■ Professionalism and ethics:
Integrating professional duties, societal expectations and personal wellbeing
Published: January 2021
Professionalism is at the core of medical practice and forms the basis of medicine's contract with society. Patients need to know their doctor will uphold the values of the profession. They want clinically competent physicians who are also compassionate, altruistic, and trustworthy. Medical professionalism is the translation of the values of the profession into daily actions.
Attributes of professionalism 1 include:
- Professional competence and continuing professional development/medical education
- Protecting confidentiality and privacy
- Maintaining appropriate professional distance in relationships and respecting boundaries
- Improving quality of care
- Accepting professional responsibilities and accountabilities
Four key elements support medical professionalism and quality care 2
- Awareness of, and adherence to, standards of care
- Responsiveness to patients’ individual clinical and emotional needs
- Engagement to working in partnership with patients, colleagues, and administrators
- Acting with integrity and participating in the process of professionally-led regulation, including holding each other accountable for our actions.
It is important to develop, monitor, and reinforce good professional practices early in training. Studies have shown that a lack of professionalism on the part of a medical trainee can be predictive of future problems with medical regulatory authorities. 3,4
Cultivating professionalism in learners is an important aspect of any medical teacher’s work. Preceptors can play an important role in the development of professionalism by modeling professional behaviours to enable the development of appropriate skills and attitudes with both patients and colleagues. In addition, preceptors play a fundamental role in promoting professionalism by identifying a trainee’s concerning behaviours at the outset, and enacting targeted efforts to help trainees address those issues. The complexity of assessing and remediating professionalism issues for trainees remains a challenging area that offers an opportunity for faculty development and practice improvement. 5
Good practice guidance
The patient-physician relationship is at the heart of medicine. The central role of trust in the patient-physician relationship creates a fiduciary relationship. This means that physicians have an obligation to their patients to act with utmost good faith and never allow their personal interests to conflict with their professional duty. The hallmark of a fiduciary relationship is trust; the patient trusting that the physician, who has more power due to their expertise, clinical knowledge, and skill, will only act in the best interests and for the good of the patient. 6
Physicians seek to maintain their patients’ trust by embodying the following values:
- Compassion – seeking to address their patients’ emotional and clinical needs
- Altruism - placing the patient’s interests above their own even when it is difficult
- Honesty – being truthful about all aspects of care, including when obtaining informed consent, providing informed discharge, and disclosing patient safety incidents
- Integrity – practising with high moral and ethical standards, holding themselves accountable
- Prudence – considering all relevant knowledge and circumstances that inform clinical decision-making, while respecting each patient’s goals and values. 7
To preserve patient trust:
- Protect the privacy and confidentiality of patients’ personal health information, sharing only enough information to benefit the patient, with those within the circle of care.
- Obtain patients’ express consent to share information with those outside the circle of care.
- Avoid any personal, public, or virtual conversations that could reasonably be seen as revealing confidential or identifying information, or as being disrespectful to patients, their families, or caregivers.
To show respect for patients’ cultural diversity and to provide culturally competent care:
- Treat patients with dignity and respect.
- Do not discriminate against anyone on the basis of age, disability, gender identity or expression, genetic characteristics, language, marital and family status, medical condition, national or ethnic origin, political affiliation, race, religion, sex, sexual orientation, or socioeconomic status.
To communicate empathically:
- Seek patient input.
- Respect patient decisions.
- Confirm patient understanding.
To act in patients’ and society’s best interests:
- Focus on meeting patients’ needs in our decision-making.
- Strive to meet reasonable accommodation requests.
- Provide appropriate assistance to any person who needs emergency medical care.
- Effectively refer patients to another source for care if the physician’s personal moral beliefs will conflict with a patient’s needs.
- Refer to your medical regulatory authority (College) policies to guide the process for terminating the physician-patient relationship when other options are not acceptable.
To maintain appropriate professional distance in the physician-patient relationship:
- Avoid potential, perceived, and real conflicts of interest.
- Do not enter into romantic relationships with patients (and even former patients depending on the circumstances).
- Limit treatment of immediate family and those with whom the physician has a similarly close relationship to minor or emergency interventions, and only when another physician is not readily available.
- Do not prescribe psychotropic medications to family and friends
Physicians who exhibit disruptive behaviour can adversely affect the safety of care by causing colleagues to fear interacting with them. This fear can lead to the development of unsafe workarounds and deviations from standards of care, policies or procedures.
Professionalism in collegial relationships implies assuming responsibility for our own behaviour and role in any conflict with colleagues. In professional relationships, colleagues are treated with respect and all communication (whatever the medium) is conscientious, dignified, and respectful.
To promote collegiality and healthy workplaces, incivility is not tolerated and is addressed early and justly. Team collaboration and shared accountability is fostered. Formal and informal mentorship and leadership opportunities are promoted.
Advocacy is an important role of physicians, who are expected to advocate for the well-being of communities and populations by striving to improve health outcomes and access to care, reducing health inequities and disparities in care, and promoting social accountability. In so doing, professionalism requires thoughtfulness, restraint, diplomacy, and consideration. The ease of use and uncensored nature of social media platforms can make the publication of unprofessional, hurtful, defamatory, or threatening comments too easy. Physicians must be mindful of the impact of their comments on their patients, colleagues, employers, and on the healthcare system at large.
