ETHICS AND PROFESSIONALISMTeaching & Learning at the IMU

Sivalingam NalliahCommittee for Teaching of Ethics and

Professional Practice

PROFESSIONALISM

EMPA

THY

ALTR

UIS

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ACCO

UN

TABI

LITY

HU

MAN

ISM

ETHICAL AND LEGAL UNDERSTANDING

COMMUNICATION SKILLS

CLINICAL COMPETENCE

Adapted from: Measuring Medical ProfessionalismDavid Thomas Stern 2005

1.1 A Glossary of Definitions

For the purposes of this document, the following definitions need to be clarified:

Ethics: The field of ethics (or moral philosophy) involves systematising, defending, and recommending concepts of right and wrong behaviour (Anscombe, 1981).

Medical ethics: The term "ethical" is used to refer to matters involving (1) moral principles or practices and (2) matters of social policy involving issues of morality in the practice of medicine. The term "unethical" is used to refer to professional conduct which fails to conform to these moral standards or policies (American Medical Association, n.d.).

Bioethics: Bioethics is a relatively new word coined by the biochemist Van Rensselaer Potter in 1970 to draw attention to the fact that the rapid advances in science had proceeded without due attention being paid to values. The word bioethics, using two Greek words, bíos – meaning life – representing the facts of life and life sciences, and éthos - meaning morals – referring to values and duties (Potter, 1971). Bioethics should not be confused with medical ethics, which is only one of its branches. The field of bioethics is as wide as the facts of life, and its study is divided into many branches, each one with its specificity: Ecological or environmental bioethics, Medical bioethics, Clinical bioethics.

1.2 Professionalism Defined

The healthcare profession in its entirety has been called to address the challenge of how it defines itself. The challenge of defining what constitutes its profession, i.e. professionalism, has seen intense debate for some time. The World Medical Association has issued several statements pertaining to bioethics over the last 35 years. The American Board of Internal Medicine (ABIM), Society of Academic Emergency Medicine, the Accreditation Council on Graduate Medical Education (ACGME), American College of Physicians and American Society of Internal Medicine (ACP-ASIM), the General Medical Council (GMC), the Royal College of Physicians (RCP) and the European Federation of Internal Medicine (EFIM) have tried defining professionalism (ABIM, 1994; 2002; Van Mook et al., 2009; GMC, 2013; RCP, 2005; Kirk, 2007). Van Mook et al. (2009) defined medical professionalism as “the ability to meet the relationship-centred expectations required to practice medicine competently.” The RCP defined medical professionalism as a set of values, behaviours, and relationships that underpin the trust the public has in doctors – this definition, they assert, can apply to other healthcare professionals as well (RCP, 2005). The King’s Fund (Rosen & Dewar, 2004) called for professionalism to put patient’s interests back at the centre of care. They also assert that stakeholder parties should be facilitated to have open and responsive discussion regarding professional standards relevant to prevailing values and expectations. Meanwhile, the Picker Institute Europe looked at patient-centred professionalism, which they defined as “doctors fulfilling their changing (and in some cases unchanging) roles in ways which coincide with changing (or unchanging) patient roles, as well as working with patients and others to see whether areas of conflict can be eased” (Askham & Chisholm, 2006). The well-known Physician Charter (Medical Professionalism Project: ABIM Foundation, 2002) reiterates professionalism on three principles: primacy of patient welfare, patient autonomy, and social justice and ten responsibilities: professional competence, honesty, confidentiality, appropriate relationship with patients, improving quality of care, improving access, equity, integrity of scientific knowledge, maintaining trust and managing conflicts of interest, and professional responsibilities. Society and the community stand to gain from ethical and professional practice.

Outline

Where are we?

Curriculum and contents

Resources

Assessment

Scholarship

Challenges

Where are we ?

Curriculum and contentsThreaded through the 10 semesters

Formal and non-formal learning

Semester 1-2

Topic Mode of Delivery

Assessment Feedback

Professionalism workshop /role playing

reflective writing.

