Originally published October 2012
The practice of medicine is undergoing unprecedented change. Whether in technology, healthcare delivery, legislation and regulations, or scopes of practice, the healthcare landscape is changing. As a result, many physicians are finding it increasingly challenging to meet their responsibilities to their patients and to society. Some doctors may even begin to question the continued relevance of professional values and behaviours.
The CMPA believes the fundamental principles and values of medical professionalism represent a constant that can guide physicians in difficult decision-making.
Professionalism: the core of medical practice
Professionalism is at the core of medicine's contract with society. It assumes physicians will place the interests of patients above their own, even when this is difficult.
This includes considering first the well-being of patients, disclosing and resolving conflicts of interest, and informing patients when one's personal values would influence a recommendation or the practice of any medical procedure the patient needs or wants.
Physician professionalism requires setting and maintaining standards of competence even when resources are stretched. It also means acting with integrity. Professionalism is manifested through the values of honesty and trust; through actions such as clear communication and advocacy; and through outcomes such as patient well-being and social justice. It is these characteristics that have defined the profession of medicine for decades, and which remain vitally important today.
Professionalism is fundamental to the relationship between physicians and patients. In its keystone policy on professionalism, the Canadian Medical Association (CMA) identified 3 major features of medical professionalism1:
the ethics of care
self- or professionally-led regulation
The CMPA strongly supports this view of medical professionalism and recognizes that each of these features bestows both obligations and privileges on the profession. This concept of obligation and privilege is common to most professions, but it is witnessed most clearly in medicine.
Maintaining the fundamental principles of professionalism is a paramount requirement for self- or professionally-led regulation. In this regard, medicine is no exception. Medical regulatory authorities (Colleges), medical associations, and many specialty societies have each defined their expectations of professionalism in their unique contexts. Medical schools also incorporate professionalism in their curricula, covering topics such as healthcare advocacy, ethics, collaboration, and physician health and wellness.
Now more than ever, patients and society expect that self-regulation goes hand in hand with a rigorous, effective, and transparent licensure process that places safety and quality at its core. While the privilege of self-regulation has been a core feature of medical professionalism, it must be earned on an ongoing basis. Foremost is the obligation of physicians to act first in the interests of their patients and the public, and to maintain appropriate relationships with patients. These obligations exist despite increased demands and shrinking clinical resources.
Principles of professionalism
The widely-adopted international Charter on Medical Professionalism2 is based on the principles of patient welfare, patient autonomy, and social justice. It also describes a set of professional responsibilities that are expected of physicians, including professional competence, honesty with patients, patient confidentiality, quality of care, and scientific knowledge.
While the traditional physician-patient relationship may have changed over the years, the importance of trust, honesty, and compassion remain significant values upon which the medical profession can guide its individual and collective actions. Patients expect their doctors to be trustworthy and to possess the necessary skills and experience to address their healthcare needs. Earning the trust and confidence of patients also means physicians must establish the appropriate confidentiality safeguards for patient information.
The work of academics, regulators, and practitioners to define and reinforce the principles of professionalism in medicine — and how to put these into everyday practice — reflect the ongoing importance of professionalism in a very demanding environment. Financial and other constraints threaten the professional values and ethics of medicine, compelling physicians to compete for diminishing healthcare resources. Today's practitioners are likely to practise in an environment defined by funding formulas, throughputs, and other performance indicators that may or may not include patient outcomes. Increased patient expectations and demands place added pressure on doctors and the institutions in which they practise. Additionally, technological advances both support and challenge many longstanding elements of the healthcare delivery system.
For physicians practising in this complex environment, the challenge is to maintain their professional commitments while meeting the changing expectations of their patients — expectations that are inevitably influenced by the service standards in other sectors and by health information available from a variety of sources. As consumers of healthcare, patients seek timely access to high quality and safe medical care. Their expectations also extend to prompt communication and follow-up.