Physicians recognize the social determinants of health, and the profession accepts responsibility to act in a way that promotes public and population health, health education, environmental determinants of health, and legislation affecting public and population health. This includes collaborative and respectful relationships with all communities and efforts to understand and implement the recommendations relevant to healthcare made by the Truth and Reconciliation Commission of Canada.
Physicians contribute, individually and in collaboration with others, to improving healthcare services and delivery to address systemic issues that affect the health of patients and of populations, with particular attention to disadvantaged, vulnerable, or underserved communities. 7
The increasingly busy and demanding Canadian healthcare environment has led to an unprecedented rise in the level of physician burnout. There is growing recognition that physician stress is also related to the conflict between the professional commitment to always put the needs of the patient first and the daily constraints providers face, which are beyond their control. 8
Providers are constantly balancing patient needs with lack of resources, technological challenges, financial constraints, and productivity metrics. This creates a double bind of being expected to focus on patient health while not having the system support to do so. Moral distress can result from these competing forces and over time, moral distress can become moral injury and burnout.
While individual physicians are accountable for making choices and adjusting their practice to optimize their wellness, physician wellness must also be promoted at the system level. It is imperative to devise healthcare systems that support individual choices to prioritize personal wellness and work-life balance, such as accommodating requests to work fewer hours where possible. The development of policies that encourage providers to seek help for themselves without fear of repercussion is paramount. To foster collegial workplaces, a just culture that promotes psychological safety should be cultivated. Addressing the system failings may be the most important solution to moral injury among providers.
There is mounting evidence that physician burnout can threaten patient safety 9. Burnout can lead to depersonalization (i.e. the development of a negative and cynical attitude toward patients and their concerns), and lack of empathy, poor memory, decreased attention and poor clinical decision-making. Burnout can also lead physicians to leave medicine, resulting in decreased access to care for patients. An important component of professionalism is thus to commit first to self-care, personal health and wellness, and making efforts to balance professional responsibilities and personal life.
While it can be exceedingly difficult to make the necessary changes we know we need, tangible steps to promote wellness can include:
- not treating oneself, and instead having a family physician and discussing stress and other health concerns with them
- reaching out to the local physician health program
- focusing on issues that are within one’s control (such as financial decisions, work hours, bringing work home, prioritizing exercise and rest, choosing to work with supportive colleagues, etc.)
- de-emphasizing one’s focus on issues outside of one’s control (staffing levels, reimbursement programs, institutional policies and decisions, etc.)
- professionally advocating for desired change
Despite challenges in the healthcare environment, professionalism remains at the core of medical practice
Professionalism is the translation of the values of the profession into daily practice.
- Put patients’ needs first, while maintaining your wellbeing?
- Advocate for patients and for safe medical care?
- Participate in continuous medical education/professional development?
- Actively seek feedback and learn from past experiences?
- Provide constructive coaching and mentoring?
- Communicate effectively to foster trust?
- Have truthful, empathic, and honest discussions with everyone?
- Share clinical decision-making with patients?
- Respect patients’ values and goals?
- Protect patients’ confidentiality and privacy?
- Provide culturally competent care?
- Treat everyone with dignity and respect?
- Remain mindful of potential conflicts of interest?
- Constructively manage conflict?
- Seek to preserve your personal health, including work/life balance?
- Support colleagues who seek to preserve their personal health?
- Foster a just culture that embodies psychological safety?
- 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. Available from: http://www.annals.org/content/136/3/243.full (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.)
- Canadian Medical Protective Association [Internet]. Ottawa (ON): CMPA; 2012 October. Physician Professionalism – Is it still relevant. Available from: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2012/physician-professionalism-is-it-still-relevant
- Lee AG, Beaver HA, Boldt HC, et al. Teaching and Assessing Professionalism in Ophthalmology Residency Training Programs. Survey of Ophthalmology. 2007 May; 52(3): 300-314. Available from: https://www.surveyophthalmol.com/article/S0039-6257(07)00014-8/fulltext
- Teherani A, et al. Domains of unprofessional behaviour during medical school associated with future disciplinary action by a state medical board. Acad Med. 2005, 80: S17-20
- Yepes-Rios M. et al. The Failure to Fail Underperforming Trainees in Health Professions Education: A BEME Systematic Review. BEME Guide No. 42. Med Teach 2016; 38(11): 1092-1099
- Picard E, Robertson G. Legal Liability of Doctors and Hospitals in Canada. Third edition. Carswell; 1996.
- Canadian Medical Association. Ottawa(CA): CMA:2018. CMA Code of Ethics and Professionalism. Available at https://www.cma.ca/cma-code-ethics-and-professionalism
- Dean W, Dean A, Talbot, S. Reframing Clinician Distress – Moral Injury not Burnout. Fed Pract. 2019 Sep; 36(9): 400–402
- College of Physicians and Surgeons of Ontario. CPSO: 2020 June. Physician Burnout and Covid-19. Available at: https://dialogue.cpso.on.ca/2020/06/physician-burnout-and-covid-19/