On line

Duties of doctorsProfessional Code of conduct..MMC guide lines

Plenary MCQ Class discussion

Introduction to medical ethics Physician misconduct

Plenary

MCQ/SAQ

Class discussion

Autonomy and Consent/ Standards of practice

Plenary

MCQ/SAQ

Class discussion

Relevant Topics PBL discussion

TOPIC Mode of Delivery

Assessment Feedback

Autonomy and Confidentiality

Plenary/ Clinic visits

MCQ Class discussion

Fitness to practiceMedical Act 1979

Plenary

MCQ Class discussion

Death Dying and KillingCriminal Procedure Code

Plenary/case studies MCQ Class discussion

End of life issues Plenary MCQ Class discussion

Relevant topics) PBL

Semester 3-4TOPIC Mode of

Delivery Assessment Feedback

Ethical and legal consideration in terminations of pregnancy.. Criminal Procedure Code

Plenary/Debate

MCQ

Class discussion

Legal and ethical issues in antenatal screening and family planning

Plenary

MCQ

Class discussion

Consent in Minors and mentally challenged Child Protection Act 1991/ Mental Health Act

Plenary

MCQ

Class discussion

Relevant topics PBLs

TOPIC Mode of Delivery Assessment Feedback

Ethical and legal considerations in medical research

Plenary

MCQ/ Practicum in

Sem 5

Class

discussion

Legal and ethical issues In accessing health careEthics of screening

Plenary

MCQ/SAQ

Class

discussion

Duty of Care/ Standard of Care/ Negligence

Plenary/Case studies

MCQ/SAQ

Class

discussion

relevant topics PBL

Others Resources : E learning Portal . Laws and Ethics: Case studies/ ForumMMS:Case studies on ethics/ online feed back

Semester 6 -10Theme: Working in hospitals and its environment

Health Issues 1. Health education and Health promotion2. Culture health and disease3. Wellness and health promotion4. Quantitative methods5. Family violence and abuse 6. International agencies in health (WHO, UNICEF etc)7. Non governmental organizations (NGO’s) in Health8. Primary Health care

Medical Ethics9. Organ donation: Organ transplant and medical research10. Death, dying and bereavement11. Ethics in abortion, contraception and embryo research12. Negligence, patient confidentiality, informed consent, 13. Ethics in HIV Infection (Mother to child infection)14. Ministry of Health core values (teamwork, caring and professionalism)

BIOETHICS CORE CURRICULUMSECTION 2: STUDY MATERIALSETHICS EDUCATION PROGRAMM

Introduction 3 Acknowledgement 4 Course Learning Objectives 6 UNIT 1: What is ethics? 7UNIT 2: What is bioethics? 10 UNIT 3: Human dignity and human rights (Article 3) 13 UNIT 4: Benefit and harm (Article 4) 17 UNIT 5: Autonomy and individual responsibility (Article 5) 23UNIT 6: Consent (Article 6) 27 UNIT 7: Persons without the capacity to consent (Article 7) 33 UNIT 8: Respect for human vulnerability and personal integrity (Article 8) 38 UNIT 9: Privacy and confidentiality (Article 9) 42 UNIT 10: Equality, justice and equity (Article 10) 46UNIT 11: Non-discrimination and non-stigmatization (Article 11) 49UNIT 12: Respect for cultural diversity and pluralism (Article 12) 53 UNIT 13: Solidarity and cooperation (Article 13) 56 UNIT 14: Social responsibility and health (Article 14) 59 UNIT 15: Sharing of benefits (Article 15) 65 UNIT 16: Protecting future generations (Article 16) 73 UNIT 17: Protection of the environment, the biosphere and biodiversity (Article 17) 77

Study Materials Cases Case 2: Conflict of interests A seventy-six year old very wealthy woman is affected with mild dementia. Her children call on her doctor complaining of her spending habits of giving liberally to members of a church cult, whom they think are scheming to deprive her of her wealth. They are worried about their rights to her inheritance and request from the doctor to declare her incompetent to manage her financial affairs. The doctor dutifully advises his patient about the visit from her children and tells her that he does not think that a psychiatric consultation is in order. The doctor himself is a member of the same church cult.

