Are Codes of Ethics Enough? Learning Professionalism on the Playing Fields of Ethics

1. Are Codes of Ethics Enough?Learning Professionalism on the Playing Fields of Ethics Healthcare Ethics & Law Institute Samford University April 9, 2010 DeWitt C. Baldwin Jr. M.D. Scholar-in-Residence ACGME

2. Appreciations • The HEAL Institute and Samford University • Lori Bateman • Professor Wilton Bunch • Dr. Edmund Pellegrino • My colleagues: • Steven Daugherty PhD • Patrick Ryan MD

3. Learning Professionalism on the Playing Fields of Ethics • The biographies of many famous British leaders often contain some variation of the sentence “ Everything I needed to know about (life, leadership,, success, getting along, etc.), I learned on the playing fields of Eton” ( a well-known, upper-class “public school” in England). • I have chosen this metaphor to portray a picture of ethics and professionalism as “contact sports”, conceived of as a struggle to “do the right thing”, between frequently conflicting values, played out daily on the “playing fields” of life and work, whose limits, dimensions, and rules are set by codes of desired conduct and behavior.

4. Professionalism:Definition • Professionalism…a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population ACGME, Minimum Program Requirements Language Approved Sept. 28, 1999

9. Levels of Professional Behavior • Ideal (e.g., consistently goes beyond the call of duty) • Expected (e.g., complete care and disposition of patients before signing them out) • Unacceptable (e.g., make passes at students or patients) • Egregious (e.g., falsify medical records) (Larkin, 2003)

10. Zone of Enforcement Actual Behaviors Judging Professional Behavior: Between the Ideal and the Deviant Ideal Standard Deviant Boundary Zone of Possibility Sanction Exclusion Positive Negative

11. Residents’ Reactions to their Residency Experience (two factor cluster analysis) Unpublished data

12. Learning Professionalism on the Playing Fields of Ethics • Professionalism must be defined before it can be evaluated or taught. • Usually presented in terms of multiple distinct ideals. • Such ideals are difficult to express in operational terms. • Often portrayed in oppositional and dichotomous terms: “professional” vs. “unprofessional”; “ethical vs. unethical”. • Frequently grasped in metaphorical or global intuitive terms. • Justice Potter Stewart: “I know it when I see it”. • Situation and Context-dependent- clinical, cultural • Professional Standards (Codes) are necessary, but insufficient.

13. How do Students LearnEthical and Professional Values? • Bring some to medical school with them. • Learn some through the formal teaching curriculum. • Learn more from faculty role models. • Learn a lot through the “hidden” curriculum. • Learn most in clinical situations, because these are the complex “playing fields” of moral, ethical, and professional action, where ideals, values, and behavior are tested, contested, and adopted or rejected.

14. Conflict between Values • Professionalism is rarely taught through simple expression of values, (e.g., “always be honest.”) • More commonly, professionalism is taught when two or more worthy values come into conflict, (e.g., honesty conflicts with confidentiality.)

15. The Informal (Hidden) Curriculum “[The] hidden curriculum can . . . be represented by the three R’s, but not . . . reading, ‘riting, and ‘rithmetic”. “It is . . . the curriculum of rules, regulations, and routines, of things teachers and students must learn if they are to make their way with minimum pain in the social institution called the school.” Jackson P. Life in classrooms. Holt. 1968: 353

16. When Are Values Taught? Shift Type Call Stern D. Acad Med. 1998; 73: 28S-30S

17. Changing Attitudes, Values, and Behavior during Medical Education • Ethical and Professional attitudes, values, and behaviors change during the course of medical education--not necessarily in ways we like. • Moral Reasoning (Kohlberg) progress shuts down with entry to medical school and remains low during residency without specific remediation. (Self et al., Baldwin & Self.) • Cynicism “Ethical erosion” and unprofessional behaviors are observed and manifested by medical students and residents. (Baldwin et al.; Feudtner et al.)

