention

This paper describes the development and characteristics of a comprehensive, integrated and sustained program for the education, recruitment and retention of physicians for rural practice in Alberta--the Rural Physician Action Plan. The participation of key stakeholders (including government, the provincial medical association, the licensing authority, faculties of medicine, practising rural physicians and regional health authorities) and a sustained program budget have been key organizational issues for success. Critical to the effectiveness of this program has been the focus on professional and lifestyle issues targeting 3 distinct groups: physicians in training, physicians in practice, and rural communities and health authorities. Substantial program funding since 1991-92 of up to $3 million per year has increased rural-based activities significantly. For example, 87% of medical students and 91% of residents in family medicine in Alberta now experience 4 weeks or more of rural practice. The authors believe that the historic issues and recent trends militating against recruitment and retention of rural physicians will continue unchecked without comprehensive and sustained approaches such as Alberta''s Rural Physician Action Plan.     

Literary inquiry and professional development in medicine: against abstractions.

The professional development discourse currently circulating in academic medicine owes much to the work of the American Board of Internal Medicine (ABIM) and their Project Professionalism.They identify the elements of altruism, duty, excellence, honor and integrity, accountability, and respect for others as forming the basis of professional development. While an admirable effort, Project Professionalism remains primarily an abstract set of attitudes and behaviors with a number of vignettes that are of limited use to medical educators attempting to foster the development of professionalism in medical students. This paper outlines an approach to professional development grounded in medical narratives written by physicians, including memoirs, essays, and poetry, that may help students grapple with the challenges of medicine that involve those very elements put forth by ABIM. An argument is made that literature may be a superior medium for engagement with these elements because of its ability to evoke discomfort and vulnerability in ways the case report does not.     

"Post-residency disease" and the medical self: identity, work, and health care among doctors who become patients

Doctors who become patients due to serious illnesses face many challenges related to issues of identity, work, and professionalism. In-depth interviews with such doctors reveal the complex ways in which illness threatens identity in these professionals. In comparison with "medical student's disease," these doctors now exhibit "post-residency disease"-minimizing physical symptoms that are in fact present, leading to decreases in care sought. Doctors often feel they are somehow invulnerable to disease and have to remain strong, not burdening others. Many describe themselves as "workaholics," which can prove to be a double-edged sword, posing problems as well as providing benefits. This professional commitment could interfere with preventive health behaviors and with "practicing what they preach." Some view their illness with their "medical self" - as if they were a physician observing another patient rather than themselves. These doctors often support their approach by choosing a colleague as a doctor who will not challenge them, thereby establishing a "denial system" as opposed to a support system. These doctor-patients confront difficult issues of how much their physicianhood is an identity or an activity, illustrating the intricate relationships and tensions between work, identity, professionalism, and health in contemporary medicine.     

Medical professionalism: one size fits all?

A number of medical specialties have recently developed their own specialty-specific charters. This proliferation of charters is representative of an unease about medical professionalism that has arisen not just from increasing medical specialization, but also from evolving needs as physicians progress through their careers. The development of such specialty-specific definitions of professionalism is undesirable: all specialties should adhere to the same basic principles. These charters and "definitions" should be incorporated into a formal developmental model, derived from needs assessments from the level of medical school through the level of specialization. Such a model would provide physicians with more concrete guidance regarding professional behavior at each stage of their careers, address unmet needs in neglected areas such as mid- and late career, and help alleviate the tension associated with expressing these ideas. Incorporating concepts derived from more classic models of development may create opportunities to address the teaching of values and identify barriers to success.     

Medical professionalism: crossing a generational divide

A comprehensive discussion of professionalism in medicine must include its impact on successive generations of physicians. Fifty years ago, doctors acting professionally emphasized medicine as a calling and an ability to act as the authority for patients in crisis at home and in hospitals. Therapeutic options were limited relative to the modern era, and the laying on of hands was practiced as science and art. Today, doctors balance increasing demands on time and efficiency with the sense of primacy of patient care. Technological innovation and patients' increasing access to medical knowledge through varying media of inconsistent quality challenge physicians in novel ways. Fifty years in the future, doctors will have access to vast amounts of information through a multitude of noninvasive diagnostics. Progressively more personalized medicine should inspire doctors to become even more adept at communicating effectively with patients. Professionalism in medicine throughout these generations embodies similar fundamental behaviors, such as demonstrating compassion, respect, and humility; adhering to high ethical and moral standards; subordinating personal interest to that of others; and reflecting on actions and decisions. Despite the dynamic nature of the profession itself, the omnipresent need for such traits will define medical professionalism for decades to come.     

Teaching professionalism: a tale of three schools

This article compares professionalism education from the vantage points of three different disciplines: medicine, law, and business. In particular, it asks how each of these professions conceives of "professionalism," and how these different conceptions affect what is taught to graduate students. The object of professionalism education differs among these three disciplines, as do the specific challenges to professionalism and professionalism education. The article offers examples of how professionalism is taught in medicine, law, and business, and what each profession might learn from the others in developing their professionalism education and pedagogy.     

