1. Professionalism as a general concept
Professionalism is like good manners that you see in someone: easy to recognise and appreciate, and yet hard to define since what constitutes good manners can change with time. However, the relevant literature suggests that there is a universally accepted core in terms of concepts, ideas, theories, attributes and characteristics when it comes to defining, understanding and practising professionalism as an individual or a group or as an institution (Sylvia and Richard, 1997).
Dictionary references on professionalism indicate that the first known use of the word goes back to 1856 and the meaning of the word focussed on two ideas. The first is the conduct and/or qualities of a person that practises a profession or a calling, wherein knowledge and skills acquisition occurred by sustained and rigorous pursuit. Secondly, such practise is carried out by a professional mostly to make a livelihood. The formal recognition of a professional, at a basic level, comes from the society and therefore professionals have ongoing obligations that are often referred as social contract (Project, 2002).
Professionals are expected to discharge their obligations to their clientele by certain observable and often verifiable behaviours that contribute to positive outcomes. The focus on the behaviour is because there is a body of evidence to support the conclusion that bad behaviours correlate well with undesirable outcomes(Mueller, 2009). The behaviour expectations apply to collectives when professionals work in a team or group, e.g. healthcare, to deliver positive outcomes to their stakeholders and it is expected that that the members of the group take a system view (Hafferty and Levinson, 2008) and contribute to improve it by aiming for highest quality outcomes as the context or environment changes. Professionalism today is heavily institutionalised and is often referred to as a societal movement and coding normative behaviours (Swick, 2000) across inter-professional or issued based groups has become complex due to commercialisation (Project, 2002, Coulehan, 2005, Hafferty and Castellani, 2010) and resulting conflict of interests.
Professional conduct, as an individual or as a distinctive group, will require a multitude of factors that include knowledge, skills, experience, reflection, analysis, development of solution in the best interest of the community and adaption to the demands of the ever-changing environment(Wendy et al., 2014).
2. Professionalism in the context of health, medicine & surgery
The social contract that exist between medical professionals heavily emphasises public trust (Swick, 2000) in individuals and the profession itself due to the very nature of the business wherein choices are presented and decisions made that can have substantial impact on quality of life of others or perhaps on life itself. While the Hippocratic oath embodied the ethics for long, the modern perspectives largely identify certain principles, behaviours and responsibilities to achieve the necessary counter-balance to increasing commercialisation and provide guide to practising professionals to retain a professional identity (Mueller, 2009).
At the core of the fundamental principles in medicine, serving the interest of the patient always, empowering patient to make decisions concerning their care and ensuring social justice by striving to eliminate discrimination in healthcare settings, are the three virtues that appear to find wide consensus in literature (Project, 2002, Lesser et al., 2010). In terms of physician responsibilities, several qualities, attributes, concepts can be found specific to contexts for which the code or charter is designed to serve, but again, the medical fraternity appear to have consensus on many. Individuals and profession committing to continual learning and scholarship, honest sharing of information with patients, maintaining patient confidentiality, striving to improve quality and care of access, fair distribution of resources and above, a commitment to maintain trust are some of these qualities and attributes (Project, 2002, Mueller, 2009).
The health profession thus relies on oath, widely agreed virtues and principles, to instil professionalism by the practitioners of the profession. However, from a patient as a community member of view, the social ethics strongly focus on individual autonomy wherein an individual is able to weigh up the information provided and exercise free will in making an informed consent decision a theoretical approach that traces back to Kant (Carson-Stevens et al., 2013). There is an alternative approach put forward by Mill wherein such individual autonomy need to take into the account the social benefit impacted by decisions or consents. The tension between the two-theoretical approach is obvious in hospital settings and varying degrees of framing occurs to obtain consent for a student to perform a procedure like a EUA.
There are suggestions of other approaches as well. The use of situated learning approach of using authentic activities can be effectively used to teach all stakeholders (Cruess and Cruess, 2006). Experiential learning and knowledge gained thereby is another theory that is thought to be effective and there is widespread agreement that there exists a balance between the two for teaching activities related to professionalism to succeed.
