Understanding medical professionalism

Opening Vignette

Doctor B, an associate consultant in a public Hospital X, was approached by a junior staff nurse (Nurse N) in the ward corridors. She asked if he could examine and give an opinion for a swelling that she had observed over her belly button for the past few months. Doctor B agreed to examine Nurse N, and to avoid the hassle of obtaining a polyclinic referral for scheduling a clinic appointment, they agreed to a quick consult in the ward pantry in the presence of a trusted female colleague as chaperone. Doctor B diagnosed the swelling as a paraumbilical hernia and explained the options for treatment, including surgical repair. Nurse N was concerned about the hospitalisation leave, and Doctor B told her not to worry, as he was usually adaptive to patient-centric ethos and leave requests. Nurse N suggested that if he could give her 6 weeks of hospitalisation leave, she could visit her elderly parents overseas, to which Doctor B agreed. Nurse N solicited a polyclinic referral and requested Doctor B to carry out the surgery as soon as possible. Although Doctor B’s usual wait time for elective surgery was about 8 weeks, he managed to allocate a slot to Nurse N and listed her as a priority case.

DEFINING MEDICAL PROFESSIONALISM

Medical or healthcare professionalism is a wide and complex concept that is difficult to define succinctly and inclusively. In the absence of a universally accepted definition, some doctors and educators become confused and at times paralysed in their attempts in defining, teaching and evaluating competency in medical professionalism. This article attempts to summarise the various elements of medical professionalism — a complex, multifaceted concept — for the benefit of medical students, trainee doctors, educators and non-doctors.

Professionalism has its historical roots in medical professional organisations attempting to establish their identity, credo, ideology and the philosophy of medicine. Professional codes of ethics and practice were established to clarify the principles and behaviours governing the doctor–patient relationship and the relationship between the profession and society.

The Physician Charter on Medical Professionalism, developed by the American Board of Internal Medicine Foundation, American College of Physicians and European Federation of Internal Medicine in 2002, has since become the most widely endorsed document on medical professionalism around the world, with the endorsement of more than 300 medical professional bodies, including the Academy of Medicine, Singapore. The Charter makes provision for the Three Fundamental Principles and Ten Professional Commitments of medical professionalism [Box 1].[1]

Box 1.

Physician charter on medical professionalism.

Three Fundamental Principles

1.Primacy of patient welfare

2.Patient autonomy

3.Social justice

Ten Professional Commitments

1.Commitment to professional competence

2.Commitment to honesty with patients

3.Commitment to patient confidentiality

4.Commitment to maintaining appropriate relations with patients

5.Commitment to improving quality of care

6.Commitment to improving access to care

7.Commitment to a just distribution of finite resources

8.Commitment to scientific knowledge

9.Commitment to maintaining trust by managing conflicts of interest

10.Commitment to professional responsibilities

Adapted from Blank et al.[1]

The medical literature abounds with definitions for professionalism, professionals and medical professionalism. Let us start with a definition from a professional association that has attempted to define the contemporary identity of a medical doctor as a professional and healer. The following is the definition used by the Singapore Medical Association Centre for Medical Ethics and Professionalism:

“Medical professionalism encompasses a set of duties, competencies, values, virtues, behaviours (professional conduct), outcomes (performance) and relationships that aims to achieve the Goals of Medicine and promote Trust and Confidence in the medical profession and the healthcare system.”[2]

This definition focuses the emphasis on the aims and goals of professionalism rather than just the attributes of medical professionalism. It can also be described as the professional credo or professional philosophy.

WHAT ARE THE GOALS OF MEDICINE?

As one of the two main aims of medical professionalism is achieving the goals of medicine, it is important to reflect periodically on the established and appropriate goals of medicine to keep our bearings.

The established and primary goals of medicine include the relief of symptoms of pain and suffering caused by maladies; care and cure of those with a malady; improving the functional status and maintaining the compromised status of those who cannot be cured; preventing untimely death and promoting a peaceful death; health education, counselling, care and support of patients; and promotion and maintenance of health and prevention of disease.[3] The secondary important and legitimate goals of medicine that support the primary goals include medical research, medical education, clinical governance and professional governance.

The controversial goals of medicine include several entities and practices that are ethically incongruous to the primary goals of medicine, but have been thrust upon medical practice by society and commercial and other forces. This includes the practice of aesthetic and enhancement procedures, euthanasia and termination of pregnancy. However, all medical professionals must be cognisant of the undesirable and inappropriate use of medical knowledge and skills, such as commercial exploitation of the sick and vulnerable, police or prisoner interrogation, torture, assistance and participation in capital punishment and experimentation or research without consent. These would be considered inappropriate goals of medicine.

WHY ARE TRUST AND CONFIDENCE IMPORTANT IN THE PRACTICE OF MEDICINE?

Medicine is a complex system filled with uncertainties and ambiguities. The science is imperfect and incomplete, with outcomes probabilistic at best. The knowledge and technology are vast and fast changing, such that it is almost impossible to master and sometimes make sense of its appropriate use. Therapy has to be instituted even when diagnoses are incomplete. Even applying the scientific basis or evidence-based medicine does not result in certainty and predictability in clinical outcome. Professional judgement has always to be exercised in situations of incomplete information, resources and time.

