Professionalism; Professionalism, Cultural Context And Medical Education

INTRODUCTION

Professionalism can be defined as a set of skills, behaviour and philosophy resulting from the basic relationships in human interactions. The use of built in habits regarding knowledge, skills, reasoning, values and emotions in routine practice for the benefit of others is considered as professionalism. It is strongly linked with social accountability, social responsibility and social justice. The diversity in health care and different cultural societies may have a versatile view about the definition of professionalism. Probably it is better to explain the term professionalism in view of the global standards with a special focus on the local context.

Medical professionalism is a moral phenomenon which is based on the demands regarding competence, integrity and high ethical standards during the practice of medicine. It develops the basis of the trust between doctor, patient and the society. It also focuses the creation and maintenance of certain behaviours and attitudes required by the medical profession. The relationship of physician and patient along with the social contract among physicians and the society is also included in the medical professionalism. The medical profession is provided with certain privileges and in turn the society pose the responsibility to provide services and extraordinary self regulation. There are three features of medical professionalism;

Ethics of Care

It includes the values of beneficence, non-maleficence, justice and respect for persons

Clinical independence

Physicians are considered as the healers and experts to provide recommendations for the treatment where as the patients have the right to choose or refuse it.

Self Regulation

Physicians and the professional bodies are expected to self regulate the profession through the development and implementation of standards of care.

Major organisations of medical profession have provided different definitions of medical professionalism. However the definition of professionalism by American Board of Internal Medicine (ABIM has six components including Altruism, Accountability, Excellence, Duty, Honor/ integrity and Respect. This board has mentioned few negative dimensions of professionalism as well. It is emphasised that some time the negative dimensions play an important role in the learning of medical professionalism. These dimensions comprise of different attitudes, actions and behaviours which can destroy professionalism including;

1. Abuse of power and sexual harassment

2. Conflicts of interest

3. Professional arrogance

4. Physicians impairment

5. Fraud in research

Physicians charter for the new millennium, endorsed by 120 medical organisations and translated in 10 different languages has defined three basic principles for professionalism including the primary focus for the welfare of patients, Autonomy of the patients and social justice. Medical professionalism in Islamic perspective has also been proposed in literature consisting of seven dimensions;

1. Faith (Iman)

2. Consciousness (Taqwat)

3. Best character (Ahsan al akhlaq)

4. Excellent performance (Itqaan al ‘amal)

5. Strive toward perfection (Ihsan)

6. Responsibility (Amanat) and

7. Self-accountability (Muhasabat al nafs).

Cultural Affects On Medical Professionalism

Culture is a notoriously difficult term to define. Around 164 different definitions of culture have been compiled by an American anthropologist. It is derived from the latin word “cult or cultus” which means refining. cultivating or tilling. It is considered as the way of life and includes the traditions, customs, living ways, festivals and viewpoint on various issues of life. Culture is a human-made environment of life transmitted from one generation to the next. It is important to mention that there may be a local, regional, national and global variation in cultures. Human beings differ in ways of greetings, clothing, customs, norms, religions, eating habits, social set ups and similarly in health care practices as well. Culture is shared by a group of people, cumulative, diverse, dynamic, learned and acquired. It gives a range of permissible behaviour patterns

The process of globalisation and internationalisation has dramatically changed the world scenario. There is an increased and frequent shifting of human resources and technology from one area to the other. This migration is probably due to the improved working environment, better learning opportunities and comparatively good job outcome. As a results there is an increased concern about the competencies related with cultural diversity and multi cultural professionalism. Health, in the recent global scenario is no more perceived as a local issue. The attention is more diverted towards the production of physicians having the capacity to deal with the global context of health. The curriculum is expected to have the inbuilt concepts related with international health and exposure to multi cultural medical professionalism. The diversity of cultures demands that there is a need to study the medical professionalism in the context of cross cultural believes, values and attitudes. The conflicting values of different cultures may affect the perception about professionalism and human resource studying or working abroad must be familiarised with the local social and cultural context.

Teaching Culturally Sensitive Issues

Professionalism is considered as a core competence in the recent systems of medical education globally. However teaching of professionalism should be conceptualised as an inventory of belief and value system based on the local context. It is required to establish and maintain the trust between physicians and the society. Teaching the culturally sensitive issues are among the challenges faced by medical educationists.9 Practically, teaching professionalism is not an issue related with the addition of a course or a subject rather it should act as an umbrella covering the whole curriculum. The change or modification in the values and belief system of the young undergraduates is a very complex and long process requiring multiple activities in different dimensions. Trust is supposed to be the corner stone of medical professionalism and same trust is required to be maintained among the learners and facilitators during the teaching of professionalism.

Medical professionalism is about meeting societal expectations of the medical professions. The expectations of the societies from medical profession are mostly common with reference to cognition, skills and attitude. However there are diverse expectations in different cultures. Research findings from Japan, Taiwan and Arabian countries represent a significant role of cultural diversity in shaping the activities of professionalism. For example the values of Confucius are reflected in the practice of professionalism in Taiwan and China. The professionalism in Japan originates from the samurai warriors. The Arabian context of professionalism has four levels including dealing, with self, dealing with task, dealing with others and dealing with God. This framework encompasses the role of Islamic values in shaping the medical professionalism.

The existing explosion of information technology has revolutionised the modern ways of health care and medical education. On one side it has benefited the entire medical community and patients but on the other hand it has raised serious issues related with medical professionalism and ethics. The use of social media is highly prevalent and everyone is sharing the daily activities with colleagues and friends. This practice is even going on in the OPDs, wards and even operation theatres. The young graduates are sharing their initial procedures and compromise the confidentiality of the patients. Probably these graduates don’t have the idea about this unprofessional behaviour.

The privatisation of medical education in Pakistan has raised versatile professional issues. A vast majority of the undergraduate students in these private medical colleges got admission as a customer and pay a high amount as the fee. The business oriented institutes also treat these students as clients and infuse the values related with input and output in pure business terms. These medical graduates primarily focus the return of their investment and compromise the professional standards. It is the high time to include this dimension especially in the education of private medical colleges.

Medical education in Pakistan is passing through an evolutionary process. The young graduates are asking for better career opportunities and financial incentives. These demands have been shifted to the roads just like a political movement. As a result it is a common practice to close the OPDs, indoors and even emergency services as well. These strikes has seriously compromised the medical professional and the attitude of the society toward medical professional is negatively promoted. This problem has also badly affected the professional respect of the seniors. As discussed earlier, professionalism is related with social responsibility and accountability and represent the relationship between doctor and the society.

These issues need place in the curriculum so that the future graduates can understand their roles and responsibilities related to medical professionalism. There are many other issues related with local culture such as, discipline, respect, doctor patient relationship, informed consent, confidentiality, justice, ethical practice, autonomy, beneficence, non maleficence, physician pharma relations, gender issues, euthanasia, family planning, AIDS, polio vaccine, Hijab of females, sexual health, advertisement, marketing, malpractice, over billing, fake medical certificates, over medication due to financial gains from pharmaceuticals and above all fraud and plagiarised research.

Teaching Professionalism

Teaching professionalism is a dynamic and ongoing activity. Different strategies and approaches for teaching and learning medical professionalism are as under:

1. Professionalism as an encompassing and embedded part of the curriculum

2. Role modelling/ Mentoring

3. Reflection

4. Conducive institutional environment

5. Role play

6. Video / dramas