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(http://www.imt.ie/features-opinion/2014/06/the-journey-to-professionalism-in-medicine.html)
The journey to professionalism in medicine
June 18, 2014
Prof Michael Brennan
Medical professionalism is aligned to trust, which is very important because it’s when vulnerability supervenes, which can happen at any time, that we most need to trust doctors, Prof Michael Brennan tells Lloyd Mudiwa.
Prof Michael Brennan, the 2001 recipient of the Mayo Clinic Distinguished Clinician Award who was elected President of Staff by his peers, becoming the first Irish-born person to hold the position, graduated from RCSI in 1969 and is an Honorary Fellow of the College as well as being a Fellow of the RCPI.
On June 4, the Irish-trained Medical Director of the Mayo Clinic Programme in Professionalism and Bioethics was back at the RCSI at the invitation of Prof Kieran Murphy, RCSI Vice Dean for Medical Professionalism — in a reversal of roles — to share his knowledge and experience at a ‘Definition of Medical Professionalism Workshop’ in Dublin.
The RCSI is the first medical school in Ireland to formalise professionalism as a discipline that will permeate the entire undergraduate curriculum. The former President of the Medical Council is heading work to progress these plans to formalise professionalism in the College (IMT 30/05/14).
Patients come first
Speaking to IMT in between the conference, where he was asked to discuss medical professionalism from the perspective of the Mayo Clinic — a worldwide leader in medical care, research and education — Prof Brennan gave a “30,000-foot-level overview” of what delegates were engaged in.
He said the main focus of the activity at the Mayo institution was superior clinical care for their patients. “For over 100 years we have said that the needs of the patients come first and this is not just a marketing ploy, it actually is something that is very much within the DNA of the organisation,” Prof Brennan commented.
“It is not possible to find anyone at Mayo at any level of the organisation who cannot recite our primary value, which is, ‘The needs of patients come first’. But these are not just words. What professionalism does is it allows us, through the expression of our professionalism duties and responsibilities, to actually promote this patient-centred culture. So it’s one of the ways that we nurture the culture of the Mayo Clinic and its organisations.”
Groundspring
Apart from the North American (Mayo Clinic) Experience presented by Prof Brennan along with Dr Darcy Reed, senior associate dean for academic affairs of Mayo Medical School, associate
director of the clinic’s programme in professionalism and ethics, and associate professor of medicine in the Mayo Clinic College of Medicine; and Linda Matti, Administrator at Mayo Clinic, the meeting heard representations from other groups both in mainland Europe as well as the UK.
There was a presentation on ‘The McGill Experience’ by husband and wife team Drs Richard and Sylvia Cruess, and Dr Yvonne Steinert.
The couple, who began their current research on professionalism and medicine’s social contract with society in 1995, have published innumerable articles and presented around the world on the topic.
In 2009, Cambridge University Press released Teaching Medical Professionalism, a book with contributions from around the world, including McGill, and edited by the two doctors in collaboration with Dr Steinert.
Peter Barnhoorn, meanwhile, presented on the Maastricht Experience at the meeting. On the differences between these models, Prof Brennan mentioned that “human needs are not too different but healthcare systems obviously are quite different”.
Noting the RCSI was in the same week graduating doctors who would fan out across the world, Prof Brennan said the students had to be equipped with these values so that they were relevant to the healthcare environments into which they were going.
However, he was of the opinion that there were certain universal principles and behaviours such as patient advocacy.
“Advocacy may look very different in one country to another,” he said. “It may in fact be more difficult to serve as a patient advocate in another country but it still remains a principle that you would need to adhere to.
“So I would say that it’s not so much national differences between these (systems), but rather a question of what are the situations on the ground between different universities, organisations, healthcare providers, for-profit organisations and non-profit organisations such as Mayo Clinic — it may look very, very different.”
The challenges as well as the opportunities could also be quite different, Prof Brennan added. “It has to be consistent with and supportive of the environments of care within the different countries — but what we are exploring is ‘what are the commonalities across all of the environments regarding professionalism?’
“One word that is present in all of them is trust, i.e., how we generate and engender and justify the trust that our patients place in medicine and that society places in the medical profession.
“So that’s really the groundspring of the profession as a movement. It has been something rather implicit over the years in medical education but it has now become explicit in that, for example, in medical education in the US there are what are called competencies that need to be mastered for graduation and for licensure.”
Prof Brennan said there were six core competencies, one of which was professionalism, the second being communication skills.
At the Mayo Clinic they have formalised this into a programme in professionalism, and also include ethics as there are certain similarities and inter-dependencies, according to Prof Brennan.
Prof Raanan Gillon, a former professor of medical ethics at Imperial College London where he now holds an emeritus chair, also presented at the RCSI meeting on an Ethical Perspective.
