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IM Sechenov First Moscow State Medical University Tempus IV 159328 - April 2012 III rd International Conference Education in Medicine System of Lifelong Training for Medical Schools Teachers Professionalization of Medical Students Pr Sylvain Meuris Facult de Mdecine Universit Libre de Bruxelles

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Profession : origin of term EnglishRussianFrench ProfessionProfession ProfessorProfesseur ProfessionalismProfessionnalisme Same Latin Root - pro & fateor => To confess before (public) - profiteor => To proclaim something publicly

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What physicians are professing ? Physicians declare publicly two things To be competent to help the patients To have the patients best interests in mind Profession or declaration of commitment to an ideal to which he should conform

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What physicians are professing ? Since centuries, physicians profess in two ways: The public act of oath taking moment of transition to become a professional ( medical degree) The doctor-patient relationship This dialog represents an every day tacit commitment

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Public expectation from practitioner nothing is more estimable than a physician who, having studied nature from his youth, knows the properties of the human body, the diseases which assail it, the remedies which will benefit it, exercises his art with caution, and pays equal attention to the rich and the poor. Voltaire (1694-1778) Bleeding and enema were the most prescribed therapeutic at this time !!!

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What qualities are expected today from a physician ? From patients point of view Reliable Accessible Dedicated Honest Accountable Respect patients autonomy Respect patients confidentiality Non-judgemental Compassionate Confident Composed From practitioners point of view Knowledge Altruism Accountability Respect Integrity Submission to an ethical code Lifelong learning Honesty Compassion Excellence Self regulation

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Are physicians attitudes & behavior always ideal Plato (428-347 BC) described paradoxal types of doctor-patient relationships (1) Medicine for 'free citizens : The physician treats their disease in a scientific way and takes the patient and his family into confidence,...

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Are physicians attitudes & behavior always ideal (2) Plato contrasted this professional wisdom attitude with the medicine for slaves The physician never listens from the slave any account of his complaints, nor asks for any; he gives some empiric treatment with an air of knowledge in the brusque fashion of a dictator, and then is off in haste to the next ailing slave. 1 st historical description for a conflict of interest between patient and physician

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Recent demystification of the medical profession Two great upheavals : Medicine changed from an autonomous, publicly respected profession to one vilified in the public as in the media. Doctors had fallen from the pedestal of public adulation. Health managers appeared to be potent rivals for the authority that physicians thought they owned.

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Today situation We observed 4 paradoxes (Le Fanu, 1999) Disillusioned doctors, seems more dissatisfied than in the past Patient express health anxiety and dissatisfaction despite population health Popularity of alternative medicine contrast with the amazing success of modern medicine Spiraling costs of health care need political control over medical decision making This situation must induce profound changes and reforms in modern medical education. Are medical schools able to adapt curricula to prepare physicians to correctly serve the population ?

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Should students work as physicians several years after studying medicine ? Sir James Paget (1814-1899) St Bartholomews Hospital Reports, 5:238-242, 1869 An old question : Is excellence of medical education sufficient to prepare professionals ?

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Destiny of medical students (n=1000)

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Among inactive physicians 1869 J Paget 6 failed because of scandalous misconduct 10 failed due to continued intemperance and dissipation 10 failed through bad luck 13 left or were expelled in disgrace 3 were wisely removed by friends 3 became actors 2 retired because too rich

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Professionalism during medical education Professionalism must be reached by attitude and behaviors that serve to maintain patient interest above physician self-interest Evaluation of professional attitudes and behaviors forms a central but incompletely defined component of assessment across the medical education continuum

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Analysis of formal medical training program topics EmphasisedUnderemphasised o Science o Art o Expertise o Professionalism o Bioscience o Humanism o Objective o Subjective o Detachment o Empathy o Evidence-Based o Relationship-centered o Specialism o Generalism o Hierarchy o Collegiality o Intra-professionalism o Inter-professionalism New meta-skills curricula must foster the acquisition of professionalism

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Medical education is a continuum From nave and idealist student Undergraduate learning To experienced mature physician Postgraduate training Life Long Learning Continuing professional development

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NEW MEDICAL STUDENT MATURE PROFESSIONAL PROTO-PROFESSIONALISM NAIVE PHRONESIS or SAGACITY Y1 Y2 Y3 Y4 Y5 Q Reg PGT PBL SDL EXPERIENCE MATURITY + ROLE MODELS Hilton and Slotnick Ideal learning and training program

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NEW MEDICAL STUDENT MATURE PROFESSIONAL PROTO-PROFESSIONALISM CYNICAL IDEALISTIC Y1 Y2 Y3 Y4 Y5 Q Reg PGT BAD EXPERIENCES ADDICTIVE BEHAVIOURS - ROLE MODELS POLITICS FATIGUE Hilton and Slotnick Hiden program

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Principles for the training to professionalism Should begin early Conducted frequently Include many different assessors Develop training for assessors Implemented long-term Use multiple methods in different settings Provide learners with opportunities to change

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Declaration of professionalism among medical student As a medical student, I recognize that I am now a member of the medical community. As such, I accept responsibility for my conduct, and expect the same of my colleagues. I will display these qualities in all academic and clinical settings. I do this as an essential part of my commitment to the provision of the highest standard of patient care, which is the central goal to which I am dedicated. I will demand these standards of myself and strive to support others to uphold them. Signed

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Conclusion Problems linked to professionalism are not new Medical schools must adapt curricula and provide lifelong learning to better prepare and help new physicians to answer society needs Trust between physicians and patients must always prevail

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Domains of professionalism in medical education Personal (intrinsic) attributes Ethical practice Reflection / self-awareness Responsibility / accountability for actions commitment to excellence, life-long learning and critical reasoning Co-operative attributes Respect for patients Teamwork working with others Social responsibility

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Profession : To proclaim something publicly The essence of a profession is the act of profession of commitment to an ideal to which the professional should conform.

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Check list to define a profession Practising requires formal education Their members : Enjoy control over their own training standards Have a journal devoted to its standards Possess relatively high social status Have their own disciplinary mechanisms Have secured protection from (1) state regulation as well as from (2) market pressures Different from a vocation

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Traditional learned professions By virtue of their Educational breadth Importance in satisfying fundamental human need They have been called learned professions This special status is reserved to Medicine, Law, Ministry Other academic occupations

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Present areas for professionalism Respect for patients Ethical practice Reflection/self-awareness Responsibility commitment to excellence & Life Long Learning Teamwork Social responsibility

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Criticism of physicians attitudes From India "Three kinds of medical practitioners are found in this world; firstly, the impostor in physician's robes; secondly, the vainglorious pretenders and thirdly, those endowed with the true virtue of the healer Charaka (120162 AD) in Ayurveda (the science of life)

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Physicians possess their own disciplinary mechanisms ! Achilles heel of the profession : Most professional bodies do not effectively discipline their members; Most do not publish records of their disciplinary actions, if any. This make it clear that effective self- regulation is non-existent and needs to be created if not too late.

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Inactive physicians J Paget Failed entirely 15 never able to pass exams due to idleness, listlessness or want of intellect 6 failed because of scandalous misconduct 10 due to continued intemperance and dissipation shown as an undergraduate 10 through bad luck Left the profession (n=96) 13 left or were expelled in disgrace 3 were wisely removed by friends 3 became actors 3 became homeopathic practitioners but without repute for wisdom or working power 2 retired too rich to need to work