Professionalism and ethics are difficult to define, and it is often a case of “you know it when you see it.” In recent years, there have been calls to renew the focus on professionalism and ethics and their teaching in the medical and allied professions, part precipitated by a perceived and probably real decline in doctors’ professional values. Medical professionalism has evolved markedly in the last couple of centuries and continues to change today at a rapid pace, spurred by technological advances and generational change. The reasons to promote medical professionalism include regulatory requirements, aligning our professions’ outcomes and behaviors, and the moral imperative that being professional is the right thing to do. Radiologists should emphasize, model, and teach professionalism to our colleagues, allied personnel, and trainees whenever opportunity permits. Medical students now receive teaching in professionalism and ethics throughout their training, and there is a need to continue training formally and informally during residency training. Faculty or those charged with teaching professionalism will need to first understand what constitutes medical professionalism, and here we attempt to define and outline what professionalism looks like in practice. The article concludes with a summary of the opportunities within radiology practice, with examples, for us to exhibit professional actions, values, and ideas.
The History of Professionalism in Medicine
Professionalism and ethics and their teaching constitute subjects of renewed interest and focus in recent years in many fields, including medicine and radiology, precipitated in part by a perceived and possibly real decline in professional values among doctors . This article describes the history and evolution of medical professionalism, with an emphasis on professionalism within radiology. The article identifies the tenets of key professional stakeholders, identifying current expectations for professionalism, and concluding with a summary of practical implications for promoting a shared understanding of professionalism that could inform efforts to teach and assess professionalism in radiology.
In Western medicine, the original professions of medicine, law, and the clergy first arose in medieval European universities . These professions addressed a class of problems for the society and as a result were granted monopoly status. Laws prohibited nonmembers of professions from practicing; granted authority to the professions to decide who enters training, and how training was organized, conducted, and evaluated; and allowed the profession to negotiate with governmental agencies in monitoring practice. Together these three elements comprise the implied “social contract.” In return for the society conceding autonomy and self-regulation to the professions, the professions were trusted to be altruistic, by not competing unfairly, and always placing primacy on clients, patients, laypersons, and public interests above their own.
In the United States, the moral courage and leadership of medicine in articulating altruistic standards for promoting population health transformed its public perception from “less a profession than a trade of practitioners who worked with their hands after being trained under an apprentice system [with] … little professional consciousness and … only a limited concept of professional ethics or responsibilities” . When the American Medical Association (AMA) was established in the United States in 1847, it declared its primary task as raising ethical standards in the medical field . The AMA code of ethics was influenced by the code of professional ethics defined by the British historian Thomas Percival in the early-19th century . Percival maintained that physicians occupied a position of public trust, and therefore had obligations to the society that transcended those of workers in other trades. Percival advocated a public-goods approach to medicine, arguing that the public trust it inspires sets it apart from all other fields. In 1858, the AMA Council on Ethical and Judicial Affairs was created to write and implement an ethics code for American medical professionals, and in 1876 the Association of American Medical Colleges (AAMC) was founded to reform medical education. The AMA played an influential role during this time in establishing standards for medical schools, medical boards, hospital internship programs, medical specialty training, and other areas of health care.
The AMA also began a process to evaluate medical schools. In 1910, Abraham Flexner, working for the Carnegie Foundation for the Advancement of Teaching, published the Flexner Report, assessing the quality of education in allopathic medical schools in the United States . The Flexner Report advocated for an alliance between medical schools and state regulators, with the aim of creating a cohesive regulatory body that would address the needs of the public through intentional reforms in the medical education system. As a result, nearly half of 168 medical schools in the United States either closed or merged due to a “bad grade.” Flexner recognized that physicians are “social instruments” whose training comes at great cost to the state and thus requires them to function in a “social and preventive” role. These changes ushered in the first wave of “medical professionalism” and charged medical schools with educating young physicians in these norms.
In 1942, the AMA established the Liaison Committee on Medical Education (LCME) to maintain standards for undergraduate medical programs and to accredit medical schools in the United States and Canada . In 1972, key organizations in medicine and medical education (AMA, the American Board of Medical Specialties, the American Hospital Association, the AAMC, and the Council of Medical Specialty Societies) came together to create the Coordinating Council on Medical Education. Their role was to approve and coordinate all areas of medical education, and to this end they created the Liaison Committee for Graduate Medical Education (LCGME) to coordinate and oversee review activities of the several independent residency review committees in existence. In 1981, the LCGME was restructured under new bylaws and renamed the Accreditation Council for Graduate Medical Education (ACGME) . Between 2000 and 2002, the ACGME identified and endorsed six general competencies to assess resident competence; the American Board of Medical Specialties endorsed the same competencies for continuing assessment of competence in practicing physicians. These competencies include patient care, medical knowledge, communication, system-based practice, practice-based learning and improvement, and professionalism.