A GP until his retirement in 2002, Prof Gillon edited the Journal of Medical Ethics from 1980 to 2001 and is credited with making a major philosophical contribution to critical thinking about moral issues raised by the practice of medicine as well as with being the leading British advocate and interpreter of Beauchamp and Childress’s four principles approach to moral reasoning in healthcare.
Viral effect
Consequently, Prof Brennan said Mayo Clinic’s programme in professionalism that was closely aligned with ethics had had a viral effect within the organisation, and the leadership of the group was “very much involved” such that professionalism and behaviours continued to be nurtured not only in its students and residents but also in its Faculty and staff.
Basically, he said, the curricula the Clinic had developed were customised to the stage of training of the learners, e.g., in the medical school the expectation is that during the period of time students are learning anatomy, physiology and pathology etc., they are also beginning to understand the values and behaviours of professionalism, and that when they go into graduate training they now have the opportunity for internalising and expressing those values as a consistent feature of their activities.
For instance, if a student is learning to be a cardiologist, during that period of time they are also expressing their professionalism values and behaviours towards their cardiac patients and colleagues.
Prof Brennan said for the Faculty and those who had been appointed to it, Mayo customised their curricula to demonstrate that they had “clearly mastered” these professionalism values and behaviours.
“Now the expectation is that they will serve as a leader in professionalism through their role-modelling, mentoring, behaviours, because if the Faculty are not behaving in a way that is consistent with what the students and the trainees have learned — that’s when you have conflict and that’s where the whole thing is undermined,” he said.
Increasing regulation
The key was to have medical professionalism put into practice with the overarching purpose that it engendered patient trust and the trust that society had in the medical profession “because if there isn’t trust in the medical profession obviously increasing regulation will occur”, Prof Brennan said.
He added: “If the profession is not self-regulating it will be regulated by Government entities and regulatory bodies, who won’t always necessarily have each individual patient’s needs in mind. These bodies may aspire to that but I think that those who are actually delivering the care are in the best position to make sure that the patient’s needs are met.”
Trust and vulnerability
“Why is trust important? Well, what does illness bring with it inevitably?” Prof Brennan inquired rhetorically, before responding to his own question: “Vulnerability.”
“So the only time that you really need to trust is when you are vulnerable,” he elaborated. “If the sun is shining, you are feeling well in every aspect of your life, you don’t have to trust.
“There is always a certain level of trust, but it’s when vulnerability takes hold or supervenes, which can happen to any of us at any moment of any day — that’s when trust is so critically important and at those times who do you turn to, to help you to restore your health and well-being? It is to the medical profession, but also the healthcare team broadly — the nurses and all who work within those hospital environments.”
Therefore, professionalism was not restricted to doctors and nurses, Prof Brennan said, adding: “It really is critically important for all who would be involved in the healing mission of an organisation and that’s how we say that the commitments of professionalism are just as relevant to any person who works within the healthcare organisation.”
“In fact, when the Joint Commission, which has overarching regulatory powers in the United States, visited our hospitals unannounced to make sure we have our act together they interviewed one of our janitors who does the cleaning of the hospitals,” Prof Brennan illustrated.
“They do these ‘on the spot’ interviews. They get the inside scoop. And they asked this janitor, ‘so what do you do here?’ He responded: ‘I am in infection control because what I do by cleaning and keeping these rooms clean and infection-free facilitates the care and the healing of the patients.’”
Walking the talk
Prof Brennan said professionalism was an important concept for the entire College. “In the case of the RCSI, now that professionalism is being formalised, much of the focus initially will be on the medical school, but it will also go into the graduate programmes and ultimately the Faculty, because there is such a thing as individual professionalism, but what about organisational professionalism?
“Because what is said has to be what also is apparently being done, in other words ‘walking the talk’ so that there is no conflict between what is taught and what is actually experienced.”
“So much of this is actually learned. There is a formal curriculum, which is what we are taught, but the informal curriculum, which is by far more important, is what we experience each day and if there is variance between those two it can be quite destructive.”
He added: “What RCSI is engaged in throughout the day today is defining professionalism, what makes relevant to the RCSI and its mission. The definition is going to be closely linked to the Strategic Plan of the organisation and its mission and value statements so that is the foundation for developing a definition that people understand and can activate.
“I think what we [the meeting] have attempted to do is to try and get beyond a certain nostalgic notion about professionalism — that it’s the doctor who is always on call, who never sends a bill, never makes a mistake — don’t we wish that that were the case, and of course it isn’t. So what we try to do is get beyond the nostalgic notion of professionalism and point to its relevance, for example, to patient safety.”