Teaching Medical Ethics to Meet the Realities of a Changing Health Care System

The changing context of medical practice—bureaucratic, political, or economic—demands that doctors have the knowledge and skills to face these new realities. Such changes impose obstacles on doctors delivering ethical care to vulnerable patient populations. Modern medical ethics education requires a focus upon the knowledge and skills necessary to close the gap between the theory and practice of ethical care. Physicians and doctors-in-training must learn to be morally sensitive to ethical dilemmas on the wards, learn how to make professionally grounded decisions with their patients and other medical providers, and develop the leadership, dedication, and courage to fulfill ethical values in the face of disincentives and bureaucratic challenges. A new core focus of medical ethics education must turn to learning how to put ethics into practice by teaching physicians to realistically negotiate the new institutional maze of 21st-century medicine.     

Measuring Professionalism in Medicine and Nursing: Results of a European Survey

Background

Leveraging professionalism has been put forward as a strategy to drive improvement of patient care. We investigate professionalism as a factor influencing the uptake of quality improvement activities by physicians and nurses working in European hospitals.

Objective

To (i) investigate the reliability and validity of data yielded by using the self-developed professionalism measurement tool for physicians and nurses, (ii) describe their levels of professionalism displayed, and (iii) quantify the extent to which professional attitudes would predict professional behaviors.

Methods and Materials

We designed and deployed survey instruments amongst 5920 physicians and nurses working in European hospitals. This was conducted under the cross-sectional multilevel study “Deepening Our Understanding of Quality Improvement in Europe” (DUQuE). We used psychometric and generalized linear mixed modelling techniques to address the aforementioned objectives.

Results

In all, 2067 (response rate 69.8%) physicians and 2805 nurses (94.8%) representing 74 hospitals in 7 European countries participated. The professionalism instrument revealed five subscales of professional attitude and one scale for professional behaviour with moderate to high internal consistency and reliability. Physicians and nurses display equally high professional attitude sum scores (11.8 and 11.9 respectively out of 16) but seem to have different perceptions towards separate professionalism aspects. Lastly, professionals displaying higher levels of professional attitudes were more involved in quality improvement actions (physicians: b = 0.019, P<0.0001; nurses: b = 0.016, P<0.0001) and more inclined to report colleagues’ underperformance (physicians – odds ratio (OR) 1.12, 95% CI 1.01–1.24; nurses – OR 1.11, 95% CI 1.01–1.23) or medical errors (physicians – OR 1.14, 95% CI 1.01–1.23; nurses – OR 1.43, 95% CI 1.22–1.67). Involvement in QI actions was found to increase the odds of reporting incompetence or medical errors.

Conclusion

A tool that reliably and validly measures European physicians’ and nurses’ commitment to professionalism is now available. Collectively leveraging professionalism as a quality improvement strategy may be beneficial to patient care quality.     

Naturopathy: a critical appraisal

"Naturopathic medicine" is a recent manifestation of the field of naturopathy, a 19th-century health movement espousing "the healing power of nature." "Naturopathic physicians" now claim to be primary care physicians proficient in the practice of both "conventional" and "natural" medicine. Their training, however, amounts to a small fraction of that of medical doctors who practice primary care. An examination of their literature, moreover, reveals that it is replete with pseudoscientific, ineffective, unethical, and potentially dangerous practices. Despite this, naturopaths have achieved legal and political recognition, including licensure in 13 states and appointments to the US Medicare Coverage Advisory Committee. This dichotomy can be explained in part by erroneous representations of naturopathy offered by academic medical centers and popular medical Web sites.     

Changes in career plans during medical training and practice: it's time to look ahead and act.

Major changes in physician-resource policies and in the structuring of medical licensure requirements in the past decade have resulted in a less flexible system with respect to both choosing and changing a career path in medicine. The survey results reported by Drs. Susan Shaw, Gordon Goplen and Donald S. Houston in this issue (see pages 1035 to 1038) indicate that a high percentage of physicians now practising in Saskatchewan changed their career plans after graduation. The author argues that this finding points to the need to reexamine the transition from undergraduate to postgraduate medical education. The present system needs to be made more flexible so that medical students can gain sufficient clinical experience before deciding on an area of practice and to give practising physicians who want to change specialties the option of retraining.     

Professional societies and industry support: what is the quid pro quo?

Professional medical societies have become increasingly dependent on pharmaceutical, device, and biotechnology companies for ongoing support of their programs, but the internal influence of this financial largesse on medical societies' practices is well hidden. Many examples exist in which societies' educational products, including clinical practice guidelines and professional publications, have been tainted by involvement by industry-paid individuals. These examples show that professional judgments of organizations can be affected in ways that are not in the best interests of our patients. Society leaders should develop policies that leave critical decisions, especially those that affect patient care, in the hands of members without financial ties to industry. Society leaders should not accept funds designated for specific industry-recommended projects unless such programs are already part of their planned agenda. These leaders, who typically serve for only a year or two, should delve into arrangements that salaried society executives make with industry, and insure that no promises are made that compromise an organization's professional goals. Professional societies should also find ways of reducing the vast, embarrassing industry involvement at their national meetings, especially the vulgar circus-like displays and the drug company-sponsored symposia. We must reduce commercialism and restore professionalism to our medical meetings.     

