Medical Professionalism and Ethics

Professionalism

Professionalism is “the attributes, behaviors, responsibilities, principles, and objectives that characterize a profession or professional person.” It implies the quality of services. In the medical profession, professionalism symbolizes the relationship and commitment of medicine (doctor) to society as it forms the basis of patient–physician trust.^{1, 2} Because of strong societal responsibility, it includes multiple emotional and humanistic virtues to deliver the best health care services. The attributes and behavior of professionalism include accountability, selflessness, commitment to excel, empathy, truth, admiration, sensitivity to the needs of diverse populations, and adherence to ethical principles (Figure 1). Thus, professionalism is defined as the “habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotion, values and reflections in daily practice for the benefit of the individual and community.” ³ In other words, professionalism emphasizes humanistic aspects (attitude, behavior, virtues, and characteristics), desirable among medical professionals in all circumstances in addition to biomedical aspects (knowledge, clinical reasoning, and technical skill).

OPEN IN VIEWER Figure 1.

Attributes of Professionalism.

Professional Competence

Professional competence is the attitude to do the best and achieve excellence in all aspects. It is an amalgamation of knowledge, skills, and behavior to improve continuously. This attitude helps the professional to grow incessantly through self-development, self-learning, and lifelong learning. The attitude quotient of a professional is more important and of greater relevance to the society than knowledge. Unfortunately, attitude being difficult to teach and assess has been conveniently sidelined in traditional medical education. In addition, competence cannot be achieved overnight, an intense desire to achieve and self-realization are essential.

Good Communication Skill

Effective verbal and written communication is key for a strong and successful doctor–patient and teacher–student relationship. Giving sufficient time while taking history and during discussion of the management plan has been found to influence patient health outcomes. There has been a definite correlation between effective physician–patient communication and improved patient health outcomes. ⁴ The greatest challenge for effective communication in the Indian workplace setting is crowded outpatient departments, overworked physicians with lack of time, and limited resources. Majority of professional misconduct and medical errors arise from communication problems. ⁵

Trustworthy

In order to earn the trust of the students and patients, integrity, honesty, and accountability must be demonstrated over a period of time by a professional. Moreover, completing the assigned task as committed and managing conflicts of interest connotes reliability and dedication. Maintaining appropriate relations with students and patients is certainly an expected and desirable quality of a professional as it generates trust and respect. A health professional should always put the benefit of the patient as the topmost priority and self-interest should never supersede the interest of the patient or clinical practice.

Soft Skills

Courteous, polite, well-mannered interactions with patients and students help in smooth functioning, avoiding disputes, and earning respect from patients and peers. Further, patience and active listening to patients’ problems without interruption are the most desired qualities in a medical professional. A professional with these attributes indicates having an extraordinary emotional quotient.

Ethical

Adherence to the standards of behavior and practice prescribed by the Code of Medical Ethics is essential to strengthening trust in the medical profession. All medical graduates in India need to comply with Professional Conduct, Etiquette and Ethics Regulations 2002, subsequently amended in 2009 by the Medical Council of India (MCI) as a professional responsibility.

Medical Ethics

Ethics can be referred to as the standard of conduct, derived from the principles of right or wrong. It is a standpoint for deciding how to act in a given situation or analyze a complex problem. Medical ethics focuses on moral conduct and principles to apply toward patients, doctor–patient relationship, and communication in the practice of medicine. However, the span of medical ethics is wider and includes research ethics and publication ethics. The fundamental principles of Medical Ethics are autonomy, beneficence, nonmaleficence, and justice. The application of these principles in medical practice includes respect for the desire of the person, informed consent, protection of privacy and confidentiality, facilitation of decision-making, giving maximum benefit, and first do no harm, fairness, and equal distribution of health care resources (Table 1). These principles are universally accepted and discussed below.

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Table 1.

Application of Principles of Medical Ethics in Clinical Practice.

Principles of Medical Ethics	Application in Medical Practice
Autonomy	- Respect the person in target group(doctor–patient), (teachers–students) - Respect patient’s choice, freedom to choose without force/threat - Communicate all details about illness - Facilitate informed decision making - Informed consent - Maintain confidentiality and privacy
Beneficence	- Commitment to do good to the patient and society - Prevent incompetent students passing out as doctors
Nonmaleficence	- Exercise utmost caution in practice and research - Protect vulnerable patients from physical, psychological, or social harm - Medical competence, utmost care, and safety - Evaluate the risk to patient
Justice	- Fairness and nondiscrimination in medical practice - Share limited health resources

Autonomy

The literary meaning of autonomy is “freedom or independence as of the will or one’s action.” In the context of medical ethics, the principle of autonomy emphasizes on Human Rights approach. Every person has the Right to decide for himself. And a doctor needs to respect the patient’s Right, desire, wish, and decision regarding his/her body and treatment. The vital elements of autonomy are informed consent, confidentiality, privacy, and communication with the patient. In India, a major part of the patient population is poor and illiterate which may interfere with effective communication by health professionals and comprehension on the part of the patient. This may also lead to reduced autonomy and make them vulnerable to exploitation. This group of patients deserves special care and consideration.

