Professionalism in Medical Informatics
Many forces are changing the paradigm of health care and testing the sanctity of the heretofore-inviolate bond of the physician patient covenant. This bond, founded in the writings of Hippocrates and secured by an ethic of trust between the patient and the physician, invokes a commitment to patient privacy and confidentiality as well as a code of professionalism for the physician. These principles are the foundations and imperatives to provide the highest quality of health care services by defining the fiduciary obligation of the physician and promoting a healing partnership between the patient and physician. The behavior of physicians and other health care clinicians, professionalism, has become a topic of interest in recent years and its importance is being emphasized more and more in medical student and house staff education. Expected behaviors, inappropriate behaviors, attitudes, integrity, knowledge of limitations, self awareness, compassion, conduct, discipline, pursuit of excellence and mindfulness are among the characteristics associated with professionalism. Closely related and integral is the tenet of humanism, an aspect of healthcare with a long tradition and a recent, much needed rekindling of interest. Advanced information technology tools are poised to further medical care, improve communications, education and healthcare delivery in the 21st. Century, but will this come at a cost; will the age-old lessons, mores, philosophies and bonds ingrained in the healing professions be lost to this technology? This paper explores the current milieu of professionalism and the necessity of its consideration and integration into the patient-centric enterprises framed by the new technologies of health informatics.
The physician is the usual point of entry of a patient into the healthcare system. From the onset of the first physician / patient encounter, a fiduciary relationship of confidence and trust is established.1 This relationship, with origins from a long-standing ancient ethic of medical practice, the Hippocratic Oath,2 is essential in protecting a patient’s privacy and in the patient’s acquisition of healthcare of the highest quality and safety. Advanced medical technologies bring hope to previously hopeless conditions and pathologies. Health information technologies (HIT) are transforming the quality and safety of medical and hospital practice, improving both an individual’s health and the public’s health. Consumer Health Informatics(CHI) “… which studies from a patient/consumer perspective the use of electronic information and communication to improve medical outcomes and the health care decision-making process" 3 is changing the roles of the providers and consumers of health information, forging a partnership in health education and information and permitting virtual dissemination of healthcare information, advice, consultation, diagnoses, treatments, counseling.4 Telesurgery, defined as long distance, remote surgery, has the potential to positively influence patient care in the appropriate settings where lack of access to surgeons and their skill sets become critical for patient care.5 Local, national and international laws and thoughts on what constitutes a physician patient relationship will need to be well thought-out, modified and updated as these technologies generate evidenced-based outcomes to show benefit to the patients and the public.6 But amidst the progress and the promise of these myriad medical and information technologies, there will realistically be accompanying failures and inexorable suffering. The paradox of all new technologies to cure and cause pain is real and evident. If we assert that physicians have been granted by oath and by ethic the privilege to examine and treat, to counsel and advise their fellow human beings while using these technologies, they must become responsible and mindful not to allow such technologies wedge the doctor/patient bond or violate the ethos of the profession. In managing dire illnesses, conscientious and compassionate physicians set their patients and their families on a course of acceptance, comfort and understanding. They sit at their ill or dying patients’bedside. When their deeds and actions, their skills and intuitions can no longer heal, they do not abandon the soul of their patients. Indeed, caring for patients is a human experience.7 Physicians bare the responsibility of holding their patient’s lives in their hands. Patients trust them with their health. When taking the Hippocratic oath, physicians “vow to prove forevermore worthy of that trust”.8 Addressing the question of whether the well defined, traditional physician (or other healthcare provider) -patient relationship and the foundation of subscribed principles of professional ethics will complement those of healthcare information technologies is germane and essential. When these principles conflict, “new dilemmas are posed.” 9 Thus, successful integration of all aspects of HIT with medical professionalism is necessary in today’s new paradigm of health care and medical care.
Professionalism in the healing professions
“…professionalism is first cousin to humanitarianism and ethical behavior. It is what we used to call character”10
There are relevant and abundant discussions in the literature regarding what defines professionalism and why is the medical profession its archetype. In the context of this paper, professionalism can be considered the work ethic of a profession [medicine] that has social value, professional privilege, and a “way of life with a moral value”. “…The Hippocratic doctrine separated medicine from religion, applying reasoning and observation to medical practice…It focused attention on the patient rather than the disease…”11 Professionalism is the demeanor of “professional work…pursued primarily for others and not for oneself.”12 The word itself is derived from ‘profess’, a commitment to an ideal. Physicians in the course of their actions profess and invoke competency, advocacy, commitment to the best interests of their patients, and trust. By the very public act of their taking an “oath” at medical school graduation, new physicians become professionals, differentiating themselves from other skilled workers.13 Physicians are expected to be virtuous and altruistic. Their image and hallmark has been of integrity and compassion. Sethuraman 13 in his essay Professionalism in Medicine cites the virtues a physician needs to possess as:
- Fidelity to trust
- Intellectual honesty
- Courage (to be the patient’s advocate in a
commercialized health care setting)
- Truthfulness–enables the patient
- Advocacy for the vulnerable
These are “virtues obligated by the dyadic nature of the medical encounter between a physician and an individual.” Furthermore such responsibility for professional behavior extends to the medical team and…it is necessary that the members of the team share in the very same values and ethical behaviors expected of their physician/team leader. 13 Closely aligned with the aforementioned ideals of professionalism are the principles of humanism and mindfulness. The American Heritage Dictionary defines humanism as “the concept that concern for human interests, values and dignity is of the utmost importance to the care of the sick.” 14 “The humanities can represent deeply philosophical, pragmatic, emotionally driven and/or entertaining approaches to understanding the human condition and the social relations of physicians, scientists, patients and the rest of the world”. 15
