Editorial

Would the Ethical and professional Training of physicians and Specialist Be possible under the Current Health Care System?

Martha Beatriz Delgado Ramírez
Profesora asociada y directora de carrera, Departamentos de Anestesiología y Epidemiología Clínica, Facultad de Medicina, Pontificia Universidad Javeriana, Bogotá, Colombia. mdelgadoramirez@gmail.com

The medical profession is currently facing a huge challenge in the light of changes in the health system in various countries and Colombia is no exception. The priority should be the patient's wellbeing but this well-being is now threatened by the requirements of the system that imposes time restrictions and splits the responsibility of caring for the patient among several actors.

The patient is subject to a medical care process whereby the holistic vision of the patient as a human being is easily weakened. Waiting times for medical visits and to initiate treatment for the patient's condition are long. By the time the patient is finally seen by the physician, usually he/she is seen by various professionals who attempt to independently approach diverse issues in their particular area of expertise and loose sight of the individual as a whole.

Physicians experience increasing difficulties to meet the needs of their patients and of society as a whole. This represents a risk to their professional practice that celebrates the primacy of patient's interests over self-interest, with respect, integrity and compassion, to respond to the needs of the patient and society with a high sense of responsibility, commitment to excellence and continued improvement of their knowledge.

The physician shall always adhere to ethical principles when providing medical care in clinical practice, ensuring confidentiality of the patient's information, respecting the patient's autonomy and being constantly sensitive to the patient's culture, age, gender and individual skills (1).

Educating physicians and specialists goes beyond acquiring the knowledge and skills of the particular discipline by developing the professional identity of the physician and strengthening his/her professional values. Building this identity should be one of the key and most important ingredients of medical education (1-3).

Learning and adoption of ethical and professional conducts in medical training have traditionally been achieved through the so-called hidden curriculum; i.e., the example the student observes everyday in the performance of their "role models". While this method of learning has been more or less adequate, it does not ensure a standardized and reproducible learning process; hence, this hidden curriculum should now be aligned within a learning environment consistent with the established values and principles formally established by health care providers (1,4,5). Therefore, current medical education demands the inclusion of these competencies in the medical education curriculum.

We are well aware that professionalism is probably one of the competencies most difficult to assess in students. One of the reasons is that the concept of professionalism itself may have different meanings depending on culture, social standards and religious believes that have a big impact on values and personal preferences.

Consequently, there is a need to establish programs for the development of identity, ethics and professionalism that are consistent with the new educational trends that demand that these competencies be explicitly incorporated in the curricula. The goal is to influence students throughout their academic training so that these aspects become part and parcel of other skills learned.

Exposure to real patients since the early stages of medical education is considered a key ingredient for the development of a professional identity. This generates opportunities to reflect on experiences lived, to discuss the lessons learned at length, and the emotional impact of specific situations such as disease, death and disability where the professor plays the role of a facilitator (1-3).

It is also key to provide experiences among peers, professors and multidisciplinary teams to discuss matters pertaining to the acquisition of an identity, ethics and professionalism.

Furthermore, the evaluation strategies should be aligned with the type of lessons learned by the student, including in this process patients, educators, peers, other health care workers and the student himself.

The environments for medical and specialized training must ensure altruism, responsibility for the patient, society and the profession and a commitment to continuous education in the search for excellence, where the performance of duty, honor, integrity and respect of others shall be the rule. However, the current health care system requirements represent a threat to the achievement of these goals.

Therefore, creativity if of the essence in designing curricular activities and practices so that students are provided with the appropriate environments for the development of ethics, promoting the establishment and maintenance of codes of honor and ceremonies that generate a commitment to and maintenance of the fundamental ethical and professional principles (1-4).

The need to deliver specific messages of the hidden curriculum is today more necessary than ever before, promoting opportunities to reflect on the experiences of clinical practice and providing feedback on the evaluation of the student's professional conduct, with a view to reflect and maintain a follow-up strategy throughout the educational process, under the guidance of a teacher who provides permanent counseling and support to the student, in addition to being a role model (4).

Moreover, the development of collaborative learning environments, committed to excellence and on-going improvement is fundamental.

But, would it be possible to meet this goal of ethical training and professionalism to accomplish the core competency of the physician and the specialist under the current health care system? Would it be possible to strike a fair balance between the right of the patient to receive humanitarian care with the highest standards of quality and the demands of a system that limits the length of time that the physician devotes to the patient in addition to considerable limitations of resources and a fragmented approach of the patient? Is this an issue to be dealt with only by the institutions devoted to the training of human resources?

The situation requires that universities become creative in the design of curricular activities aimed at developing ethical behaviors and professionalism of the medical professional or trainee specialist, jointly with a determined participation of health care providers and universities that agree to deliver a meaningful clinical experience to the students. This entails aligning the goals of university training with the goals of medical practice, in an on-going conversation between the academia and the health care centers.

Universities must explicitly develop the awareness that the teaching and evaluation of professionalism is not haphazard and stress in the discussions with health care providers that patients expect to be served by physicians and specialist with an unquestionable ethical and professional behavior that results in the best outcomes in terms of health related matters.

The strategies that could facilitate the teachings of ethical and professional competencies include lectures, discussion groups, role-play, simulated patients, team learning and clinical experience, all within an environment that favors discussion and analysis. Several of these strategies shall be planned jointly with the professionals who assist students in their undergraduate and graduate training practice (2).

Evaluation strategies should be in line with the corresponding skills learned by students, with the participation of various stakeholders in the process of student education and patient care. This will ensure a comprehensive evaluation from different perspectives (3).

In summary, the development of a professional and ethical conduct of physicians and specialists requires a formative process that should encourage students to become agents of change, empowered and able to transform the society in which they will be practicing their profession, aware of the fact that patients are social beings bonded to their families and their communities. This gives the doctor-patient relationship a very special identity; sometimes the disease can be cured, sometimes the symptoms are relieved; but it should always be possible to deliver compassionate care and accompany the patient throughout the process.

REFERENCES

1. Stern DT, Papadakis M. The developing physician-becoming a professional. N Engl J Med. 2006;355(17):1794-9.

2. Mueller PS. Incorporating professionalism into medical education: the Mayo Clinic experience. Keio J Med. 2009; 58(3):133-43.

3. Wilkinson TJ, Wade WD, Knock LD. A Blueprint to assess professionalism: results of a systematic review. Acad Med. 2009;84(5):551-8.

4. Irby DM, Cooke M, O'Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med. 2010;85(2):220-7.

5. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376:1923-58.