Informed Consent

The pillar of ethics in medical practice is informed consent. It is a procedure of providing detailed information to a patient, and obtaining consent means authorization for treatment and procedures. It indicates that the right to information and respect for the patient has been maintained. Each patient has the right to know about his/her disease, available treatment options, risks involved, cost of treatment, prognosis or expected outcome, etc. Once the patient satisfactorily understands the treatment plan and willingly agrees, it is documented as a written, signed, and dated informed consent form. Informed consent is especially required for invasive procedures, surgery, anesthesia, and special investigation. The objective of taking informed consent needs to be understood to avoid unnecessary litigation and misunderstanding. The doctor may delegate the task of the informed consent process to one of his/her health team members, but not the responsibility.

The essential elements of informed consent are disclosure, understanding, capacity, and consent (authorization). The disclosure means providing all information pertinent to the treatment of the patient such as procedures, risks, benefits, alternative treatments, rights, potential harm, discomfort, inconvenience, etc., which helps the patient in the decision-making process. While understanding refers to the conscious efforts of the doctor to use nontechnical language, avoid the use of medical jargons, and make it easy for the patient to understand. Further, capacity refers to mental capability (sound mind), an ability to understand relevant information and make a choice. If the patient is incapable either because of disease (mentally disabled) or age (child), the consent must be obtained from a legally acceptable representative. Extra care is warranted for vulnerable groups; for example, unconscious patients, minority groups, prisoners, etc.

Confidentiality and Privacy

Confidentiality and privacy are core concepts in medical ethics and doctor–patient and educator–student relationships. Any kind of medical, personal, physical, or health-related information of patient details if divulged by the doctor, is a violation of respect and trust in doctor–patient relationship. Similar restrictions are also applicable to medical and personal records, data, investigation reports, images, photographs, etc. of the patient. The concept of confidentiality also applies to examination, assessment of paper, clinical research, and publication of data.

Privacy in medical practice implies ensuring physical privacy during examination and treatment at all times. Screens around the patient’s examination table, bedsheets to cover the patient, and restricted access to the patient’s room are some of the measures to provide physical privacy. Privacy helps to ensure the mental and physical comfort of a diseased person.

Beneficence

The literary meaning of beneficence is “the state of being kind, beneficial” and is commonly interpreted as to do good. A physician has an obligation to provide selfless service in medical care not only to the patient but also to the society including public health, prevention of disease, research, etc. The decision of the physician should be in the best interest of the patient, over any other consideration. Attributes of compassion, responsiveness, sensitivity, and commitment to excel can help achieve this goal.

Nonmaleficence

The meaning of nonmaleficence is “not to do or act badly or wrongly” and is articulated as “first do no harm.” This principle emphasizes professional competency, taking care and protecting the vulnerable population, identifying the risk to the patient, and undertaking all measures to minimize harm. The attribute of compassion plays a vital role in the conduct of this principle.

Justice

It refers to fairness and nondiscrimination in medical practice. It is the duty of the doctor to make sure that every patient has equal access to the standard of care, irrespective of their social and economic background. The principle equally applies to clinical practice, health care policy, and distribution of limited resources. Integrity, accountability, and sensitivity to the needs of diverse populations can help in the implementation of the principle of “justice.”

Difference Between Morality, Ethics, and Law

A very thin line divides morality and ethics. Moral values, behavior, belief, and what is good and evil are decided by an individual, and it comes from within. It controls the behavior and interaction of the individual. Immoral behavior of an individual will have personal consequences. Medical ethics can be regarded as a set of values or principles, duties, and obligations based upon standards of right and wrong that govern members of a particular profession. These set of standards are prescribed by the governing council of a professional group, for example, the Code of Medical Ethics proposed by the MCI. Code of Ethics is essential for the profession which requires a high degree of trust in professional–client relationship. Noncompliance to the code of ethics by a few persons reflects badly and creates doubts about the credibility and integrity of the entire professional community. On the other hand, law is determined by the regulatory body (Government) that provides directions to people on how to behave in a given situation. Thus, law is enforced upon and controls external behavior. Additionally, breaking the law is an offense and punishable. It may be noteworthy that all illegal acts are unethical; nevertheless, not all unethical acts are illegal.

The National Medical Commission with the approval of the Central Government has prescribed regulations relating to the Professional Conduct, Etiquette, and Ethics known as The Indian Medical Council Regulations, 2002. These regulations describe the role and responsibilities of a doctor and duties toward their patients and colleagues, what constitute unethical acts and unethical behavior (professional misconduct), and subsequent disciplinary actions and punishments, if found guilty. ⁶

Ethics and Professionalism

Interestingly, ethics and professionalism are like two sides of a coin and at times, difficult to differentiate. Table 2 describes overlapping principles and attributes of medical ethics and professionalism.

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Table 2.

Overlapping Principles of Medical Ethics and Attributes of Professionalism.