Mindfulness has been defined as “the quality of being fully present and attentive in the moment during everyday activities.” 16
“Through humility and continual self-evaluation, mindful individuals (physicians) become tacitly aware of their own limitations and continually address these deficiencies through everyday actions-with patients, families, and other professionals”17
There are contemporary forces that are testing and transforming the foundations of professionalism addressed above. Changing health needs of the population with chronic diseases and co morbidities requires skill sets of many healthcare providers and institutions, resulting in changing health policies and paradigms on how medical care is delivered-or in the case of an individual physician-how medical care is practiced.18 Students are taught the tenets of Hippocrates and the mores of the traditional physician-patient relationship and many have entered the profession for these reasons alone, seeking a personal and professional identity exemplified by altruism, responsibility, compassion, and generosity.19 Yet. today they must find these core values and pursue them in an age of medical practice different from any other, defined now by a healthcare culture immersed in business models, performance measures, increasing regulations and accountability, and a plethora of information. Set within a solid and growing framework of advanced medical and information technologies, both the young medical student and the experienced clinician must embrace and adopt these technologies and use them for their patient’s advantage and care. The challenge is to do so and not lose the fervor, the “soul of medicine” and to maintain that their “service of medicine is not a relationship between an expert and a problem [but] a human relationship… a work of the heart and soul.” 20
Professionalism in Health Information Technologies
Foremost to the discussion of professionalism and HIT are the concepts of privacy and trust; principal ethical foundations of the Hippocratic doctrine and their relevance to the new paradigm of the doctor patient relationship. If the “ practice of medicine is an art…a calling”,13 then its commitment to privacy, beneficence and protection of the patient must be preserved in any and all systems of care. Patients who are concerned about breeches in the security of their health record may withhold essential health information from their physician and compromise their care.21 The physician-patient encounter of the 21st century is carried out in a clinical care settings where the patient arrives in the physicians office with information obtained from online searches; information that may or may not be relevant or accurate. It is information used to jump start the consultation examination in way that physicians heretofore have not encountered. The paternalistic model of care has transitioned to a shared, patient-centric model. In the office, the 21st century physician documents the patient encounter and the course of diagnoses and treatments in the electronic medical record (EMR) and this in turn is available and shared with the patient in a personal health record (PHR). Formerly taught and practiced ethical guidelines, e.g. the doctrines of Hippocrates, as well as guidelines of professionalism from medical societies must be maintained in this new age of medical care. Because of this evolving model of record keeping that replaces the patient’s paper chart(s) with an interoperable electronic health record (EHR), concerns about breaches in security and confidentiality of protected health information abound. Patient information must be secure at multiple points of access, transmission and storage. It is imperative to protect the privacy of a patient’s health record in order to provide the highest quality of health care services, maintain the fiduciary obligation of the physician and promote a healing partnership that upholds the patient-physician covenant. The security of protected health information is obligatory and primary for the maintenance of the principles of professionalism. Patients need to know that their personal health information will not be exposed or used for devious purposes and that their physicians will preserve their privacy. Otherwise, the efforts to realize the overarching advantages of a universal electronic health information system will be hindered. Patients’ health information must be safe to keep patients safe. Maintaining and assuring patients’ privacy is among the greatest challenges of the EHR.22 When the ethical, legal, and technical aspects of working with identifiable health information is maintained, the physician’s culture of professionalism, integrity and mindfulness is preserved. 23
The paradigm of health care delivery, education, financing, and information management is changing. Health Information technologies have become assimilated into the daily care of a patient . Facets of consumer health informatics are altering the interactions between physician and patients. The EMR, programs for chronic disease management, and platforms for remote monitoring, telemedicine, telesurgery, virtual consultations, social networking, support, and patient-centric care via the personal health record are among the tools of this change. Ironically, the individual physician has been slow to adopt these new technologies “despite the promises [they] offer health care and quality improvement.”34
However, HIT in many if not all of its domains challenges the traditional physician- patient relationship, the Covenant, that engages the minds and souls of physicians and drives their resolve of professionalism and personal ethics. This too may be a hidden barrier to adoption heretofore unspoken. Failure to adopt HIT can actually test one component of the professionalism model: “advocacy for the vulnerable”. Physicians and ambulatory health care systems serving the poor and uninsured may be less likely to adopt an electronic health record, thus not making available to their patients the tools of health information technology that can improve their care, i.e., clinical decision support and computerized order entry. In a large study to examine this question, Hing and Burt found that EHR adoption was lower in the providers of care of uninsured and in Medicaid populations.36 Provider disparity directly translates to patient disparity as the uninsured patients are not benefited by the multiple advantages an EMR can provide to improve their care.
The need for advancement and utilization of HIT in the 21st century is clear and evident. Within the confines of a physician’s personal ethic and desire to Primum non nocere (first, do no harm), physicians must find their way to use these new technologies to advance the care of their patients. “The roots of professionalism begin at mother's knee, embedded in early exposure to parents, teachers, older siblings, peers who "teach" about right and wrong, caring for others, the virtues of honesty, integrity, and selflessness--all the elements that form the character of the decent human being… Either we are moral, thoughtful, caring, humane, honest, ethical human beings or we are not.”10 In this age of new technologies, the physician must be and remain true to these moral and character traits, stay focused on the mission of healing and remain “advocate [for]the individual patient”10 Pursuit of these ideals, integrated into the use of health information technologies will appropriately serve the needs of the patient and preserve the covenant of the physician.
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Submitted by Michael R. Berman, M.D.