The rising level of medical student debt: potential risk for a national default

At the turn of the 20th century, mostly as a result of the Flexner report, medical education changed dramatically by establishing a scientific basis for the study of medicine within the institutions of the major universities. There have been major and dramatic changes in medicine during the past 80 years that have improved medical education in the United States, but these changes have also placed major economic strains on students who have educational debts. If medicine is a social responsibility to the public, then the public should share the responsibility of identifying and supporting new approaches to funding and financially managing the teaching of future physicians. There is no universal solution because there are various approaches institutions may take to structure these financial responsibilities. This article describes trends in medical student educational debt, identifies the financial needs of medical students, and proposes ways of addressing those needs to avert a possible national financial crisis among medical students. We must invest in medical students because they will be the leaders we need to help care for our society and our own families in the next century.     

The YouTube generation: implications for medical professionalism

While medical education has remained relatively constant over the past century, the rising popularity of internet-based technologies, such as applications for social networking, media sharing, or blogging, has drastically changed the way in which physicians-in-training interact with educators, peers, and the outside world. The implementation of these new technologies creates new challenges and opportunities for medical educators. Representation, the absence of established policies and legal precedents, and the perception of the lay public exemplify some of the issues that arise when considering the digital images used by trainees. While some of these issues affect higher education generally, medical schools are faced with additional challenges to ensure that graduates exemplify the ideals of medical professionalism. We present a case vignette with subsequent discussion to highlight the complexities of ensuring medical professionalism in the digital age.     

Assessment of physician performance in Alberta: the Physician Achievement Review

The College of Physicians and Surgeons of Alberta, in collaboration with the Universities of Calgary and Alberta, has developed a program to routinely assess the performance of physicians, intended primarily for quality improvement in medical practice. The Physician Achievement Review (PAR) provides a multidimensional view of performance through structured feedback to physicians. The program will also provide a new mechanism for identifying physicians for whom more detailed assessment of practice performance or medical competence may be needed. Questionnaires were created to assess an array of performance attributes, and then appropriate assessors were designated--the physician himself or herself (self-evaluation), patients, medical peers, consultants and referring physicians, and non-physician coworkers. A pilot study with 308 physician volunteers was used to evaluate the psychometric and statistical properties of the questionnaires and to develop operating policies. The pilot surveys showed good statistical validity and technical reliability of the PAR questionnaires. For only 28 (9.1%) of the physicians were the PAR results more than one standard deviation from the peer group means for 3 or more of the 5 major domains of assessment (self, patients, peers, consultants and coworkers). In post-survey feedback, two-thirds of the physicians indicated that they were considering or had implemented changes to their medical practice on the basis of their PAR data. The estimated operating cost of the PAR program is approximately $200 per physician. In February 1999, on the basis of the operating experience and the results of the pilot survey, the College of Physicians and Surgeons of Alberta implemented this innovative program, in which all Alberta physicians will be required to participate every 5 years.     

The physician as a patient educator. From theory to practice.

Patient nonadherence to therapeutic regimens is a serious issue in the practice of medicine. Empiric studies done by professionals from diverse backgrounds have shown that physicians who use educational strategies can be effective in gaining the cooperation of patients to follow their recommendations. The educational model that currently is most familiar to physicians and the one they use most frequently when educating patients is pedagogy, the theoretic basis for teaching children. Andragogy, a theoretic basis for teaching adults, is now being suggested by medical educators as an alternative model. To illustrate the clinical relevance and application of the andragogic approach, studies focusing on physician behaviors associated with behavioral measures of adherence were reviewed, analyzed, and categorized according to a framework called the "ADULT" model. Physicians in a postgraduate training program who have had exposure to this framework and have incorporated it into their practices report less difficulty functioning as patient educators. The systematic use of this approach can have a positive effect on patient adherence.     

Issue of fraud raised as MD self-referral comes under spotlight in Ontario.

Physician self-referral, fraud and conflict of interest are causing increasing concern in Ontario, where 100 physicians are now being investigated for such activities. These and related offences recently have been pushed to the top of the agenda of the provincial college, which recently asked physicians to vote on what kind of self-referral regulations they prefer.     

The soul of medicine

This article considers contributions that the medical humanities have made to biomedical ethics. Philosophy has contributed methods of ethical justification to case analysis and has given birth to the New Professionalism movement. Taking biography as its paradigmatic resource, this movement has refocused medical education on the formation of physicians who not only have certain responsibilities to their patients, but also a regard for the role of the medical profession in working toward social justice. However, reliance on biography is now giving way to a renewed emphasis on autobiography, as educators seek to support medical students through the personal and spiritual journey that confrontation with death, disease, and injustice naturally entails. Reflective methods and techniques characterize this emerging era as educators and students try to preserve and reinvigorate the soul of medicine.