Bioethics Discussion Blog: Codes of Professional Behavior for Medical School and Beyond

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Thursday, August 31, 2006

Codes of Professional Behavior for Medical School and Beyond

A study (NEJM Dec. 23, 2005 issue “Disciplinary Action by Medical Boards and Prior Behavior in Medical School” Maxine A. Papadakis, M.D and others) had shown that bad behavior in the later years of practice appear to be related to bad behavior which had been observed while the doctor was still in medical school.

Codes of professional behavior have been written by medical schools for their students to follow during their years in school. What should codes of professional behavior contain which we present to our medical students as they start out in their medical education? My opinion is that these codes not only should look at defining acceptable and ethical behavior of these students as they work in their educational environment in the classroom and on the hospital wards but also to emphasize to them they represent a “look ahead” to how they are expected to behave years from now when they have the full responsibility for patient care.

Here are my “look ahead” criteria definitions of honesty, integrity, responsibility, reliability, accountability and respect for patients which should be incorporated into medical schools codes of behavior, hopefully making the students understand why as students these elements of professionalism are necessary to observe now, identifying and correcting bad behavior to prevent loss of patients and even medical license in the future.


Honesty and Integrity:
Honesty and Integrity means Trust and Trust is the fiduciary responsibility that we must give to our patients and for which they expect from us.

Responsibility:
Responsibility includes the care of the patient that trumps the physician's self-interest.

Reliability:
Reliability means that the patient can depend on the doctor's medical skills and behavior to meet the challenges of patient care.

Accountability:
Accountability means that the physician is in the service of the patient and outcomes including medical errors and unattained goals or promises must be told and explained by the physician to the patient and whatever personal responsibility the physician holds should be accounted for.

Respect for Patients:
Respect for Patients means respect for their welfare as well as their autonomy. In addition, there must be respect for the patient's privacy (including issues of patient modesty along with any written or spoken personal details of the patient's life). There must be respect for the patient's religious beliefs, culture, their own personal view of the quality of their life and respect that the patient may be part of a family or other community.


Let me know if you have any suggestions about other points we should be teaching our students with regard to professionalism in medicine. ..Maurice.

11 Comments:

At Friday, September 01, 2006 9:32:00 AM, Anonymous Jaine said...

My first concern Maurice is over who is modeling the ‘right’ behaviour during the training? The first trick is to make sure only those who actually have the qualities outlined are involved in training. The next trick is to make sure that practicing doctors live by the rules/reinforce them everyday.

Below are the tenets of Tae Kwon Do:

Courtesy: To be thoughtful and considerate of others. Tae Kwon Do students and instructors should be polite, and show consideration for others.

Integrity: To be honest and good. Tae Kwon Do practitioners should live by a code of moral values and principles.

Perseverance: To never give up in the pursuit of one's goals. Students should welcome challenges, because challenges cause us to grow and improve.

Self-Control: To have control of your body and mind. A Tae Kwon Do student should practice controlling his actions and reactions.

Indomitable Spirit: To have courage in the face of adversity. A Tae Kwon Do student should never be dominated by, or have his spirit broken by another.


It is interesting to look at ‘indomitable spirit’ (TKD list) and ‘accountability’ (Medical list) and consider whether the medical profession has allowed its collective spirit to be broken via not seeking alternatives to lawsuits. Blaming lawyers doesn’t wash. The medical profession is hardly a powerless group. A lawyer can suggest a doctor not admit a mistake but the individual doctor is free to decide to go along with that approach or not.The profession as a whole is free to decide and support direction.

 
At Friday, September 01, 2006 5:12:00 PM, Anonymous Hans G. Engel, M.D. said...

All the traits and behavior you list, as well as the Tae Kwon Do named by "Jaine" are essential. However expecting development of such characteristics is far too late. Mores have to be taught in the earliest childhood, whether by parents' example, religion or teachers (preferably by all three).
Once these concepts are fulfilled, medical ethics will needed to be added to produce a true and respected physician.

 
At Friday, September 01, 2006 5:55:00 PM, Blogger Maurice Bernstein, M.D. said...

Hans, I think those of us in medical education know that development of the traits and behavior necessary for "a true and respected physician" originates well before entry into medical school. The problem is that our medical schools admission committees fail in picking out all the potential bad apples. We have to do something. So we produce a code of ethical behavior and hope to catch those who don't meet the requirements of the code.
As I have amply noted elsewhere, unfortunately even when the student with poor professional behavior is found and then doesn't respond to attempts at behavior rehabilitation, there may be resistance on the part of the medical school to remove the student from the profession. ..Maurice.

 
At Sunday, September 03, 2006 9:27:00 AM, Anonymous Jaine said...

Hans, your comments bring to mind a quote I read, but can’t put my finger on right now, along the lines of: ‘The way to change a child is to change society 100 years before the child is born.’ This puts the responsibility onto the shoulders of people today to change for the greater good of those yet to come. After chatting with a highly respected and experienced lawyer, who sees the inner workings of society, I don’t expect change for well over several 100 years because the human race is not that highly evolved. He told me that professions are no longer professions (none of them) but instead have evolved into businesses and there is no motivation to change.