Readings Video/Movie Movie: 12 Angry Men (1957, Director: Sidney Lumet) 12 Angry Men is the gripping, penetrating, and engrossing examination of a diverse group of twelve jurors (all male, mostly middle-aged, white, and generally of middle-class status) who are uncomfortably brought together to

CERTIFIED ON LINE COURSE TAKEN BY ALL SEMESTER 4 STUDENTS

ALSO DONE BY CLINCIAL FACULTY (KPI)

2nd School of Medicine Retreat5 April 2014Executive Summary Professionalism, Ethics & Medical LawPresenter: Prof. Dato’ Dr N SivalingamModerator:Prof. Dato’ Dr P Kandasami DSN shared and took members through his comprehensive slides, and sought members’ comments on the topic. He shared the value of E&P and how its was incorporated into the MBBS curriculum. He also alluded to the broader perspective of including Biosafety and Medical Law to the curriculum.The UNESCO Core Curriculum on Bioethics has been adopted and each of the 17 units of the curriculum are to be delivered as the student goes through the clinical school.All students have had been sensitized to the topics on Bioethics and there is a curriculum drawn by the Community Medicine ( A. Prof Verasingam). Discussion/Feedback Dr Rohaizan viewed that professionalism should be imparted to medical students so as indude quality care in the woking environment A/P Sui Chen thought student should value the advantage of this important aspect and incorporate into research. This aspect has been incorporated in all student research in the clinical school. Currently students are expected to present and get approval from the Ethics and Research Committee IMU. Some members felt this personality trait should be embedded into students, nevertheless framework on acquisition of concepts and knowledge as well as application of ethicas in the clinical setting should be established. This should move smoothly as in the teaching of integrated curriculum from early semesters to later semesters.

Members concurred it will be challenging as this attribute also depends on students’ background. Professionalism and good moral values should have been inculcated into their upbringing. This is very much so in the Asian culture.t was acknowledged that most departments are following UNESCO Bioethics Core Curriculum as guidelines and references available in teaching and curriculum delivery. DSN suggested the SOM should emphasize the need ti integrate various elements of P&E inot the clinical curriculum apart from formal teaching as stated above. HOD should assist in ensuring new faculty joining the SOM in both familiarizing and delivering the curriculum on Bioethics. All , members agreed that delivering P&E curriculum should be both formal or non-formal teaching. Various teaching methods including reflective writing and narrative medicine were presented and spelt out in the slides. It was reiterated that the contents of E&P should include : BioethicsMedical LawProfessional Development of students and facultySocial Responsibility though community serviceHumanism, cultural diversity and literaturePatient Safety 360 degree Student Feedback based on portfolios maintained by the student would an effective assessment mode. ConclusionThe IMU has incorporated and integrated the teaching of Bioethics and Professional Practice in all programs as part of the transformation process.

Resources

http://elearn.imu.edu.my/course/view.php?id=567

Ethics and Professionalism for Clinical School

http://elearn.imu.edu.my/course/view.php?id=393

Some examples of Case Summaries

Objectives:

Professionalism and ethics in the new medical curriculum

To educate and train students to become physicians with high levels of competence, compassion and moral integrity

“”

Assessment

Contents: Sem 1-5 T/L activities Themes

SEM 1 PPD workshop Professional Values, Reflective writing

CSU Communication skills

Community Oriented Project Team work /communication

PBL Team work/ behaviours

Plenary Introduction to ethics/Consent

SEM 2 Clinic Visits/CSU Communication/Teamwork

Plenary Confidentiality/End of life issues

PBL Team work/ behaviours

SEM 3 Clinic Visits/CSU Communication/Teamwork

Plenary Reproductive ethics

PBL Team work/ behaviours

SEM 4 Clinic Visits/CSU Communication/Teamwork

Completion of Norwegian ethics module Knowledge /application of ethics

PBL Team work/ behaviours

SEM 5 Community Medicine Survey Teamwork/Timeliness/communicationEthics of research

CSU Ethical case scenarios

Hospital Posting Reflective portfolio/Case summary

PBL Team work/ behaviours

Ethics and Professional activities in Phase 1 Medical

TOPIC Mode of Delivery Assessment Feedback

Autonomy and Confidentiality Plenary/ Clinic visits MCQ Class discussion

Fitness to practiceMedical Act 1979 Plenary MCQ Class discussion

Death Dying and KillingCriminal Procedure Code Plenary/case studies MCQ Class discussion

End of life issues Plenary MCQ Class discussion

Relevant topics) PBL

TOPIC Mode of Delivery Assessment Feedback

Ethical and legal consideration in terminations of pregnancy.. Criminal Procedure Code Plenary/Debate MCQ Class discussion

Legal and ethical issues in antenatal screening and family planning Plenary MCQ Class discussion

Consent in Minors and mentally challenged Child Protection Act 1991/ Mental Health Act