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Why Promote and Teach Professionalism in Medicine and Radiology?
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Table 1
The 10 Commitments of Professionalism with Examples of Each
Commitment Examples Professional competence Board certification with ABR, staying up-to-date with CME and MOC, doing SAMs, working in a certified radiology practice, participating in peer review Honesty with patients Being truthful at all times Patient confidentiality Not discussing patient information with friends or family or in public areas Maintaining appropriate relations with patients Having no personal relationships with patients Improving quality of care Participating in departmental quality improvement efforts, including peer review Improving access to care Not denying imaging to patients based on factors other than medical indication Just distribution of finite resources Scanning only the patients who really need the test, when they need it Scientific knowledge Lifelong learning, using evidence-based imaging principles, keeping up-to-date with literature, attending CME courses, doing SAMs Maintaining trust by managing conflicts of interest Disclosure of potential conflicts of interest, not interpreting your family or relatives’ imaging Professional responsibility Getting clinical and prior imaging information, protocoling study to best answer clinical question, supervising study, systematic reviewing of images, structured reporting, prompt reporting of studies, communicating urgent/unexpected/significant findings to referring physician
ABR, American Board of Radiology; CME, Continued Medical Education; MOC, maintenance of certification; SAM, Self-Assessment Module.
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Professionalism—You Know It When You See It!
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Professionalism in Radiology
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Table 2
The Professional Duties That Might Be Expected of a Radiologist at Each Step in the Radiology Patient Encounter, with Examples of Each
Step Examples Diagnostic imaging is requested Freely available consultation from radiologists for clinicians who have questions regarding imaging requests or optimization Access to imaging Outpatients are not denied imaging based on any characteristic other than medical indication; appropriate prescreening in cases undergoing CT, MRI, or interventional procedures for pregnancy, allergy, renal impairment, or metallic implants Access time to imaging performance Department ensures that patients with urgent or significant diagnosis (e.g. cancer) get imaging done in a timely fashion Study is protocoled by radiologist Radiologist checks history of patient to ensure that diagnostic imaging is appropriate and there are no contraindications; radiologist discusses with clinicians if testing is not appropriate and advises alternate imaging; radiologist checks history of patient to optimize imaging protocol with respect to volume covered, contrast, phases of imaging, use of ECG gating, 3D reformats Patient arrives to reception Adequate facilities in waiting area with provisions for patient privacy at check in; clean changing areas; pleasant waiting area; staff available to patients at all times Patient is scanned Correct identification of patient prior to imaging, screening of females of childbearing age for pregnancy if ionizing radiation or gadolinium planned; safe transfer on and off scanner table; correct scan protocol used; correct body part or area imaged Procedure is performed Nurse prescreening of patient, including pregnancy status in women of childbearing age; written informed consent as appropriate; patient privacy in preparation area; safe transfer on and off procedure table; appropriate time-outs and checks for correct patient-correct procedure-correct side; appropriate post-procedure care Use of contrast material Use the correct contrast material for the exam and body part; use the correct amount of contrast material; use contrast material only if needed to answer clinical question; ensure no contraindication or allergy Images sent to radiologists, interpretation lists Appropriate labeling of patients, examinations, and series; urgent studies clearly indicated on work lists; 3D imaging and reformatted images performed when appropriate Radiologist interprets study Systematic review process; radiologist seeks out relevant clinical information; structured reporting process; report answers the clinical question asked Radiologist communicates findings to referring and treating clinician Urgent, unexpected, or significant findings directly communicated in a timely fashion to referring and/or treating physician; radiologist ensures that referring and/or treating physician understands findings and their implications
CT, computed tomography; ECG, electrocardiogram; MRI, magnetic resonance imaging.
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Conclusion
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References
1. Egan E.A., Parsi K., Ramirez C.: Comparing ethics education in medicine and law: combining the best of both worlds. Ann Health Law 2004; 13: pp. 303-325.
2. Shah N., Anderson J., Humphrey H.J.: Teaching professionalism: a tale of three schools. Perspect Biol Med 2008; 51: pp. 535-546.
3. Hilton S.R., Slotnick H.B.: Proto-professionalism: how professionalisation occurs across the continuum of medical education. Med Educ 2005; 39: pp. 58-65.
