ETHICAL THINKING&

PROFESSIONALISM

Dr MeiLing Denney & Dr John Dunn

SE Scotland Trainers conference workshop

2018

Aim of Session

• To increase our understanding of medical ethics and professionalism

• To develop tools we can use to help us teach these to our trainees

Plan for the Session• Medical ethics 15 minutes

• How we teach it• Why it is important to think ethically• Using the ethical grid as a tool to teach ethics

• Professionalism 15 minutes • How it relates to ethics• What is it and why it is important

• Talking About Professionalism 30 minutes• Scenarios to help us discuss professionalism

Big Picture• Why are we GPs?

• To try to relieve human suffering

• What should we do?

• Be Competent Be Kind

• How do we do this ?

• Think Ethically Act Professionally

We Need Your Help !!!

How do you teach your trainees about medical ethics ?

• Please discuss in pairs

• 2 minutes and feedback

GPs MUSTBE FLEXIBLE

SEE THINGS FROM DIFFERENT POINTS OF VIEW

ADAPT AS CIRCUMSTANCES CHANGE

Flexible Perspective

• Very important as a Dr to be able to see a situation from different perspectives.

• Often there is more than one way of looking at a situation

• We can learn to do this if we work at it

•Look at this image

WHAT DID YOU SEE ?

RABBIT OR DUCK ?

Learn to see things in different ways

• You can learn to see the same event or thing for example a simple line drawing in 2 or more different ways

• You can learn to see patients or doctors experience in different ways . An interaction is often a different experience for the different agents taking part in it , we need to understand this and be willing to see these differences.

The Value of having an understanding of medical ethics

• Learning to think ethically can help us to see situations from different points of view

Medical ethics

That branch of ethics that studies problems arising from medical practice. All medical decision making has ethical dimensions………..

Basic Medical ethics

• We should aim to ensure our trainees have a sound understanding of medical ethics

Medical ethics

That branch of ethics that studies problems arising from medical practice. All medical decision making has ethical dimensions………..

Ethical theory and the 4 principles

• Principles have developed from ethical discussions about medicine over the years

• No one principle is privileged over another

• They have to be though about in each situation presented

• Then we as Doctors need to make a decision that is our job - to make decisions and to justify our decisions

THE ETHICAL GRIDAPPLYING THE 4 PRINCIPLES

Four Principles Ethical Grid

GRID Patient Doctor Colleague Society

Benif

Non-Malif

Justice

Autonomy

Using the Grid

• What will you do in the following situation

• Justify your actions using the ethical grid

Dilemma

• Practice policy no fitness certifs if off work less 7 days

• F17 trainee hairdresser viral illness 4 days requests certif

• On probation Boss says if no certif will let her go

• What will you do use grid to justify your actions

Four Principles Ethical Grid

GRID Patient Doctor Colleague Society

Benif

Non-Malif

Justice

Autonomy

How does professionalism fit in here ?

Professionalism

What is professionalism?

• IN SMALL GROUPS:

• What does professionalism mean to you?

Relationship professionalism to ethics

A definition

• 4 Basic characteristics:

• the observance of explicit standards and ethical codes

• a calling or vocation linked to public service and altruistic behaviour

• the ability to apply a body of specialist knowledge and skills

• a high degree of self-regulation over professional membership and the content and organisation of work.

• Rosen & Dewar, Kings Fund discussion paper, compiled from Irvine 2003, Cruess R, Cruess S 2003; Medical Professionalism Project 2002)

How we learn professionalism

• Professionalism is a vital aspect of modern medical practice

• often perceived as something doctors learn ‘on the job’ rather than via structured teaching

• can we be more proactive?

• How do we equip our trainees with knowledge of professional behaviour?

• that’s what this session is about!

Cruess & Cruess (BMJ 1997; 315(7123) )

• “Professional status is not an inherent right, but is granted by society. Its maintenance depends on the public’s belief that professionals are trustworthy and to remain trustworthy, professionals must meet the obligations expected by society”

A medical definition

•A set of values, behaviours, and relationships that underpins the trust the public has in doctors.

• Royal College of Physicians (RCP) Doctors in Society: Medical Professionalism in a Changing World p14 (2005)

What do patients expect?

• Ensure the well being of patients and to protect them from harm

• Be technically competent• Be open and honest• Show patients respect.

• By demonstrating these qualities, doctors earn the trust that makes their professional status and privileges possible.

• Doctors once enjoyed freedom to define acceptable standards of care and to control the content and organisation of their work

What are the challenges to Professionalism ?

• Discuss in pairs - 2 minutes

Challenges to medical professionalism 1• Widely publicised incidents (eg unauthorised retention of

organs at Alder Hey, surgeon branding name into a patients liver, poor care & Mid Staffs) = failures by the profession to stay in tune with prevailing public values and maintain standards.

• Increasing public expectation for timely and convenient access to an ever-wider range of services, provided with greater openness and accountability.

• Growing demand among patients for consultations with doctors enabling shared clinical decision-making.

