A survey of the Assessment of the A survey of the Assessment of the General Practitioners’ View General Practitioners’ View Points about the Physician Points about the Physician CharterCharter

Hashemi Fatemeh, Amini Mitra, and Hashemi Fatemeh, Amini Mitra, and Saberfirousi MehdiSaberfirousi Mehdi

Physician charterPhysician charter

The charter is the product of several The charter is the product of several years of work by leaders in the ABIM years of work by leaders in the ABIM Foundation , the ACP-ASIM Foundation , the ACP-ASIM Foundation, and the European Foundation, and the European Federation of Internal Medicine. The Federation of Internal Medicine. The charter consists of a brief charter consists of a brief introduction and rationale, three introduction and rationale, three principles, and 10 commitments.principles, and 10 commitments.

Preamble :Preamble :

Professionalism is the basis of medicine’s Professionalism is the basis of medicine’s contract with societycontract with society. It demands placing . It demands placing the interests of patients above those of the interests of patients above those of the physician, setting and maintaining the physician, setting and maintaining standards of competence and integrity, standards of competence and integrity, and providing expert advice to society on and providing expert advice to society on matters of health. The principles and matters of health. The principles and responsibilities of medical professionalism responsibilities of medical professionalism must be clearly understood by both the must be clearly understood by both the profession and society. Essential to this profession and society. Essential to this contract is public trust in physicians which contract is public trust in physicians which depends on the integrity of both individual depends on the integrity of both individual physicians and the whole profession.physicians and the whole profession.

Fundamental principlesFundamental principles

Principle of primacy of patient Principle of primacy of patient welfarewelfare. This principle is based on a . This principle is based on a dedication to serving the interest of dedication to serving the interest of the patient. Altruism contributes to the patient. Altruism contributes to the trust that is central to the the trust that is central to the physician- patient relationship. physician- patient relationship. Market forces, societal pressures, Market forces, societal pressures, and administrative exigencies must and administrative exigencies must not compromise this principle.not compromise this principle.

Principle of patient autonomyPrinciple of patient autonomy. . Physicians must have respect for Physicians must have respect for patient autonomy. Physicians must patient autonomy. Physicians must be honest with their patients and be honest with their patients and empower them to make informed empower them to make informed decisions about their treatment. decisions about their treatment. Patient’s decisions about their care Patient’s decisions about their care must be paramount as long as those must be paramount as long as those decisions are in keeping with ethical decisions are in keeping with ethical practice and do not lead to demands practice and do not lead to demands for inappropriate care.for inappropriate care.

Principle of social justicePrinciple of social justice. The medical . The medical profession must promote justice in the profession must promote justice in the health care system, including the fair health care system, including the fair distribution of health care resources. distribution of health care resources. Physicians should work actively to Physicians should work actively to eliminate discrimination in health eliminate discrimination in health care, whether based on race, gender, care, whether based on race, gender, socioeconomic status, ethnicity, socioeconomic status, ethnicity, religion, or any other social category.religion, or any other social category.

A set of Professional A set of Professional ResponsibilitiesResponsibilities

Commitment to professional Commitment to professional competencecompetence..

Physicians must be committed to Physicians must be committed to lifelong learning and be responsible lifelong learning and be responsible for maintaining the medical for maintaining the medical knowledge and clinical and team skills knowledge and clinical and team skills necessary for the provision of quality necessary for the provision of quality care. More broadly, the profession as care. More broadly, the profession as a whole must strive to see that all of a whole must strive to see that all of its members are competent and must its members are competent and must ensure that appropriate mechanisms ensure that appropriate mechanisms are available for physicians to are available for physicians to accomplish this goal.accomplish this goal.

Commitment to honesty with Commitment to honesty with patientspatients..

Physicians must ensure that patients Physicians must ensure that patients are completely and honestly are completely and honestly informed before the patient has informed before the patient has consented to treatment and after consented to treatment and after treatment has occurred.treatment has occurred.

Commitment to patient Commitment to patient confidentialityconfidentiality..

Earning the trust and confidence of Earning the trust and confidence of patients requires that appropriate patients requires that appropriate confidentiality safeguards be applied confidentiality safeguards be applied to disclosure of patient information. to disclosure of patient information. This commitment extends to This commitment extends to discussions with persons acting on a discussions with persons acting on a patient’s behalf when obtaining the patient’s behalf when obtaining the patient’s own consent is not feasible.patient’s own consent is not feasible.