An important element of professionalism is appropriate behaviour with patients, colleagues, providers, and administrators. The absence of positive and constructive behaviour can have a detrimental impact on patient safety and team-based care. It is recognized that healthcare teams perform sub-optimally and staff morale suffers when health professionals exhibit disruptive behaviours. In addition, physicians may be confronted with medico-legal difficulties (e.g. College complaints, hospital investigations, Human Rights complaints) if their behaviour causes undue disruption to patients, colleagues, or the institution in which they practise.
Attempts to modernize the concept of professionalism in medicine are compounded by a shift from the traditional model of independent practice to one in which the delivery of care is increasingly integrated. This has resulted in significant changes to the roles, responsibilities, and operating paradigms that have underpinned the practice of medicine for decades. This new healthcare delivery environment will continue to undergo significant evolution in the coming years, and many of today's operating models are likely to be replaced by new paradigms. Physicians are already, both individually and collectively, adapting to this changing environment.
The medico-legal perspective
The CMPA identifies 4 elements that support medical professionalism, enhance safer care, and reduce medico-legal risk for physicians. These elements are intended to supplement the professionalism charters and codes of ethics that provide guidance for physicians and other healthcare providers.
Clinical competence. At the core of any profession is the maintenance of competence and this is especially true for the profession of medicine. Adherence to standards of care not only leads to safer care and better patient outcomes, but it reduces a physician's medico-legal exposure.
Responsiveness. Physicians must remain alert to patients' clinical and emotional needs. Should an adverse event (accident in Québec) occur, physicians should strive to learn from the event and take steps to prevent a similar occurrence. Responsiveness implies expressing regret to patients and their families for an adverse outcome and sharing with them the lessons learned. Physicians must also be responsive to their profession. For example, when faced with legal actions or College complaints, they remain open to redress or appropriate follow-up actions in order to make healthcare safer.
Engagement. Engagement with patients, families, colleagues, other healthcare providers, and administrators is anchored in respect. Physicians are committed to working in partnership with patients and their families in all aspects of care. This includes promoting a patient-centred culture, and behaving professionally with patients, other physicians, and administrators.
Integrity. With patient well-being as the central tenet of care, physicians act with integrity. This includes being respectful and supportive of colleagues and working collaboratively to maximize patient care. As a part of this process, physicians are expected to participate in the process of self- or professionally-led regulation, including holding each other accountable for their actions.
The challenges facing physicians in today's practice environment are considerable: heightened patient expectations, information overload, constrained healthcare resources, changing technologies, and complex regulations. Patients, too, face a changing and often confusing healthcare system where they may be confronted with conflicting health information and difficult care decisions. In this new reality, patients will continue to look to their doctor as their trusted healthcare source. Despite the evolving healthcare environment, physician professionalism should continue to be a guidepost in the new era of medicine.
Recognizing the obligations inherent in their profession, doctors must continue to act first in the interests of their patients and the public. Beyond their fiduciary obligations to patients, physicians are also called upon to embody the values and behaviours that resonate with the profession: trust, compassion, and integrity. These values have been synonymous with the medical profession for decades, and they remain so today.
The CMPA maintains that the principles of professionalism, including the 4 elements of clinical competence, responsiveness, engagement, and integrity, have never been more important. The principles and behaviours that have characterized the profession for decades remain pillars of strength in an uncertain future. These principles not only serve to guide physicians, they enable patients, policy-makers, and citizens to know that the profession understands its obligations. It is up to the medical community, both individually and collectively, to continue to put these principles into action.
Canadian Medical Association. "Medical Professionalism." Revised 2005. Retrieved on June 14, 2012 from: http://www.cma.ca/medical%20professionalism
Medical Professionalism in the New Millennium: A Physician Charter was issued jointly by the American Board of Internal Medicine, the American College of Physicians, and the European Federation of Internal Medicine in 2002. More than 100 medical and professional associations have endorsed the Charter, including the Royal College of Physicians and Surgeons of Canada and the Medical Council of Canada. Retrieved on December 9, 2011 from: http://www.annals.org/content/136/3/243.full