• Increased managerial control over medical work; wider government reform of the health service.

Challenges to medical professionalism 2• New ways of working, more team and multi-

disciplinary working, increasing diversification of medical roles

• Changes in doctors’ working conditions have taken place, driven partly by EWTD and by a higher proportion of LTFT doctors.

• Organisational and political reforms, undertaken to improve patients’ experiences of health care, may increasingly conflict with professional views about how best to serve patient interests.

How do you think we can teach professionalism?

• IN SMALL GROUPS

Professionalism –required traits

• Aspiration to altruism

• Accountability

• Excellence

• Duty

• Service

• Honour

• Respect for others

• Conscientiousness

• Competence

• Timeliness

• Sensitivity

• Confidentiality

• Effective Communication

• Integrity

Skills for professionalism

• As well as the right values and attitudes, trainees must have the necessary skills

• Clinical skills, keeping up-to-date

• A range of communication skills, verbal and written

• Record keeping, clinical notes, messages to others

• Organisation e.g. Referrals, prescriptions, prioritising work

Prof Kieran Sweeney& professionalism

• “ GP is a tough job and it requires the skills of a serious person. It requires us to be technically competent and to identify with the humanity of the patients we have the privilege of trying to help”

• In essence to be competent and to be kind

Scenarios

Distribute scenarios between small groups of 3s• Each Group discusses on own - 5 mins

• General discussion 5 scenarios

A grateful patient

• One of the partners is away on sabbatical for three months. The GP trainee has been asked to take over one of the elderly patients who receive a monthly visit. She mentions that after spending some time at the patient's house, this grateful patient gave her an envelope to “buy something for the children”.

• After leaving the house she opened the envelope to find it contained 2 x £20 notes. She tells you she bought the children some Lego and chocolates, and wonders if she should let the patient know.

Clinical holistic care

• CbD discussion. Trainee reports the sad and unexpected death 1/52 ago of a 35 year old lady who at home of a drug overdose. She had a long history of psychosocial problems, and was on prescription and other drugs.

• Trainee saw patient in surgery a week before death, and gave counselling to try to reduce medication. The patient was found by her 14 year old son and the trainee visited to pronounced life extinct, and contacted the procurator fiscal for a post-mortem to be arranged. The deceased patient's cohabiting partner was also in the house.

• Trainee has not mentioned any follow-up for the family, and no visits or appointments have been made to do this.

A moan in reception

• You are passing reception, and happen to overhear the trainee having a grumble about some of the patients he has seen to the receptionist (away from the immediate reception desk). You hear the phrases “Half of these people are bonkers”, and “I really get fed up with time-wasting social problems that I can't do anything about”

Delayed referrals• Your trainee is somewhat disorganised, but

went on holiday last week and will be away for three weeks. The salaried doctor who shares the same room has reported that she has found a folder of notes on patients who are to be referred, in the top drawer of the desk in the consulting room. The secretary has told her that none of these referrals have yet to be made

Late for meetings

• The ST1 Trainee is repeatedly late for practice meetings, despite being in the building prior to the meeting taking place.

• The Practice manager says that, when she has passed his room, he appears to be at his computer doing practice MCQs for the AKT. He is due to sit the AKT in 6 months. When she mentioned that the meeting was about to start, he stated that exam preparation was more important for him at his stage, and the meetings were just about practice business and updates he could read from the minutes.

Summary MLD and JD• Professionalism and fitness to practice should be part of

routine GP training

• General practice provides ample opportunity for discussion on professionalism

• Schedule teaching time for trainees for specific discussion on professional behaviour, what is acceptable, what is not

• Discuss appropriate values and attitudes to patients, encourage patient-centred care

• Use examples of role modelling of self and others

• Address any behavioural deficiencies promptly, and encourage reflection in trainees to enable insight and improvement

Finally…• A NES colleague in fourth valley is doing a masters in education,

with the topic of teaching professionalism to generation Y. Please help her to complete the survey!

• The following slide has her contact details and twitter handle as there is a pinned tweet with a link to the survey.

• She also recommends 2 papers for bedtime reading if you are interested:

• Eckleberry-Hunt, J., Tucciarone, J. (2011). The challenges and opportunities of teaching “Generation Y”. Journal of Graduate Medical Education

• Matthews, J., Morley, G., Crossley, E., Bhanderi, S. (2017). Teaching leadership: the medical student society model.

Understanding changing views

Does Professionalism mean the same to all GPs?

Dr Trudy Foster- GP Forth Valley, Associate Adviser NES, student!trudyfoster@nes.scot.nhs.uktrudyfoster@nhs.net@dr_t_foster

Previous research has looked at differences between professions (doctors/nurses), departments (medical/surgical), training stage (trainer/trainee).

Anecdotal evidence of difference in professional values and behaviours over generations. Aim study to prove or disprove this?

Short survey, less than 10minutes.

https://response.questback.com/nhseducationforscotland/sgeyssqr61