Principles of Medical Ethics	Attributes of Professionalism
Autonomy: Respect the person; give the patient the right to choose or refuse treatment; involve the patient in decision-making	Empathy, compassion, respect
Beneficence: The decision of doctor should be in the best interest of patient; give maximum benefit to the patient	- Altruism (absence of self-interest) - Commitment to excellence
Nonmaleficence: First do no harm	Care, responsiveness, sensitivity
Justice: Fair selection and distribution of resources; avoid discrimination	Honesty, integrity, accountability

Ethical Dilemma

Quite often, medical professionals come across situations that cause ethical dilemma because physicians, patients, and their relatives may not agree on the “one right way” of treatment or disease management. ⁷ For example, advising to disconnect the ventilator from an elderly unconscious patient with irreversible brain damage (who is not likely to recover), when relatives do not agree. This scenario involves a conflict of societal obligation to be sensitive, loyal, and respect the desire of the patient (autonomy). COVID-19 pandemic has further challenged the principles of medical professionalism especially patient welfare, autonomy, and social justice to prioritize patient care and make tricky decisions based on insufficient resources including deterring and withdrawing potentially lifesaving treatments.^{8, 9} In addition, the advances in medical technology with the rising health care cost of modern clinical practice adds pressure (a sense of guilt) and may refute professional and ethical commitments.

Similarly, medical educators face ethical dilemma because of dual ethical obligations. The society expects medical educators to produce expert health professionals. Frequently, medical educators encounter a classic situation: whether the incompetent students (who require few marks to become eligible for university examination) should be failed (conflict with professional responsibility) or pushed up (do no harm).

There is no simple straightforward answer to these complex situations. Ethical decision-making in these complex situations can be challenging, and it varies from case-to-case basis. It requires patience, a deep understanding of ethical behavior in medical practice, and a call for consultation and counseling with professional colleagues, patients, and their family members. Decision-making needs to be considered according to principles, code of ethics, laws against the desire of patients, social context, and available resources.

Teaching Medical Professionalism and Ethics

The National Medical Commission, India implemented “competency based undergraduate curriculum” in 2019. ¹⁰ This new curriculum includes teaching and learning attitude, ethics, and communication skills (AETCOM) right from the first professional year to the entire duration of training. The previous Revised Graduate Medical Education Regulation (2012) and VISION 2015 by the MCI had also proposed professionalism and medical ethics to be an integral part of the undergraduate curriculum.^{11, 12} Unfortunately, it did not find a place in most university curricula. Until now, the formal curriculum and teaching programs were designed only to achieve knowledge and clinical skills. The attributes of professionalism and ethics such as values, virtues, attitudes, communication, and empathy fall under affective domain of educational objectives. The classroom teaching of these components of affective domain and its evaluation by the traditional examination system has been difficult. ¹³ It has been considered that with the rapid advancement of diagnostic technology and increase in the number of super-specialties and sub-specialties in medical science, the focus is more on disease and case, rather than treating the patient as a whole person. ¹⁴

How Did Medical Students Learn?

It is presumed that professionalism and ethics are “caught” and not “taught.” Virtues of professionalism should be reflected in the behavior of medical educators as students learn by watching their teachers as “role models” and get influenced by “external environment” that promotes self-interest. ¹⁵ It has been reported that students who demonstrate unprofessional behavior during undergraduate and postgraduate training are likely to be found guilty of unprofessional acts after graduation. ¹⁶ The common unethical behaviors following graduation are medical errors, adverse outcomes, malpractice, medico-legal cases, and difficult workplace relationship. ¹⁶

Unlike other medical subjects, the teaching of professionalism and ethics cannot be restricted to a particular professional year as a subject of medical training. It should be a continuous, longitudinal step-by-step process enmeshed throughout the undergraduate and postgraduate curricula. Teaching medical professionalism and ethics may require a nondidactic approach. In the initial professional years, the students can be sensitized to the importance of professionalism and ethics using appropriate cases (hypothetical or real) followed by exposure to the clinical scenario by means of bedside teaching, cinema education/video clips, or any other appropriate interactive teaching–learning method. ¹⁷ Subsequently, the students can be asked to reflect upon the cases, the behavior of the physician, selecting the right action in the context of the best interest of the patient, and code of ethics while dealing with patients and complex situations. The reflection exercise makes the learner analyze and think critically (mental processing), which results in learning. This is a key attribute to changing the attitude. ¹⁸ A thoughtful combination of various teaching methods at appropriate times with relevant examples in a sequential manner would be helpful. However, the assessment of professionalism is challenging and difficult. The descriptors of unprofessional behavior and what is expected from medical students and resident doctors should be explicit, continuous, and throughout their journey in the teaching institute. Teaching professionalism will sensitize and facilitate conversation among students and teachers and a fair assessment will lead to a valuable formative learning experience. Learners gradually develop a professional attitude. Further research in this area will be helpful. The new proposed AETCOM module will be helpful to make an impact in this regard.