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Medical practice is a profession and is therefore bound by a strong code of ethics. The fundamental principles of medical ethics include concepts of beneficience, non-maleficience, respect for autonomy and justice. In addition, it is important to understand the concept of the “best interests” of patients. In modern day practice, potential financial conflicts of interest can occur in numerous areas. Examples of such areas are managed or contracted care; medical assessments for third parties, medical research, financial relationships with patients and families, gifts and bequests from patients, doctors in healthcare and non-healthcare businesses, relationships with medical industry and the concept of an “ethical limit” to doctors’ fees for services. This talk will scan these territories, identify risks and give some guidance on how best to mitigate these risks and act ethically in a variety of situations so as to avoid financial conflicts of interest or even the appearance of such conflicts.
The aim of professionalism in medicine is to ensure that physicians remain worthy of the trust of patients and the public. Yet, physicians do not share a uniform understanding of what professionalism requires of practitioners, or even of what the word “professionalism” means. How to teach and train for professionalism therefore also presents ongoing challenges. This lecture will explore the history of professionalism, a contemporary definition of professionalism, the roles of professional associations, and the importance of explicit professional formation during medical education.
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Why MOC? | by Dr Matthew K. Wynia | 5 November 2013
Since ancient times, physicians have made both implicit and explicit promises to not only attain a certain level of skill before becoming a physician, but to pursue lifelong learning and continuous advancement of their knowledge and skills. Until recently, the profession has focused largely on ensuring the qualifications of those entering practice; our promises regarding lifelong learning and advancement have been informally monitored or enforced, if at all. Today there is a growing movement to adopt self-regulatory systems to verify that practitioners’ learning and skill development continue throughout their careers. These new “maintenance of certification” (MOC) systems have posed challenges, but when implemented well they have also shown benefits both for patients and for physicians.
Teaching ethics and professional values to adult learners is challenging. Many of the easiest, cheapest, and most popular methods – such as lectures about ethics – are widely-recognized as almost completely ineffective. Therefore, in this lecture about ethics (which is #10 on the list of teaching methods) we will explore 9 additional methods for teaching and learning about the shared standards and values that bind us together as professionals.
Professionalism entails being bound by sets of shared values, standards of practice, and mechanisms for professional self-regulation. Historically, the one irreplaceable feature of professional associations has been their key role in articulating, debating, refining, distributing and enforcing these shared values and standards. When our organisations accomplish this task, they garner trust and respect for our profession. But professionalism and our professional organisations operate in tension with market and state forces that also seek to establish the values and rules that will govern medical practice. Professional associations must protect and advocate for the shared values they establish, even when doing so conflicts with state or market powers, if they wish to retain the trusted position of professionals in society.
Like many national medical professional organizations, the American Medical Association has struggled to contain declining membership for decades. These struggles reflect the impacts of demographic, socio-cultural, and technological changes in medicine and in the larger community – but they also reflect choices made by our associations about what activities to pursue and how to understand the core purpose of these associations. Absent a new direction, could our associations continue to lose members and eventually wither away to nothing? What would be the implications of the slow dismantling of our national medical professional associations?
The profession of medicine is based on a shared set of tacit and explicit agreements about what patients, doctors and society at large should be able to expect from each other, a social contract that defines the profession. But in the West, the notion of medicine as a profession is both younger and less robust than many might believe. In the US and internationally, professionalism in medicine is now often under threat from fragmentation, lack of cohesion and integrity, and loss of the public’s confidence; and other ways of organizing and delivering care are being developed that rely less on trusted professionals and more on market or state forces. These changes reflect the fact that our present social contract is one dimensional, overly simplistic and has failed to sustain the public’s trust. But what will it take to renew the social contract and reinvigorate professionalism?
Health professionals have long sought to improve quality, and the pursuit of improved quality is generally recognized as an ethical duty. Recently, those interested in ethics and quality improvement have largely focused their attention on ethical and practical concerns about modern quality improvement methods and review processes. But there are other key lessons to be learned at the intersection of ethics and quality improvement. For instance, while quality and safety science have recognized the importance of organizational culture, human factors, and structural barriers to safe care, many people still see ethics as primarily about individual morality and personal virtue. Just as we have done with patient safety, it is time to think carefully about how the environment of care can make it easier, or much harder, for health professionals to live up to their ethical promises.
The US is in a period of large scale experimentation around how to pay health professionals. All methods – including fee-for-service, salary, and performance-based payments – have both positive and worrisome attributes. In particular, performance-based payment (pay-for-performance or P4P) has tremendous intuitive appeal as a means to encourage high quality care. A variety of P4P programs are now being implemented, though concerns have been raised about possible unintended adverse effects on quality of care as well as on intrinsic motivation and professionalism.
