Prof Omar Hassan

Presented at the IMANA Convention at the International Medical Center Jeddah on 29 December 2014by

Professor Dr. Omar Hasan Kasule, Sr.MB ChB (MUK).MPH (Harvard), DrPH (Harvard) Professor Faculty of Medicine, and Chairman of the Ethics Committee and Institutional Review Board,King Fahad Medical City, Riyadh, Saudi Arabia

TEACHING TEACHING PROFESSIONALISM PROFESSIONALISM forfor DOCTORS: CONTENT DOCTORS: CONTENT and and METHODSMETHODS

TEACHING PROFESSIONALISM for DOCTORS: CONTENT and METHODS

on 29 December 2014by

Professor Dr. Omar Hasan Kasule

2 components: content and methods of teaching. Will focus on content Teaching doctors is too late; we need to start at medical school Medical student professionalism should be assessed too early and if

necessary weed out bad ones Apprenticeship is the best vehicle of teaching professionalism

INTRODUCTIONINTRODUCTION

Medical professionalism is poorly conceptualized and understood; therefore not easy to define .

As a concept and practice it has its own history and has been evolving. The concept has different formulations depending on space-time

variations Medical students get confused with apparently contradictory concepts

of professionalism if they do not realize that they are dealing with different models of professionalism .

Concept of ProfessionalismConcept of Professionalism




In general professionalism is defined as attributes and behaviors expected of a physician.

A fair level of agreement can be reached by physicians, nurses, and the public on tangible behaviors that constitute professionalism, .

Behaviors are easier to observe and measure than are attitudes and other intangibles that are acquired by apprenticeship or experience but which cannot be described in concrete terms.

Definition of Professionalism as Definition of Professionalism as Attributes and BehaviorsAttributes and Behaviors




Intangible aspects of professionalism can explain similar reactions of professionals to a situation without having to discuss or refer to a rule or code.

The intangibles could almost be called ‘trade secrets’ or practical wisdom (phronosis).

Intangibles can be considered under the Islamic legal principle of custom, ‘urf, with various formulations such as: what is known as customary has the force of law, al ‘aadat muhakkamat (Majallat Article No 36) and what is known customarily is considered an agreed condition among the practitioners of a profession like trade, al ma’aruf ‘urfan ka al mashroot shartan (Majallat Article No. 43 and 44).

Definition of Professionalism as Definition of Professionalism as IntangiblesIntangibles




Professionalism can also be defined as skills: A professional who is engaged in the same activities on a daily basis develops special skills.

In earlier times with limited knowledge and technology it was possible to list skills that a professional was supposed to have

It is not possible to list comprehensively skills of a professional today but the skill dimension is still assumed in attributes of professionalism such as such as ‘excellence’ because you cannot achieve excellence without being skilled.

Definition of Professionalism as Definition of Professionalism as SkillsSkills




The definition of professionalism varies by place, time, and culture,. A panel of Arab medical professionals and academics found the 6 dimensions

of the formulation of professionalism by ABIM appropriate to the Arab context, they added autonomy to make 7 dimensions.

A US study found little difference between native and immigrant medical students in perceptions of professionalism but differences were found between graduates of Indian and North American schools.

A Taiwan formulation found differences from the western perception with special emphasis on the centrality of self-integrity and harmonization between personal and professional roles.

Variation of Professionalism Variation of Professionalism Perceptions by Place and TimePerceptions by Place and Time




Altruism Accountability Excellence Duty honor and integrity Respect for others

6 Dimensions of professionalism – 6 Dimensions of professionalism – ABIM (American Board of Internal ABIM (American Board of Internal

Medicine) Medicine)




5 attitudes, behaviors, and actions erode professionalism Abuse of power and sexual harassment Conflicts of interest Professional arrogance Physician impairment Fraud in research

Negative ‘dimensions’ of Negative ‘dimensions’ of Professionalism – ABIM Professionalism – ABIM




The ABIM formulation is very practical and pragmatic by having both positive and negative definitions that leave little room for ambiguity.

The ABIM formulation is not exhaustive enough The ABIM formulation has no statement of an underlying moral theory

that could be the basis for the intangibles of professionalism which as mentioned above exist but are not obvious.

Hence the attempt at a formulation from the Muslim perspective attempts to overcome these defects.

Discussion of the ABIM Discussion of the ABIM Dimensions of ProfessionalismDimensions of Professionalism




Faith (iman) Consciousness (taqwat) Best character (ahsan al akhlaq), Excellent performance (itqaan al ‘amal), Strife toward perfection (ihsan), Responsibility (amanat), Self-accountability (muhasabat al nafs).

