Acad Psychiatry 29:413-415, December 2005
doi: 10.1176/appi.ap.29.5.413
© 2005 Academic Psychiatry
Professionalism and the Ethics-Related Roles of Academic Psychiatrists
Laura Weiss Roberts, M.D., M.A.,
John Coverdale, M.D., M.Ed., FRANZCP and
Alan Louie, M.D.
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INTRODUCTION
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Professionalism, ... aspires to altruism,
accountability, excellence, duty, service,
honor, integrity, and respect for others.
—J. Stobo and L. Blank (1)
Academic psychiatrists are often called upon to serve in ethics-related roles in medical schools: on patient care ethics committees, on institutional review boards, on peer review panels, on conflict mediation teams, and on student performance committees (2, 3). Because many ethical issues are resolved by communicating carefully; by clarifying motivations; by making explicit the conflicts that may exist in values, attitudes, or perspectives; and by detecting when "ethics concerns" mask psychiatric symptoms or psychological issues the skill set of a faculty psychiatrist may be especially helpful in these diverse "administrative ethics" tasks (4, 5). In this issue, Bennett et al. (6) remind us of the thorny responsibility that psychiatric educators may assume, or may be asked to undertake, in relation to the identification of "problem students" of all kinds, including those who do not appear to measure up to the standards of professionalism expected of physicians-in-training.
A total of 57 psychiatric educators participated in the survey project of Bennett et al., and nearly all these evaluated "professional attributes" of medical students, with a majority seeking to provide feedback to students, to identify problematic behaviors, to gather specific information for Dean’s letters, and to identify exemplary behaviors. In general, unprofessional behaviors were rarely identified by respondents. In terms of procedural issues, mental health evaluations and treatment were a common component of remediation efforts, with routine mental health referrals for students with "professionalism deficits."
"Sentinel events" requiring automatic referral to an ethics or academic promotion board were those behaviors that would be widely acknowledged as very grave. Interestingly, intoxication with substances while performing clinical duties was the most frequently identified (N=46) "sentinel event"—ahead of drug theft, violation of criminal code, cheating on examinations, sexual impropriety, threats of harm or defamation, falsification of records, and sexual harassment (range of N=36–45).
There are two considerations that we wish to highlight in reflecting on these findings in the work of academic psychiatrists. The first pertains to definitions of ethics and professionalism and how they are observed and assessed in educational settings. The second pertains to professional boundaries in administrative or educational faculty roles.
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Definitions, Observables, and Assessment
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Being a professional is an ethical matter,
entailing devotion to a way of life, in the service of others ...
as well as appropriately reverential stance
of the physician before his chosen profession.
—L. Kass (7)
Professionalism is not a matter
of trying but of being
—M.A. LaCombe (8)
Definitions of professionalism are inconsistent and provide ambiguous guidance to educators. Sometimes they emphasize aspirations, beliefs, and the ideals of the profession. Sometimes they emphasize the bedrock obligations of the profession. Sometimes they emphasize attitudes, and sometimes they affirm virtues, and sometimes they focus specifically on ethical practices. With the relatively recent introduction of professionalism as a formal competency in graduate medical education (9), there is greater need to utilize a definition that translates to observable, measurable behaviors (10, 11). This focus, to our way of thinking, neglects the scholarly discipline of ethics as well as the emerging standards in the field of clinical ethics (12), including empirical or evidence-based ethics (13) and informed medical decision making (14). Indeed, there is a need for greater clarity in understanding professionalism and its relationship to ethics in medical education.
This tension related to the definition of professionalism as requiring "measurables" is apparent in the findings of Bennett et al. Respondents endorsed different characteristics and behaviors (which the survey instrument referred to as "areas") in the evaluation of professionalism during the psychiatry clerkship experience—ranging from "duty: reliability and responsibility" and "respect for patients regardless of diagnosis" to "appropriate clinical attire" and "use of professional language (no foul language or slang)." In listing "sentinel events," the range is broader. For example, less serious "language difficulties impairing patient interactions" and "lack of initiative inpatient care" are listed on the survey, along with serious behaviors that violate societal norms for appropriate conduct such as "threats of harm or defamation to patients, staff, or colleagues," "theft of drugs," and "falsification of medical records." "Sexual impropriety with a patient or colleague" is also listed, which is an interesting issue in itself. Sexual interactions with patients are a clear violation of psychiatric and medical codes of conduct that are well-supported by ethical analysis and arguments (15–17), but the addition of the phrase "or a colleague" is intriguing. Does this imply that all sexual relationships with colleagues are "improprieties"? This is a complicated issue (18). If the sexual relationship is with a more empowered individual, such as a supervising resident or faculty member, then ironically the student may be held responsible when the more senior individual (who has fiduciary responsibility for the student) is not. Our intent is not to criticize, but rather to emphasize how these ambiguities in our constructs and our language are very confusing and may lead to challenges in defining, observing, and measuring professionalism expectations for our trainees.
An interesting approach was taken by Swick et al. in a paper published in the Journal of the American Medical Association in 1999 (19). They defined professionalism in medical education as based on four cardinal elements: subordination of self-interest; adherence to high ethical and moral standards; response to societal needs; and demonstration of core evincible humanistic values. This definition has the advantage of linking explicitly with historical views of professionalism as committed to service to others and altruistic in nature and requiring adherence to shared conduct with regard to certain attitudes as well as conduct. It does not require that trainees hold certain beliefs, but that they act in accordance with high ethical and moral standards in the field and demonstrate humanistic values, such as compassion and truthfulness. One limitation to this definition is that it, too, fails to draw the connection with the scholarly discipline of ethics, which at this point in history should be seen as an essential knowledge area—not merely a "soft" subject where personal opinion of a certain stripe is seen as sufficient. On the other hand the definition does align with practical ethics standards, which implies knowledge of this material. The second concern is related to the first. It neglects, or at least skirts, the issue of skill in decision making, especially in preference-sensitive or values-sensitive decisions of patients regarding their personal health care. The ability to obtain informed consent or refusal, in its true spirit (not just its legal or bureaucratic sense) comes close to this, but it is a richer notion tied with the ethical principles of respect for persons and autonomy (20, 21). Nevertheless, the work of Bennett et al. and the four-component approach of Swick et al. represent important steps forward and, with such efforts, many of the knotty issues related to concepts, observables, and measurables in professionalism will be better understood in the coming decade.