18. The problem is that medicine has had a culture, in which: • Medical students have been humiliated for not knowing and so have learnt to hide their ignorance, • Junior doctors are reluctant to call their seniors and so take • on more than they should, • It is seen as weakness to admit to anxieties or shortcomings, • Errors are seen as unacceptable and so are hidden, and • Doctors find it hard to confront colleagues who are • performing poorly. Source unknown

19. The Ethical Environment of Undergraduate Medical Education Medical Student Studies

20. Reports of Perceived Mistreatment First-year Residents (n=571) Medical Students (n=580) Baldwin et al. Western J. Med. 1991; Acad Med. 1998

21. Reports of Perceived Mistreatment First-year Residents (n=571) Medical Students (n=580) Baldwin et al. Western J. Med. 1991; Acad Med. 1998

22. Percent of Third Year Medical Students Reporting at Least One Episode of Observing What They Believed to Be Ethical or Professional Misconduct Sheehan et al. JAMA 1990;263:533-7

23. “Ethical Erosion” in Third Year Medical Students (N=665) 58% believed they had done something unethical 52% believed they had misled a patient 98% had heard physicians refer to patients derogatorily 62% had observed unethical behavior by a clinical team member. (54% felt like accomplices) 67% had felt bad or guilty about something they did as clerks 62% felt that some of their ethical principles had eroded Feudtner et al. ACAD. MED 69(1994):670-9

24. The Ethical Environment of Graduate Medical Education

25. Development of Graduate Medical Education in the US

26. Development of Graduate Medical Education in the US (Cont.)

27. Development of Graduate Medical Education in the US (Cont.)

28. Lifestyle Work Shifting Dimensions of Subjective Well-being in Graduate medical Education Year High 2010 $50,000 Sleep $40,000 2000 MonetaryCompensation $30,000 1990 $10,000 1975 Well-being $1,000 1950 $0 1900 Low Less Freedom of Choice Satisfaction More

29. Changing Issues for Residency Training Lifestyle Sleep • Required Knowledge • Complexity of Medical care Work Time Time A B

30. Quick Review of Our Previous Resident Survey Data (1988-89 and 1998-99)

31. Distribution of Reported Resident Work Hours (1999) 80 hrs/week PGY 1 & PGY 2 Residents (1998-99)

32. Work Hour Distributions for Selected Specialties (1999)

33. Average Weekly Hours By Specialty (1999) PGY 1 & PGY 2 Residents (1998-99)

34. Reported Errors by Average Weekly Work Hours PGY 1 & PGY 2 Residents (1998-99)

35. Reported Errors by Average Daily Hours of Sleep X2=56.5, DF=5, p<.0001 PGY 1 & PGY 2 Residents (1998-99)

36. Interprofessional Conflict and Medical Errors Baldwin and Daugherty. J. Interprofessional Care. 2008: 22(6); 1-14

37. Choices in Residency Choice Difficulty 50 hrs 120 hrs Easy Choices No Real Choices (40%) (20%) N=1,274 N=695 70 hrs 90 hrs Difficult Choices (40%) N=1,320 80 hrs Work Hours

38. Expanding Our Search Past Work Present Work Sleep Future Work Sleep Personal (Defined areas are estimates for illustrative purposes)

39. Ethical and Professional Environment of Residency Training * Not Directly Comparable

40. Ethical and Professional Environment of Residency Training * Not Directly Comparable

41. Ethical and Professional Environment of Residency Training * Not Directly Comparable Preliminary Data

42. Ethical and Professional Environment of Residency Training *Preliminary Data Not Directly Comparable

43. Ethical and Professional Environment of Residency Training *Not Directly Comparable Preliminary Data

44. Ethical and Professional Environment of Residency TrainingChanges 1989-1999

45. Ethical and Professional Environment of Residency Training Changes in Satisfaction by Specialty

46. Ethical and Professional Environment of Residency Training Changes in Satisfaction by Specialty

47. Ethical and Professional Environment of Residency Training Changes in Satisfaction by Specialty

48. Changing Demographics

49. Negative Experiences in Residency Training • Overwork • Sleep Deprivation • Inadequate Supervision • Falsification of Records (observing others) • Mistreatment of Patients (observing others) • Sexual Harassment • Psychological Abuse • Physical Abuse • Racial Discrimination • Medical Errors • Impaired Performance (self) • Impaired Performance (observing others) • Interprofessional Conflict • Malpractice Suits • Stress • Alcohol Use and Abuse • Drug Use and Abuse • Weight Change • Accidents and Injuries

50. Science strives for certainty (generalizations) Medicine deals with uncertainty (individual variation). Not everything can be empirically known, predicted, or measured. Institutions dislike variation; promote standardization. Individuals dislike standardization; seek variation. Zero tolerance for errors Learning involves mistakes Some Unavoidable Tensions