The public view on medical professional’s ability to keep their interest as the focus of care has diminished in recent times due to a variety of reasons and it is argued that the professionals and the profession needs to self-regulate to find the necessary balance to repair and reinstate its unique position and voice or risk external forces to determine and manage its conduct. It is for this reason, the focus on professionalism has increased and its institutionalisation rigorous.
3. Personal observation of a (potential) professional lapse
Despite the professionalism related codes, charters and intent, lapses can be observed in the health care settings, routinely for a variety of reasons. The summary below narrates a scenario wherein lapses that were perceived, reported and investigated in a teaching hospital relating to intimate examination (of patients) under anaesthesia (EUA) and I had some involvement in the investigation.
Medical students regularly attended operating rooms in this hospital and often performed pelvic examinations on anesthetised patients in the presence of their supervisors. During one rotation period, two complaints were informally reported initially, one by an anaesthetic registrar and the other by the Head of an anaesthetic department and subsequently got escalated higher for independent investigation. In both the instances, the complaint was about students perceived to have not obtained prior consent from the patient and that, their supervisors allowed them to perform EUA.
As the investigations began, the divisions and tensions in the work environment became obvious and two broad themes emerged. One theme focussed on the need for every student to ask patient due consent to be involved in the care, let alone perform a EUA. The other view was that the students are a part of a team that cared for the patient in a teaching hospital and the consent obtained by their supervisor prior to the procedure is sufficient for them to perform an EUA under direct supervision. The students also appeared to rely on the consultant or supervisor to inform about their presence in the operating rooms to observe, assist or perform care related activities and such practice was seen by many as “routine”. While the students also introduced themselves to the patients, the process was not always transparent and documented. The investigation drew interest from all stakeholders, formal and informal debates ensued about relevant practices and the independent investigation systematically obtained an array of facts from people who were involved in the incidents to determine the issues, root causes and any improvement solutions. It may be noted that in both instances, there were no complaints from patients.
4. Key issues related to EUA
At the core, taking responsibility for obtaining a valid consent by the student prior to undertaking an EUA was generally agreed as the key issue. However, several key issues, several them directly related to professionalism, also surfaced from this incident from a health professionals’ and system point of view and these issues and related contributory factors needed to be understood.
From a student perspective, the issues were:
- Does a student need an explicit consent to be present in a theatre as an observer in a teaching hospital?
- Who is responsible for obtaining consent from the patient for a student to participate in care related activities, or to learn an intimate examination, EUA specifically in this instance?
- What is the legal risk exposure of a student to performs an intimate EUA without explicit consent?
- Is there a uniform practice of obtaining consent by students prior to undertaking any procedures on anesthetised patients?
- Who is responsible for ensuring a uniform practice by students to obtain valid consent?
- Are the students covered for any medico-legal liabilities?
- Who will cover the medico-legal costs of a student in the event of a patient complaint?
- Are there real or perception barriers to students obtaining consent from patients? If they are what are they? (Carson-Stevens et al., 2013).
- Are there alternate methods to learn pelvic examinations with comparable outcomes?
- Is there a hidden curriculum in training medical students? If yes, what are the implications?
From the perspective of surgeons or other supervisors of medical students, the issues were:
- Supervisors mention “team care” to patients while obtaining procedural consents, i.e. presence of students in the theatre to observe or perform care related activities. Is it sufficient for a student to perform EUA?
- Were patients made aware of the possibility of students getting involved in care, specifically perform intimate EUA, during pre-operative clinic appointments by surgeons or their surrogates? If yes, was it sufficient to be treated as patient consent?
- Does the surgeon or supervisor for the students have a responsibility to ensure that the students obtained specific consent prior to asking them to undertake an intimate EUA?
- Is there a uniform practice of obtaining consent by surgeons across all theatres?
- What is the medico-legal risk exposure of a surgeon or student supervisor if a student were to have performed an intimate EUA without explicit consent?
From the organisations point of view, i.e. the teaching hospital and the university
- Are health professionals made aware of the institutional policy regarding interventions and trained to apply them in real life scenarios?
- What is the university policy on its student examination of patients? Is there a specific policy related to students performing EUA?
- Does the university have a policy and procedure to ensure student compliance re patient examination and more specifically, EUA?