Commitment to maintaining Commitment to maintaining appropriate relations with appropriate relations with patientspatients..

Given the inherent vulnerability and Given the inherent vulnerability and dependency of patients, certain dependency of patients, certain relationships between physicians and relationships between physicians and patients must be avoided. In patients must be avoided. In particular, physicians should never particular, physicians should never exploit patients for any sexual exploit patients for any sexual advantage, personal financial gain, advantage, personal financial gain, or other private purpose.or other private purpose.

Commitment to improving Commitment to improving quality of carquality of care.e.

Physicians must be dedicated to Physicians must be dedicated to continuous improvement in the continuous improvement in the quality of health care. This quality of health care. This commitment entails not only commitment entails not only maintaining clinical competence but maintaining clinical competence but also working collaboratively with also working collaboratively with other professionals to reduce medical other professionals to reduce medical error, increase patient safety, error, increase patient safety, minimize overuse of health care minimize overuse of health care resources, and optimize the resources, and optimize the outcomes of care.outcomes of care.

Commitment to improving access Commitment to improving access to careto care

Medical professionalism demands that Medical professionalism demands that the objective of all health care the objective of all health care systems be the availability of a systems be the availability of a uniform and adequate standard of uniform and adequate standard of care. Physicians must individually care. Physicians must individually and collectively strive to reduce and collectively strive to reduce barriers to equitable health care.barriers to equitable health care.

Commitment to a just Commitment to a just distribution of finite resourcesdistribution of finite resources

While meeting the needs of individual While meeting the needs of individual patients, physicians are required to patients, physicians are required to provide health care that is based on provide health care that is based on the wise and cost-effective the wise and cost-effective management of limited clinical management of limited clinical resources.resources.

Commitment to scientific Commitment to scientific knowledgeknowledge

Much of medicine’s contract with Much of medicine’s contract with society is based on the integrity and society is based on the integrity and appropriate use of scientific knowledge appropriate use of scientific knowledge and technology. Physicians have a and technology. Physicians have a duty to uphold scientific standards, to duty to uphold scientific standards, to promote research, and to create new promote research, and to create new knowledge and ensure its appropriate knowledge and ensure its appropriate use. The profession is responsible for use. The profession is responsible for the integrity of this knowledge, which the integrity of this knowledge, which is based on scientific evidence and is based on scientific evidence and physician experience.physician experience.

Commitment to maintaining Commitment to maintaining trust bytrust by

managing conflicts of interestmanaging conflicts of interest. Medical . Medical professionals and their organizations professionals and their organizations have many opportunities to have many opportunities to compromise their professional compromise their professional responsibilities by pursuing private responsibilities by pursuing private gain or personal advantage.gain or personal advantage.

Commitment to professional Commitment to professional responsibilitiesresponsibilities

As members of a profession, As members of a profession, physicians are expected to work physicians are expected to work collaboratively to maximize patient collaboratively to maximize patient care, be respectful of one another, care, be respectful of one another, and participate in the processes of and participate in the processes of self- regulation, including self- regulation, including remediation and discipline of remediation and discipline of members who have failed to meet members who have failed to meet professional standards. professional standards.

Introduction and aim:Introduction and aim:

The practice of medicine in the modern era is beset The practice of medicine in the modern era is beset with unprecedented challenges in virtually all with unprecedented challenges in virtually all cultures and societies. So, physicians today are cultures and societies. So, physicians today are experiencing frustration as changes in the health experiencing frustration as changes in the health care delivery systems in virtually all industrialized care delivery systems in virtually all industrialized countries threaten the very nature and values of countries threaten the very nature and values of medical professionalism. To maintain the fidelity medical professionalism. To maintain the fidelity of medicine’s social contract during this turbulent of medicine’s social contract during this turbulent time, we believe that physicians must reaffirm time, we believe that physicians must reaffirm their active dedication to the principles of their active dedication to the principles of professionalism, which entails not only their professionalism, which entails not only their personal commitment to the welfare of their personal commitment to the welfare of their patients but also collective efforts to improve the patients but also collective efforts to improve the health care system for the welfare of society. The health care system for the welfare of society. The charter on medical professionalism is intended to charter on medical professionalism is intended to encourage such dedication and to promote an encourage such dedication and to promote an action agenda for the profession of medicine that action agenda for the profession of medicine that is universal in scope and purpose.is universal in scope and purpose.