Plenary

MCQ Class discussion

Relevant topics PBLs

TOPIC Mode of Delivery Assessment Feedback

Ethical and legal considerations in medical research

Plenary MCQ/ Practicum in Sem 5 Class discussion

Legal and ethical issues In accessing health careEthics of screening Plenary

MCQ/SAQ Class discussion

Duty of Care/ Standard of Care/ Negligence Plenary/Case studies MCQ/SAQ Class discussion

Relevant topics PBL

Assessment Topic Mode of Delivery Assessment FeedbackProfessionalism

workshop /role playing reflective writing. On line

Duties of doctorsProfessional Code of conduct..MMC guide lines Plenary MCQ Class discussion

Introduction to medical ethics Physician misconduct

Plenary

MCQ/SAQ

Class discussion

Autonomy and Consent/ Standards of practice Plenary MCQ/SAQ Class discussion

Relevant Topics PBL Discussion

ASSESSMENT AND DELIVERYSemester 6-10

• MULTIMODAL• EACH UNIT IS INCORPORATED INTO EACH ROTATION

( SEM 6-10)• LOG BOOK: Attributes ( 360 degree )• EOP and EOS : clinical exams and summative ( OSCE/MEQ)• SEMESTER 10:

• ONE DAY SEMINAR ON MEDICAL LAW AND PROFESSIONALIMS• HALF DAY : DEBATE ON BIODIVERSITY AND HEALTH WITH

EXHIBITION ( DEPT OF SCIENCE AND ENVIRONMENT)• PORTFOLIO : ETHICS AND PROFESSIONALISM ( EACH OF 5 /10

PORTFOLIOS

The expanded curriculum

The expanded curriculum

ETHICS BIOETHICSPROFESSION

ALISM & PROFESSIONAL PRACTICE

PATIENT SAFETY

MEDICAL LAW

SOCIAL RESPONSIVE

NESS AND SOCIAL

RESPONSIBILITY

Medical law

Medical Law: http://elearn.imu.edu.my/pluginfile.php/37921/mod_resource/content/1/Professionalism_Medical_Law_list.pdfMalaysian Medical Act 1971: http://www.mma.org.my/Portals/0/medical%20act%201971.pdf

http://elearn.imu.edu.my/course/view.php?id=567

Patient SafetyAnaesthesia: http://elearn.imu.edu.my/mod/page/view.php?id=10328&inpopup=1

Scholarship Workshops on Bioethics and SOM retreat

Conferences

Presentation & Publication

1st and 2nd Bioethics Conference

Research and Publications

The environmentConducive and Safe

Core values, ethics and professionalism

Recruitment

Embed core values to activities

Social Media Guidelines

IMU Social Responsibilities Activities

Teaching & Learning

Mentoring System

Get-together events

Individual’s Developmen

t

EvaluationResearch

SOPs

Healthcare

E-bulletinPosters

Videos Website(Social Media)

Core values,

ethics and

professionalism

Handbook

General guidelines on ways to embed core values to the

activities

Success Stories and Role Models

Articles oncore values

International Medical University Ethics and Professionalism Working Group – Summary of Initial Meeting on 2nd May 2013 and Minutes of Meeting for 17th May 2013 Date of Meeting 2nd May 2013 Time 4.00 p.m. to 5.30 p.m. Venue MR 2, IMU Bukit Jalil Name of Meeting IMU Ethics and Professionalism Working Group Meeting Attended by: Tan Sri Dato’ Dr. Abu Bakar Suleiman (ABS)

Prof Dato’ Dr Sivalingam Nalliah (SN) A/Prof Dr. Verasingam Kumarasamy (VK) A/Prof Dr. Muneer Gohar Babar (MB) A/Prof Dr. Nazimah Idris (NI) Dr. Haider Abdulameer Al-Waeli (HA) Syed Imran Ahmad (SI) Wong Chin Hoong (WCH) Apologies: Prof Dr. Winnie Chee (WC) Sheba DMani (SD)

Social accountabilityObligation of medical schools to direct education

• Education• Research• Service activities

• Towards addressing priority health concerns of the community, regions and nation they mandate to serve

• Need to be jointly addressed by government healthcare organizations, health profession and public

Boelen C, Heck JE Defining and measuring accountability in medical schools

Geneva WHO 1995 (WHO/HRH/95.7)