Illness makes patients vulnerable, anxious, depressed or fearful. Patients bring along their own unique preferences, expectations, concerns, bias and issues. Doctors working in teams are expected to communicate and perform consistently, swiftly and humanely. Doctors, like all humans, also have their own vulnerability and fallibility.

Professionalism, as an ideology and applied philosophy, provides a framework that allows stability and certainty in medical practice through the building of trust and confidence in patients and a sense of solidarity among all the stakeholders in medicine. The trust and confidence created by professionalism enable effective management of the uncertainty and complexity of medical practice, thus enabling healthcare professionals to meet the challenges and expectations in their work. The pillars of professionalism that promote and preserve trust and confidence in the healthcare system are marked by clinical competence, ethical competence, altruism and organisational professionalism in clinical and professional governance.

WHAT IS THE LEGAL BASIS AND FRAMEWORK FOR MEDICAL PROFESSIONALISM IN SINGAPORE?

Historically, medical associations lobbied governments to establish medical licensure and to grant them monopoly over scientific medicine, in an attempt to fight the intrusion of unqualified individuals or charlatans, as well as to be differentiated from traditional medicine practices.

In Singapore, medical professionalism is codified in law in the Medical Registration Act (MRA) and regulated by the Singapore Medical Council (SMC), a statutory body under the Ministry of Health. The objective of MRA is to ensure that registered medical practitioners are competent and fit to practise medicine at all times, uphold the professional standards of practice within the medical profession and maintain public confidence in the medical profession.

The MRA allows for the creation of a register of medical practitioners, and registered medical practitioners are bound to follow the directives of SMC (including taking the SMC Physician’s Pledge and conforming to the SMC Ethical Code and Ethical Guidelines). The MRA also provides for professional accountability through the formation of the Inquiry Committee, Complaints Committee and Disciplinary Tribunal. The principal areas of accountability lie in professional misconduct in clinical work and outside of clinical work — any improper act or conduct that brings disrepute to the profession. In addition, convictions in courts for fraud and dishonesty and any offence implying a defect in character that makes the doctor unfit to practise as a medical practitioner invariably lead to a sanction.

WHAT DOES COMPETENCY IN MEDICAL PROFESSIONALISM ENTAIL?

Professional competence is multidimensional, developmental, continuous learning, context dependent and continuously developed through clinical experience by application of knowledge and skills in clinical practice. Epstein and Hundert[4] provide a concise and precise definition of professional competency: “The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and community being served.”

WHAT ARE THE VALUES OF MEDICAL PROFESSIONALISM?

Values are defined as principles or standards of behaviour that are important to be upheld. The values that are commonly attributed to medical professionals include integrity, respect for persons, compassion, humility, pursuit of excellence (or continuous improvement), altruism and service. Professional values are expressed in the doctor–patient relationship as the professional obligations of veracity (truth-telling), preservation of privacy and confidentiality, and fidelity or non-abandonment. These values are further expressed in the professional commitment to the scientific basis of knowledge, research, lifelong learning and teaching, and healthy collegial relationships based on mutual respect and support.[1,5]

WHAT ARE CONSIDERED THE FUNDAMENTAL VIRTUES IN MEDICAL PROFESSIONALISM?

A virtue is a trait of character that is socially valuable. A professional virtue is one that is valuable to the practice of the profession. For a virtue to be effective and habitual, it has to be internalised and expressed as a habitual professional behaviour. The seven core virtues that are important and relevant in professional medical practice include integrity, discernment (prudence), compassion, trustworthiness, conscientiousness, humility and moral courage.[2]

WHY ARE RELATIONSHIPS IMPORTANT IN MEDICAL PROFESSIONALISM?

The most important relationship in medical practice is the therapeutic relationship between the doctor as a healer and the patient, marked by mutual respect, empathy and sincerity. The fiduciary nature of the relationship, which places the interest of the patient above that of the clinician and other third parties, is pivotal to promoting trust and the healing process. Maintaining an appropriate and professional doctor–patient relationship supported by integrity and loyalty (non-abandonment) is an important professional responsibility. Continuous improvement of access and quality of care are hallmarks of the doctor–patient relationship based on patient advocacy. As family is considered an important integral of the health unit of the patient, a similar cordial relationship is extended to the patient’s family. In addition, medical professionals have several other important relationships and roles, which include the scientist–researcher role (interacting with the research subject and other research colleagues) and the scholar–teacher–student role in the lifelong journey of medical education.

Medical professionals have an important obligation to build healthy collegial relationship not only with other medical colleagues, but also with a range of other healthcare professionals (e.g. allied health), to promote harmonious sharing of knowledge and decision-making for the benefit of the patient. Healthy collegiality promotes collaborative teamwork for the common purpose of achieving the goals of medicine — good clinical outcomes, promotion of patients’ welfare and patient safety. As the clinical team leader and resource manager, the doctor as a clinician has to interact and develop effective relationships with others in the wider healthcare system, such as hospital administrators and policymakers.