Methods:Methods:

Based on the 10 commitments in the physician Based on the 10 commitments in the physician charter, a two part questionnaire was charter, a two part questionnaire was prepared. In the first part we asked the prepared. In the first part we asked the subjects about their awareness of the subjects about their awareness of the charter. In the second part, we clarified 10 charter. In the second part, we clarified 10 commitments of the physicians that are commitments of the physicians that are discussed in the physician charter, and we discussed in the physician charter, and we asked the subjects to rank each commitment asked the subjects to rank each commitment based on its importance and applicability in based on its importance and applicability in our culture and political system based on our culture and political system based on their view point (0 for the lower and 10 for their view point (0 for the lower and 10 for the highest rank). Validity and reliability of the highest rank). Validity and reliability of the questionnaire was confirmed in a pilot the questionnaire was confirmed in a pilot study. Then, after gathering the data from study. Then, after gathering the data from 30 GPs, they were analyzed and interpreted, 30 GPs, they were analyzed and interpreted, upon the study objectives.upon the study objectives.

Results:Results:

The findings of this study revealed that The findings of this study revealed that 100% of the subjects had no any 100% of the subjects had no any information about the physician information about the physician charter. The results of the subjects’ charter. The results of the subjects’ view points and ranking of the 10 view points and ranking of the 10 commitments of the physicians commitments of the physicians based on their importance and based on their importance and applicability in our culture and applicability in our culture and political system are shown in Table 1.political system are shown in Table 1.

Table : Ranking of the 10 commitments of the Table : Ranking of the 10 commitments of the physicians based on their importance and physicians based on their importance and

applicability by the subjects:applicability by the subjects:

CommitmentCommitmentGrade of Grade of importanceimportanceout of 10out of 10

Grade of Grade of applicability applicability

out of 10out of 10

Professional Professional CompetenceCompetence

9.719.7155

Honesty with patientsHonesty with patients994.854.85

Patient confidentialityPatient confidentiality9.79.75.805.80

Maintaining Maintaining appropriate appropriate

relations with relations with patientspatients

9.289.285.855.85

Improving quality Improving quality of careof care

9.289.284.574.57

Just distribution of Just distribution of finite resourcesfinite resources

995.145.14

Scientific knowledgeScientific knowledge8.858.855.715.71

Maintaining trust Maintaining trust by managing by managing

conflicts of interestconflicts of interest

8.58.54.54.5

Professional Professional responsibilitiesresponsibilities

9.719.718.88.8

Discussion:Discussion: The charter supports physicians’ efforts to ensure The charter supports physicians’ efforts to ensure

that the health care systems and the physicians that the health care systems and the physicians working within them remain committed both to working within them remain committed both to patient welfare and to the basic tenets of social patient welfare and to the basic tenets of social justice. Moreover, the charter is intended to be justice. Moreover, the charter is intended to be applicable to different cultures and political applicable to different cultures and political systems. Our subjects also believed in all 10 systems. Our subjects also believed in all 10 commitments (8commitments ranked >9 out of commitments (8commitments ranked >9 out of 10 and the others ≥8.5). But, unfortunately they 10 and the others ≥8.5). But, unfortunately they ranked applicability of the most of the ranked applicability of the most of the commitments (9 commitments) ≤5.85 out of 10 commitments (9 commitments) ≤5.85 out of 10 in our culture and political system. Moreover, in our culture and political system. Moreover, 100% of our subjects had no any information 100% of our subjects had no any information about the physician charter. As a result, the about the physician charter. As a result, the subjects found it increasingly difficult to meet subjects found it increasingly difficult to meet their responsibilities for patients and society while their responsibilities for patients and society while everyone who is involved in health care should everyone who is involved in health care should read and ponder its meaning and apply it. So we read and ponder its meaning and apply it. So we suggest:suggest:

Active and serious learning of the Active and serious learning of the commitments in the Medical schools commitments in the Medical schools curriculum.curriculum.

Provision of some facilities to make sure Provision of some facilities to make sure that 10 commitments of the physician that 10 commitments of the physician are applied by every doctor.are applied by every doctor.