- Is there a policy and procedure for intervention within the hospital system when lapses are observed? Are there different levels of intervention within such policy?
- How are the intervention policies, if any, communicated to stakeholders and are they trained routinely in intervention methodologies?
- Is there a structured dataset in the operating notes to document patient consent for student presence or examinations so that primary providers and others can comply in a uniform and systemic manner?
- Does the university or hospital provide learning opportunities for students to learn pelvic examinations using alternate methods?
From a patient point of view:
- How do they feel about student involvement in care related activities while in a teaching hospital?
- Do they expect to be asked for specific consent when a student EUA is involved in care?
- Do they subscribe to the idea of “team care” and place the trust in the lead surgeon to manage their care appropriately?
- Given that a student performs an intimate examination may not have any therapeutic value, are there factors that influence their decision to consent or not?
From a community point of view:
- Can the doctors be trusted to do the right thing?
- If there are barriers to students obtaining patient consent, how would they feel to have insufficiently trained doctors entering work force? (Carson-Stevens et al., 2013)
- Is there a need for community to understand the conflict that may arise from patient autonomy and societal needs?
5. Discussion on EUA related literature and associated professionalism and ethical aspects
While the lapse related investigation took its own course, I was not privy to all its findings. However, it is relevant to examine the literature specific to EUA since it routinely occurs in all teaching hospitals and the broader picture may present a comprehensive view of underlying ethical issues, the legal perspective and the professionalism aspects.
Firstly, there is an issue documented in literature wherein medical students perform EUA under the direction of their supervisors without obtaining an explicit consent from patients and such occurrences have been reported in literature, globally (Wilson, 2005, Yvette et al., 2003, Rees and Monrouxe, 2011) . There is also a general acknowledgement of a hidden curriculum in the teaching hospitals where supervisor instructions and prevailing culture appear to take precedence to consent requirements (Herbert M et al., 1999, Hickson et al., 2007, Leape et al., 2012, Burack et al., 1999, Browning et al., 2007).
Almost, all the literary papers reviewed from a professionalism perspective suggest in varying degrees that the patient not only be informed and consent obtained prior to a medical student participating in care, but also recognise the right to change their mind at any point and the same must be respected (Wall and Brown, 2004, Schniederjan and Donovan, 2005, Leung and Patil, 2011, Bagg et al., 2015, Sokol, 2004). There are several reasons and one of the prominent argument is that they are not fully qualified doctors and as such their involvement predominantly for the purpose of learning must be explicitly consented (Wall and Brown, 2004).
There are several surveys wherein patients have clearly expressed that they would like to be informed of student involvement in their care and their right to exercise choice (Cohen et al., 1988).
From a clinical perspective, students performing EUA is considered essential learning needed to plan surgical interventions (Cohen et al., 1989, Dugoff et al., 2016, York-Best and Ecker, 2012, Goedken, 2005, Liu et al., 2017) and the expert opinion is that the theatre is the ideal setting to perform and gain confidence in their clinical skills (Abraham, 1995, Papagiannis, 1992, Powell et al., 2006, Pradhan et al., 2010). Despite its value to students, research suggests that there are significant barriers for students to obtain consent due to a variety of reasons that include gender, race, framing by other personnel etc. (Buck and Littleton, 2016, Bhoopatkar et al., 2017, Koehler and McMenamin, 2012, Bagg et al., 2015, Project, 2002) in addition to the ethical issues they may face (Fard et al., 2010).
Interestingly, a decline in medical students’ attitude towards consent has also been reported (Neumann et al., 2011) where they appear to place less importance to due process due to changing values (Ubel et al., 2003). Such evidence is sporadic and by no means conclusive.
Legally, performing an EUA or an intimate examination without explicit patient consent may be viewed as anything from battery to rape depending upon the law of the land, the surrounding context and a student is most likely to be liable and face adverse outcomes (Gibson and Downie, 2012, Kermode-Scott, 2012), especially in countries where legal decisions are jury based. Decisions are arrived based on information made available to patients and their capacity and voluntariness to consent only and a student may not get leniency or sympathy (Bewley, 1992).