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Professional Boundaries
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Pickering: Have you no morals, man?
Doolittle: Cannot afford them, Governor
—G.B. Shaw (20)
The professional boundaries that circumscribe the role of a faculty member differ from the professional boundaries that circumscribe the role of a treating psychiatrist (2). The orientation of one’s fiduciary-type responsibilities is toward the institution when one is serving in an administrative faculty role (e.g., committee work), whereas they are oriented toward the student in straightforward teaching roles, and oriented toward the patient who happens to be a student when providing clinical treatment in, say, the student mental health program.
This said, it can be difficult to separate the various roles of academic psychiatrists when we use a similar set of skills in both activities and when our institutions keep hoping we will use our clinical talents in administrative duties. From an ethics perspective, this represents a classic "dual or overlapping role" problem (some would call this a "conflict of interest" problem), and it represents a high-risk situation for making errors in judgment (23). For instance, when a student is referred for a mental health evaluation as part of an ethics panel review, the faculty member’s fiduciary-type responsibility must remain oriented toward the institution. This is true even when the faculty psychiatrist may have knowledge of the student from other roles or feel great compassion for the student because of other aspects of the situation. If the psychiatrist who performs the evaluation then becomes the treating psychiatrist, as may occur, then the responsibilities change. To be concrete, confidentiality expectations and documentation needs are radically different in these varying and evolving roles.
The paper of Bennett et al. is very valuable and does a great service to the field, in our estimation, because it highlights the potential for ambiguity in this important aspect of an academic psychiatrist’s work. It also brings to the fore one other seldom-discussed but very important issue. There is a subtle complexity embedded in the practice of referring "problem students" for psychiatric care, when the triggering complaint or concern relates to "professionalism deficits": it is that we ourselves are uncertain whether the student’s professional conduct should be viewed only as a symptom. This, again, is an issue where we need to find greater clarity as educators, and we invite discussion of this concern in the upcoming special issue on personal health care and impairment issues in medical students and residents (deadline for submissions is April 1, 2006). Under most circumstances, if the faculty psychiatrist sees the student-patient for a required evaluation, the behavior will have significance for its meaning as both a potential symptom and as a professional behavior. Psychiatric treatment may then be the correct "intervention" for the professionalism "problem," but it may not, and this should be considered with great care, intentionality, and deliberateness—preferably with the correctly composed group of advisers. This is burdensome and murky. Two of our principal gifts to the profession of medicine, however, are the formally cultivated and disciplined use of self-observation and great patience for subtle issues, and this is true across our roles (4, 23). This capacity is where psychiatry may greatly assist institutions and our colleagues in being explicit about the parameters and duties associated with our various academic activities.
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REFERENCES
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- Stobo J, Blank L: ABIM’s project professionalism: staying ahead of the wave. Am J Med 1995; 97:1–3
- Townsend T: Health care ethics committees, in Concise Guide to Ethics in Mental Health Care. Edited by Roberts LW, Dyer AR. Washington, DC, American Psychiatric Publishing, 2004
- Aulisio MP, Arnold RM, Youngner SJ: Health care ethics consultation: nature, goals, and competencies: a position paper from the Society for Health and Human Values—Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation. Ann Intern Med 2000; 133:59–69[Abstract/Free Full Text]
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- Leeman CP: Ethics consultation masking psychiatric issues in medicine. Arch Intern Med 1995; 155:1715–1177[CrossRef][Medline]
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- Kass LR: Professing ethically. On the place of ethics in defining medicine. JAMA 1983; 249:1305–1310[Abstract]
- LaCombe MA: On professionalism. Am J Med 1993; 94:329[CrossRef][Medline]
- Accreditation Council for Graduate Medical Education. 2005. Retrieved Aug 16, 2005, at http://www.acgme.org/
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- American Medical Association: American Medical Association Code of Medical Ethics. Retrieved Aug 16, 2005, at http://www.ama-assn.org/ama/pub/category/2498.html
- American Psychiatric Association: The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry, 2001 ed. Retrieved Aug 16, 2005, at http://www.psych.org/psych_pract/ethics/ppaethics.pdf
- Gabbard GO, Nadelson C: Professional boundaries in the physician-patient relationship. JAMA 1995; 273:1445–1449[CrossRef][Medline]
- Ryan CJ: Sex, lies and training programs: the ethics of consensual sexual relationships between psychiatrists and trainee psychiatrists. Aust N Z J Psychiatry 1998; 32:387–391[Medline]
- Swick HM, Szenas P, Danoff D, et al: Teaching professionalism in undergraduate medical education. JAMA 1999; 282:830–832[Abstract/Free Full Text]
- Faden R: Informed consent and clinical research. Kennedy Inst Ethics J 1996; 6:356–359[Medline]
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- Shaw GB: Pygmalion and Major Barbara. Bantam Books Classics, 1992
- Roberts LW, Dyer AR (eds): Concise Guide to Ethics in Mental Health Care. Washington, DC, American Psychiatric Publishing, 2004
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INTRODUCTION
Definitions, Observables, and...