IMU Cares in Clinical School

Elderly Homes IMU Cares Project

Promoting Adolescent Health ProjectKampung Sebir, Kampung Project

Flood Relief Project – Kuala Krai, Kelantan

Sem 10 Kampung Projects

Batu Pahat Kampung Parit Lapis Project

Inauguration speech by Guest of Honour – MP- Batu Pahat

30MAY2014IMU and IMC students promote Adolescent Health in Kuala Pilah

CHALLENGES SWOT ANALYSIS BY COMMITTEE ON ETHICS AND PROFESSIONAL PRACTICE

SWAT Analysis(2013): Issues Assoc. Prof Verasingam

1. Culture of organisation:

Transparency (PMS placement),/ Dress Code some faculty are poor role models. Other organizational processes involving students need to be reviewed in light of transparency and ethical issues. 2. Assessment:

Inadequate

3. Plenaries : Not effective in modulating professional behaviours, small groups discussion are better.

4. Common definition of Professionalism across board.

The course will be conducted as a vertical strand running along all the semesters Lecture PBL / TBL Case scenarios (EBM and ethics) Seminars Workshop Portfolio (elective) The course will be further strengthened during the health clinics visits programme where the students will be asked to study the organization of the health centre and the role and responsibility of the staff at the health centers. A research project will also be given to the students to implement what they have learnt during the lecture sessions. The details of the workshop and seminars will be developed during the rotations week as part of the rotation slots in Community Medicine. Some of the sessions are covered during the health issues week. If approved the details of the implementation of the programme will be worked out.

SWOT analysis on the teaching of ethics and professionalism (E/P) in Phase 1 (SEM 1-Sem 5) in the medical curriculum.

Strength Weakness Opportunities Threats SuggestionsAdmission Interview before

admissionUnable to discriminate students with potential behavioural and ethical problems Interviews here seem to be more of a marketing /public relations exercise rather than a discriminating one

More stringent interviews. To reveal data how many students were rejected on interview (if any)

In a competitive business environment deficiency in moral decision making may take a back seat

Interview process need to be reviewed to weed out potential unethical students

Current situation Suggestions/ comments

How Patient Safety and Medical law has been incorporated into the curriculum.

Pt safety and Medical Laws are incorporated into relevant plenaries on Medical ethics2. Elements of professionalism, medical ethics and patient safety are incorporated into the PBL and CSSU

Adequate theoretical input

Are the topics on Ethics and Professionalism only delivered by CM faculty?

All the plenaries pertaining to Ethics and professionalism is being delivered by CM staff in phase 1 except in the Forensic module some are delivered by Pathology dept. (Dr. Vasu)

Do we incorporate aspects of professional practice in CSSU and PBL?

Elements of professionalism are incorporated in PBL and CSSU for medical students at varying degrees and is faculty dependent. Some are strict some are not

No assessment structure based on behavioural attributes in PBL and CSSU

Assessing learning in Professionalism and Ethics in Phase 1 (Sem 1-5)?

A few OBA in the theory exams. Sometimes Air topics is given based on specific ethical issues. Completion of Norwegian Medical Ethics online course

Generally inadequate. No assessment of behavioural attribute is being measured.

Strength Weakness Opportunities Threats Suggestions

Curriculum Organized curriculum with learning outcomes and competenciesSpread throughout the curriculum

Not much coordination between various departments conducting teaching and professionalism activities.

Many activities are undertaken where professionalism and ethics can be incorporated in a formal manner

Lack of staff to undertake the extra load may scuttle any plans for efficient coordination

Process of coordination need to be inbuilt in the curriculum

References: 1. Code of Professional Conduct, Malaysian Medical Council, 1986

2. Teamwork, Ministry of Health, Malaysia, 1996

3. Medical Professionalism in the new Millennium: A Physician Charter,

2003. ABIM foundation, ACP- ASIM Foundation& European Federation of Internal Medicine

4. SR Cruess, RL Cruess: Professionalism must be taught. BMJ 1997;

315:1674-1677

5. Yadav H. Hospital Management. University Malaya Press. 2006

6. Bioethics and Professionalism for Stakeholders: booklet for the IMU

AcknowledgementInput from Members of the Committee on E&PDr Wong Chin Hoong ( Family Medicine)Community Medicine Dept ( A.Prof Verasingam & Prof Yadav)Sharifah Sulaiha Tan Sri Abu BAKAR Sulaiman