6. Strategy for dealing with the lapse (Solution options)
Pelvic EUA and other such student interventions are essential for student learning and gaining of confidence. However, the whole student experience in a theatre environment can be daunting if there is no sufficient preparation, clear purpose and support from a variety of sources to obtain consent from the patient. This is even more necessary due to presence of barriers for a student to obtain patient consent for an intimate examination for the purpose of learning a skill. There are several broad considerations that must be addressed to ensure that a patient’s participation in the consent process is voluntary and non-discriminatory. They are:
- Professionalism must be taught to help understand its roots and evolutionary nature (Sylvia and Richard, 1997).
- Students must learn the necessary skills to front up and obtain consent successfully (Westberg et al., 2001) and where not successful must have a low threshold to accept and respect patient decisions. Teaching institutions must take accountability for imparting relevant knowledge and blue prints for assessments of professionalism and competence (Epstein and Hundert, 2002, Arnold, 2002, Wilkinson et al., 2009, Mueller, 2009, Lucey and Souba, 2010).
- Student performance in obtaining consent should be evaluated through-out their curriculum using tools (Cruess et al., 2006, Roberts et al., 1999).
- Rotation co-ordinators should ensure that the context, clarity of purpose and preparedness of the student prior to entering theatres to maximise chances of overcoming barriers and overall learning experiences (Fernando et al., 2007).
- The accountability for the student to obtain due consent must be placed upon the registered health professional responsible for the patient care in theatre and this approach is already a part of a consensus position statement by district health boards and large teaching hospitals in New Zealand (Bagg et al., 2015).
- The hospitals must train their health professionals to create the necessary environment and appropriate framing of the students’ efforts to obtain consent.
- The hospitals must also have systematic documentation to ensure that the due process is followed, and consent or denial duly recorded in operating notes.
- The method of teaching pelvic examinations must be reviewed and improved (Dugoff et al., 2016).
- Use of alternative methods, e.g. simulation, must be incorporated to reinforce theatre based learnings in the light of encouraging results reported from research (Pugh and Youngblood, 2002, Kwan et al., 2014, Mackel et al., 2007).
- Soft skills are a necessity for students to exhibit a professional behaviour. Faculty and role model development is necessary in this regard and the same must be rigorously undertaken by teaching institutions as a complimentary approach, in view of the societal benefits arising from training competent doctors (Herbert M et al., 1999, Hickson et al., 2007, Wilson et al., 2013, Cohen et al., 1988, Carson-Stevens et al., 2013).
The healthcare system is complex (Hafferty and Levinson, 2008) and professional conduct at all can be a daunting prospect. While producing this academic work and my involvement in the aforesaid EUA related investigations, student learning of procedural skills with due consent does come across as a complex issue from my practice perspective. However, with sufficient empathy it is not hard to understand the patient perspective when it comes to pelvic examinations and the vulnerability of the student. The surgeons and other registered professionals have numerous opportunities to act as role models and exhibit behaviours that can emulated by students and instil confidence in patients that they are being cared for by a competent and trustworthy team. At the heart of all this professional behaviour is honest and transparent communication with the patient regarding the care being provided and the purpose of the student participants. I can hardly remember a patient refuse to accept a student in my clinic or theatre and I do believe that honest and consistent communication prior to anesthetizing patients helps. I also introduce any students present to the patients and give them the time they need to communicate with the patient. Systematic data collection in theatre notes and a robust definition of levels of intervention within the hospital will further help to avoid future lapses.
While reading the reference materials, it is easy to notice that the student teaching mostly occurs in public hospitals where we have patients who cannot afford private health cover (Wilson, 2005). The guiding principles governing the behaviour of professions articulates the mandate to ensure equity and yet, health professionals are somewhat helpless in this regard (Wynia et al., 1999, Livingston et al., 2016). While I agree that professionalism can be taught to students, I believe that certain behaviours are deep rooted in individuals and traces back to their family upbringing and community culture where they grew up. Given such background, a largely systematized, compliance based approach is more likely to deliver consistent results (Teherani et al., 2005) rather than unrealistic expectations of altruistic behaviour that relies on narratives to teach professionalism to health professionals and the profession.
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