WHO IS RESPONSIBLE FOR PROMOTING AND DEVELOPING MEDICAL PROFESSIONALISM?

Medicine belongs to the society. Doctors and healthcare professionals are the promoters and custodians. It is the primary responsibility of the leadership of the medical profession to promote and preserve medical professionalism. However, this can only take place effectively when all the stakeholders in medicine play a responsible role in creating a suitable ethical fabric, culture and environment for professionalism to thrive. Stakeholders in medicine include health administrators, regulators, policymakers, politicians, legislators, the press, the public and patients. Ambivalent and contradictory narratives and messages about the commitment to and status of professionalism in medicine by non-clinical stakeholders are a sure way to undermine the efforts of medical teachers and clinical leaders, not to mention doctors in training.[5]

CONCLUSION

In conclusion, while oscillating in this bipolar state of business or profession, trade or calling, I would like to leave the readers with a quote from Dr. Arnold S Relman — a physician, former medical editor and emeritus professor in medicine — to reflect on the value of medical professionalism to an economic-based and mercantile society: “Professionals have an ideology that assigns a higher priority to doing useful and needed work than to economic rewards, an ideology that focuses more on the quality and social benefits of work than its economic profitability.”[6] Medicine, at its core, remains a social, ethical and scientific enterprise, and medical professionalism supports this core.

KEY LEARNING POINTS

1. Medical professionalism encompasses a set of duties, competencies, values, virtues, behaviours (professional conduct), outcomes (performance) and relationships that aim to achieve the goals of medicine and promote public trust and confidence in the healthcare system.

2. The goals of medicine include primary (e.g. diagnose and treat a disease), secondary (e.g. education and research) and controversial (e.g. termination of pregnancy, euthanasia) ones.

3. Professional governance enhances consistency of healthcare quality and safety, which nurtures stakeholders’ (e.g. public) trust and confidence in the profession.

4. In Singapore, medical professionalism is codified in law in MRA and regulated by SMC.

5. Clinical and ethical competence are integral pillars of medical professionalism, along with attributes of altruism, integrity, humility, compassion, service, veracity (truth-telling) and organisational governance.

6. Professional competency involves habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of society.

7. Medical profession is a social, ethical and scientific enterprise that focuses more on the quality and social benefits of work than its economic profitability.

Closing Vignette

The doctor–patient relationship between Doctor B and Nurse N was initiated when Doctor B agreed to offer his professional advice. In the absence of medical records, a physical examination and treatment advice offered to Nurse N are inappropriate and unnecessary. Doctor B should suggest that Nurse N make an outpatient appointment instead. It is necessary to have a chaperone present during a doctor–patient consult, but it is not sufficient in this case. A consult in corridors and a physical examination in non–clinical premises are to be avoided. A doctor’s duty includes providing appropriate duration hospitalisation leave after a surgical procedure and to customise this to the individual patient, rather than simply agreeing to a patient’s leave requests. Doctor B also needs to uphold the values of social justice and not treat patients preferentially or extend undue favours to colleagues, as this leads to a loss of confidence in the profession and an erosion of public trust.

Conflicts of interest

There are no conflicts of interest.

SMC CATEGORY 3B CME PROGRAMME

Online quiz: https://www.sma.org.sg/cme-programme

Deadline for submission: 6 pm, 17 March 2025

Question: Answer True or False
1.Fundamental principles of healthcare professionalism include:
(a)Patient autonomy and economic profitability.
(b)Patient autonomy and social justice.
(c)Economic profitability and social justice.
(d)Social justice and patient welfare.
2.Professional commitment of medicine includes:
(a)Accepting care inequalities, honesty and professional competence.
(b)Asking leadership for fee waivers, improving care access and quality, and social justice.
(c)Commitment to scientific knowledge, managing conflict of interest and patient confidentiality.
(d)Empathy, professional governance and tolerating colleague harassment.
3.The primary goals of medicine include:
(a)Abortion, enhancement medication and medical education.
(b)Aesthetic medicine, assist in capital punishment and patient counselling.
(c)Care and cure of patients, disease prevention and promoting peaceful death.
(d)Euthanasia, health education and pain relief.
4.The legal framework for medical professionalism in Singapore includes:
(a)Complaints against medical practitioners are dealt with under the Medical Registration Act (MRA).
(b)The sole objective of the MRA is to ensure that registered medical practitioners are competent and fit to practise medicine at all times.
(c)The MRA provides professional accountability through the formation of the Inquiry Committee, Complaints Committee and Disciplinary Tribunal.
(d)A medical professional can be charged for misconduct, fraud and dishonesty, defect in character, or bringing disrepute to the profession.
5.Good professional conduct is an integral pillar of safe, effective and high-quality clinical care. The values of medical professionalism are:
(a)Altruism, compassion, integrity and veracity.
(b)Anxiety, bias, fallibility and vulnerability.
(c)Excellence, fidelity, humility and service.
(d)Clinical competence, defensive approach, economic profitability and ethical competence.

Funding Statement

Nil.