Maurice, I’d venture a guess that medical schools do not kick students out based on empathy for the amount of time a student has invested in education. It might even be that if a school kicked students out it would develop a reputation that would intimidate prospective students/reduce business for the school. This ignores the thousands of patients who will be subjected to poor behaviour and care down the road and employs an ‘out of sight out of mind’ mentality. The problem student will graduate and disappear into the world and no longer be the school’s problem. Perhaps if medical schools were heavily fined each time a graduate of their school messed up it might motivate the schools to, for self-serving reasons, think twice about unleashing a problem onto society. More likely, based on the way the medical system handles complaints, it would just increase the motivation to hide mistakes. Somehow the wellbeing of patients has to be put first. How to accomplish that is beyond me when complaints are ignored.

 
At Sunday, September 03, 2006 11:26:00 AM, Blogger Maurice Bernstein, M.D. said...

Jaine, the reason the schools don't remove the students is indeed self-serving: concern about being sued by the student. And then the publicity. ..Maurice.

 
At Sunday, September 03, 2006 7:38:00 PM, Anonymous Jaine said...

This is sad isn’t Maurice? I keep hearing from people that doctors get away with poor behaviour because they have so much power. I accepted this to a degree until it hit me. The only power doctors have is to blacklist people, ignore poor care, make false records, lie during the complaint process and to underhandedly provide poor care. That is the same power a gang of thugs have. It is power taken not given.

People who have real power do everything above board and can defend their actions. If a medical school can’t kick a student out of med. school, based on knowing the student is going to cause harm, then they don’t even have the power to control their own profession at the entry level. If the fear of bad publicity stops people from doing the right thing then my guess would be those people have very little real power.

Please correct me if I'm missing something here.

 
At Wednesday, September 06, 2006 1:41:00 PM, Anonymous Jaine said...

My first sentence on my last post should have read: ‘This is sad isn’t ‘it’ Maurice?’ I didn’t mean to imply that Maurice was sad. Although I’m sure it makes you sad, Maurice, to know people who shouldn’t be practicing medicine are allowed to slip into the job.

 
At Monday, September 25, 2006 12:59:00 AM, Anonymous Anonymous said...

I think that the medical schools have a responsibility to the people to ensure that only morally sound students become doctors. It may be hard to tell whether or not an admitted student is going to be ethical or not, but at some point the teachers should be able to tell on their own. The students who don't display compassion for their patients and have a bad attitude to their job should be kicked out immediately. It won't hurt the school's reputation as much as it would if the school had the reputation of sending rotten doctors into the world!

 
At Tuesday, October 31, 2006 1:12:00 AM, Anonymous Anonymous said...

the more I read all these bio-ethical musings more I laugh Why peple have so little faith in a free-market , where the problem creators will be automatically outpriced . I think nobody goes to medicine or law or anything to help people purely . They can only survive in the market only if their skill and education brings 'help' to someone else . I think arm chair bioehicists should have a proper job . I am not a doctor but that is the way I feel.

 
At Friday, February 02, 2007 8:22:00 PM, Anonymous Anonymous said...

i withdrew from medical school to avoid getting dismissed for behavior i did not commit. my friends sent out joke emails to another classmate from my ip address. they were m4 and were graduating, so naturally, they had a lot of time on their hands. the school subpoenad my ip address and i took the blame. the girl made a formal complaint of it, i took the blame thinking she would be able to forgive me since i knew her and thought she would withdraw the complaint, but she didn't. the student affairs dean had said he wanted to kick me out of the school. so i don't believe medical schools should kick out students for bad behavior. people make mistakes, they should be forgiven. i hate zero tolerance policies because of what they did to me and my friends.

 
At Friday, February 02, 2007 9:24:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous from today Feb. 2, 2007, if you are innocent of the behavior which led to your decision to leave school under pressure, this represents a tragic error of inadequate investigation by your medical school's administration. With respect to removing students from medical school, there are behaviors and there are behaviors. Some behaviors, such as criminal felonies would be clearly anti-social and represent a valid rationale for removal. On the otherhand there are behaviors which, if isolated and not repeated, may not reflect an ongoing problem to interfere with further medical education or subsequent medical practice.

One such behavior was described recently to the first year medical student class by a third year student. He was trying to find last moment time to study for the first part of the National Boards after finishing his second year. He was under multiple other emotional and financial pressures at the time. He didn't attend a couple days of 3rd year clerkship so he could study and told his superiors that he was away because his grandfather had died. Actually his grandfather was not ill or dead. He took the boards and knows he did well. When he returned to his clerkship, he realized he did something unethical and against medical school policy. He promptly confessed to the dean of student affairs that he had lied but also disclosed all the pressures he was under. The dean was understanding and appreciated that the student had promptly acknowledged and confessed about his unethical behavior. The dean told the student the proper behavior would have been before lying to come to administration and describe the student's problems and an attempt would be made to mitigate them through counceling and finacial aid programs within the medical school. The student was required to appear before the ethics board of the school but survived and learned a lesson which he emphasized to the first year students, that there was resources avaiable at his school which if utilized might have reduced the pressures that led to the unethical behavior and the students should be proactive in that regard. By the way, the student also promptly told his granfather what he had said to his superiors about the death and apologized to him.


There could be behaviors in between which if repeated in one form or another may cause concern of deans whether the student should be allowed further training. If you are innocent and there were no previous or frequent questionalble incidents on your part, I would think your dean's expression was unjust and unwarrented. Maybe your decision regarding leaving medical school was premature, if so, that was unfortunate. However, your action might reflect some ambivalence regarding a career as a doctor and maybe you will be successful in another occupation. ..Maurice.

 

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