4. Duffy J.: From humors to medical science: a history of American medicine.Second ed.1993.University of Illinois Chicago Press
5. Accreditation Council for Graduate Medical Education (ACGME) : The history of medical education accreditation. Available at http://www.acgme.org/acgmeweb/About/ACGMEHistory.aspx Accessed June 8, 2015
6. Starr P.: The social transformation of American medicine.1982.Basic BooksNew York
7. Liaison Committee on Medical Education : Functions and structure of a medical school. Available at http://umsc.org.uic.edu/documents/LCME_standards.pdf Accessed March 1, 2016
8. Emanuel E.J., Emmanuel L.L.: Four models of the physician-patient relationship. JAMA 1992; 267: pp. 221-226.
9. Emanuel E., Wendler D., Grady C.: What makes clinical research ethical?. JAMA 2000; 283: pp. 2701-2711.
10. Physicians for the twenty-first century. Report of the Project Panel on the General Professional Education of the Physician and College Preparation for Medicine. J Med Educ1984.pp. 1-208. 59(11 Pt 2)
11. General Medical Council : Good medical practice. Available at http://www.gmc-uk.org/guidance/index.asp Accessed June 8, 2015
12. General Medical Council : Tomorrows doctors. Available at http://www.gmc-uk.org/education/undergraduate/tomorrows_doctors_2009.asp Accessed June 8, 2015
13. Summary of the Institute of Medicine (IOM) Report : To err is human: building a safer health system. Available at http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf Accessed June 8, 2015
14. Summary of the Institute of Medicine (IOM) Report : Crossing the quality chasm: a new healthcare system for the 21st century. Available at http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf Accessed June 8, 2015
15. ABIM Foundation. American Board of Internal Medicine , ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine , European Federation of Internal Medicine : Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002; 136: pp. 243-246.
16. Summary of the Institute of Medicine (IOM) Report : Health professions education: a bridge to quality. Available at http://www.iom.edu/Reports/2003/Health-Professions-Education-A-Bridge-to-Quality.aspx Accessed May 30, 2013
17. Dunnick N.R., Applegate K.E., Arenson R.L.: The inappropriate use of imaging studies: a report of the 2004 Intersociety Conference. J Am Coll Radiol 2005; 2: pp. 401-406.
18. Institute of Medicine : Vital signs: core metrics for health and health care progress. Available at http://www.nap.edu/catalog/19402/vital-signs-core-metrics-for-health-and-health-care-progress Accessed March 1, 2016
19. American Board of Radiology , Accreditation Council for Graduate Medical Education : Diagnostic radiology milestones project. Available at http://acgme.org/acgmeweb/Portals/0/PDFs/Milestones/DiagnosticRadiologyMilestones.pdf Accessed June 8, 2015
20. The American Board of Radiology initial certification in diagnostic radiology. Available at http://www.theabr.org/ic-dr-landing Accessed June 8, 2015
21. The American Board of Radiology maintenance of certification diagnostic radiology part IV practice quality improvement. Available at http://www.theabr.org/moc-dr-comp4 Accessed June 8, 2015
22. Seltzer S.E., Lee T.H.: The transformation of diagnostic radiology in the ACO era. JAMA 2014; 312: pp. 227-228.
23. Laine C., Davidoff F.: Patient-centered medicine. A professional evolution. JAMA 1996; 275: pp. 152-156.
24. Koehn P.H., Swick H.M.: Medical education for a changing world: moving beyond cultural competence into transnational competence. Acad Med 2006; 81: pp. 548-556.
25. Cruess R.L., Cruess S.R., Steinert Y.: Teaching medical professionalism.2009.Cambridge University Press
26. Brody H., Doukas D.: Professionalism: a framework to guide medical education. Med Educ 2014; 48: pp. 980-987.
27. Brandeis JLD. An address delivered at Brown University commencement day, 1912.
28. The Social Welfare History Project. Available at http://www.socialwelfarehistory.com/social-work/is-social-work-a-profession-1915/ Accessed March 1, 2016
29. Stern D.T.: Measuring medical professionalism.2006.Oxford University Press
30. American Board of Internal Medicine (ABIM) : Project professionalism.1994.American Board of Internal MedicinePhiladelphia, PA
31. Swick H.M., Szenas P., Danoff D., et. al.: Teaching professionalism in undergraduate medical education. JAMA 1999; 282: pp. 830-832.
32. Swick H.M.: Toward a normative definition of medical professionalism. Acad Med 2000; 75: pp. 612-616.
33. Public Broadcast Service Online : Modern version of the Hippocratic Oath. Available at http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html Accessed June 8, 2015
34. Swensen S.J., Johnson C.D.: Radiologic quality and safety: mapping value into radiology. J Am Coll Radiol 2005; 2: pp. 992-1000.
35. Armstrong J.D.: Morality, ethics and radiologists’ responsibilities. AJR Am J Roentgenol 1999; 173: pp. 279-284.