Proposed 7 Dimensions of Proposed 7 Dimensions of Professionalism - 1Professionalism - 1




Iman improves professionalism in two ways: holism and humility. Iman motivates the practice of holistic medicine emanating from the

integrative doctrine of monotheism. Iman makes the physician more humble and less arrogant through the

realization that he is an agent and the not the cause of cure; cure is in Allah’s pre-determination, qadar.





Taqwat makes the physician conscious of his duties and meticulous in performance in the full knowledge that Allah is watching and knows all what is being done unlike human observers who cannot see hidden mistakes and bad intentions.

Akhlaq ensure the best human interaction between the physician on one hand and the patients and professional colleagues on the other hand manifesting as balance (tawazun), humility (tawadh’u), brotherhood (ukhuwwat), social respectability (muru’at).





Itqan and ihsan motivate the physician to improve his skills and knowledge to have the best outcome in his medical procedures.

The physician should take his work as a trust (amanat), involving: sincerity of intentions (ikhlas al niyyat); quality work (itqan & ihsan), and social responsibility (masuliyyat ijtima’iyyat).

Professionalism is part of the social contract involving responsibility of the professional to society.





Growing awareness of the importance of professionalism and the horrors of the consequences of its failures have forced including professionalism in medical curricula at undergraduate and postgraduate levels,

Schools struggled to introduce a culture of professionalism using various strategies including integration of ethics and humanities.

Teaching Professionalism: Teaching Professionalism: MotivationMotivation




The teaching should be as early as possible in the medical course before students pick up bad habits.

Teaching of professionalism can be passive as apprenticeship. Apprenticeship remains the best method because it is one to one and

teaches practical wisdom and students learn from good role models. The disadvantage of apprenticeship is that students may feel deficient

in professionalism if they do not get teachers who are good role models.

Teaching Professionalism: 2 ApproachesTeaching Professionalism: 2 Approaches




Ireland: professionalism in Ireland was taught as an interdisciplinary course assessed by a student essay.

California: professionalism was taught as part of an integrated longitudinal program starting early in the medical course.

Among teaching methods used were: use of simulated emails, using movies, medical television programs portraying hospital practice, discourses on professionalism, online programs, and learning from malpractice suits and malpractice experiences.

Teaching Professionalism: MethodsTeaching Professionalism: Methods




Traditional Muslim education based on a student being with the teacher all through the waking hours and being awarded permission to teach others, ijazah, at the end of a long apprenticeship.

The system was not only about transferring knowledge but also transferred ethics, behavior, and attitudes by actual observation and interaction with a mentor.

The mentor also had ample time to observe the student and correct any deviations.

Teaching Professionalism: revival of a Teaching Professionalism: revival of a holistic educational tradition 1holistic educational tradition 1




The Qur’an describes this system in the education of Musa (PBUH) who travelled with the righteous man Khidhr and learned deep ethical lessons from him.

The prophetic teaching at Dar al Arqam: one to one, observation Hadith literature: words, actions, and iqrar.

Teaching Professionalism: revival of a Teaching Professionalism: revival of a holistic educational tradition 2holistic educational tradition 2




Relative separation of service from teaching; Doing service while teaching vs. teaching while doing service Teaching confined to only those who can / are willing to be good role

models Teachers should have enough time to teach with reduced clinical loads

Implications of Reviving the Holistic Implications of Reviving the Holistic Education TraditionEducation Tradition




Due to its central role in medical practice, professionalism has been assessed among students and among physicians in practice.

Assessment enables us assess whether what students know is what the teachers taught.

Student assessment can be at the start, during, and at the end of the medical course.

Assessing Professionalism: MotivationAssessing Professionalism: Motivation




Assessment at the start is useful to detect and start correcting unprofessional behaviors and attitudes.

Professional attitudes are set quite early in the student’s career by the ‘hidden curriculum’.

Early assessment enables discoveries of unprofessional attitudes and behaviors quite early.

Assessing Professionalism: At the StartAssessing Professionalism: At the Start




Exposure to unprofessional behavior was least in the first year and highest in the fifth year.

Unprofessional behavior in student days is likely to resurface during internship and professional practice.

Students with low professionalism are more prone to errors.

Assessing Professionalism: During Assessing Professionalism: During Training 1Training 1




Nijmegen Professional Scale developed in the Netherlands Professional Mini Evaluation instrument developed in Canada. Assessing knowledge, attitudes, and practice of professionalism; Peer assessment of professionalism, Assessment of student behaviors such as fulfilling duties Analysis of student narratives on critical incidents.

Assessing Professionalism: During Assessing Professionalism: During Training 2Training 2




Thank you!Thank you!

Prof Omar Hassan

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