ETHICS AND PROFESSIONALISM
Teaching & Learning at the IMU
Sivalingam Nalliah
Committee for Teaching of Ethics and
Professional Practice
HUMANISM
ACCOUNTABILITY
ALTRUISM
EMPATHY
PROFESSIONALISM
ETHICAL AND LEGAL UNDERSTANDING
COMMUNICATION SKILLS
CLINICAL COMPETENCE
Adapted from: Measuring Medical Professionalism
David Thomas Stern 2005
1.1 A Glossary of Definitions
For the purposes of this document, the following definitions need to be clarified:
Ethics: The field of ethics (or moral philosophy) involves systematising, defending, and
recommending concepts of right and wrong behaviour (Anscombe, 1981).
Medical ethics: The term "ethical" is used to refer to matters involving (1) moral principles or
practices and (2) matters of social policy involving issues of morality in the practice of
medicine. The term "unethical" is used to refer to professional conduct which fails to conform
to these moral standards or policies (American Medical Association, n.d.).
Bioethics: Bioethics is a relatively new word coined by the biochemist Van Rensselaer Potter
in 1970 to draw attention to the fact that the rapid advances in science had proceeded
without due attention being paid to values. The word bioethics, using two Greek words, bíos
– meaning life – representing the facts of life and life sciences, and éthos - meaning morals –
referring to values and duties (Potter, 1971). Bioethics should not be confused with medical
ethics, which is only one of its branches. The field of bioethics is as wide as the facts of life,
and its study is divided into many branches, each one with its specificity: Ecological or
environmental bioethics, Medical bioethics, Clinical bioethics.
1.2
Professionalism Defined
The healthcare profession in its entirety has been called to address the challenge of how it
defines itself. The challenge of defining what constitutes its profession, i.e. professionalism,
has seen intense debate for some time. The World Medical Association has issued several
statements pertaining to bioethics over the last 35 years. The American Board of Internal
Medicine (ABIM), Society of Academic Emergency Medicine, the Accreditation Council on
Graduate Medical Education (ACGME), American College of Physicians and American Society
of Internal Medicine (ACP-ASIM), the General Medical Council (GMC), the Royal College of
Physicians (RCP) and the European Federation of Internal Medicine (EFIM) have tried defining
professionalism (ABIM, 1994; 2002; Van Mook et al., 2009; GMC, 2013; RCP, 2005; Kirk, 2007).
Van Mook et al. (2009) defined medical professionalism as “the ability to meet the
relationship-centred expectations required to practice medicine competently.” The RCP
defined medical professionalism as a set of values, behaviours, and relationships that
underpin the trust the public has in doctors – this definition, they assert, can apply to other
healthcare professionals as well (RCP, 2005). The King’s Fund (Rosen & Dewar, 2004) called
for professionalism to put patient’s interests back at the centre of care. They also assert that
stakeholder parties should be facilitated to have open and responsive discussion regarding
professional standards relevant to prevailing values and expectations. Meanwhile, the Picker
Institute Europe looked at patient-centred professionalism, which they defined as “doctors
fulfilling their changing (and in some cases unchanging) roles in ways which coincide with
changing (or unchanging) patient roles, as well as working with patients and others to see
whether areas of conflict can be eased” (Askham & Chisholm, 2006). The well-known
Physician Charter (Medical Professionalism Project: ABIM Foundation, 2002) reiterates
professionalism on three principles: primacy of patient welfare, patient autonomy, and social
justice and ten responsibilities: professional competence, honesty, confidentiality,
appropriate relationship with patients, improving quality of care, improving access, equity,
integrity of scientific knowledge, maintaining trust and managing conflicts of interest, and
professional responsibilities. Society and the community stand to gain from ethical and
professional practice.
Outline
Where are we?
Curriculum and contents
Resources
Assessment
Scholarship
Challenges
Where are we ?
Curriculum and contents
Threaded through the 10 semesters
Formal and non-formal learning
Semester 1-2
Topic
Professionalism
Duties of
doctors
Professional
Code of
conduct..
MMC guide
lines
Introduction to
medical ethics
Physician
misconduct
Autonomy and
Consent/
Standards of
practice
Relevant Topics
Mode of
Delivery
Assessment
Feedback
workshop /role
playing
reflective writing.
On line
Plenary
Plenary
Plenary
PBL
MCQ
MCQ/SAQ
MCQ/SAQ
Class discussion
Class discussion
Class discussion
discussion
TOPIC
Autonomy and
Confidentiality
Fitness to
practice
Medical Act
1979
Mode of
Delivery
Plenary/ Clinic
visits
Plenary
Assessment
MCQ
MCQ
Feedback
Class discussion
Class discussion
Death Dying
and Killing
Plenary/case
Criminal
studies
Procedure Code
MCQ
Class discussion
End of life
issues
MCQ
Class discussion
Plenary
Relevant topics) PBL
Semester 3-4
TOPIC
Ethical and legal
consideration in
terminations of
pregnancy..
Criminal
Procedure Code
Legal and ethical
issues in
antenatal
screening and
family planning
Consent in
Minors and
mentally
challenged Child
Protection Act
1991/ Mental
Health Act
Relevant topics
Mode of
Delivery
Plenary/Debate
Plenary
Assessment
MCQ
MCQ
Feedback
TOPIC
Class discussion
Ethical and legal
considerations
in medical
research
Class discussion
Plenary
MCQ
PBLs
Class discussion
Legal and ethical
issues
In accessing
health care
Ethics of
screening
Duty of Care/
Standard of
Care/
Negligence
relevant topics
Mode of
Delivery
Assessment
Plenary
MCQ/ Practicum in
Sem 5
Plenary
Plenary/Case
studies
Feedback
Class
discussion
MCQ/SAQ
Class
discussion
MCQ/SAQ
Class
discussion
PBL
Others Resources : E learning Portal . Laws and Ethics: Case studies/ Forum
MMS:Case studies on ethics/ online feed back
Semester 6 -10
Theme: Working in hospitals and its environment
Health Issues
1.
2.
3.
4.
5.
6.
7.
8.
Health education and Health promotion
Culture health and disease
Wellness and health promotion
Quantitative methods
Family violence and abuse
International agencies in health (WHO, UNICEF etc)
Non governmental organizations (NGO’s) in Health
Primary Health care
Medical Ethics
1.
2.
3.
4.
5.
6.
Organ donation: Organ transplant and medical research
Death, dying and bereavement
Ethics in abortion, contraception and embryo research
Negligence, patient confidentiality, informed consent,
Ethics in HIV Infection (Mother to child infection)
Ministry of Health core values (teamwork, caring and professionalism)
BIOETHICS CORE CURRICULUM
SECTION 2: STUDY MATERIALS
ETHICS EDUCATION PROGRAMM
Introduction 3
Acknowledgement 4
Course Learning Objectives 6
UNIT 1: What is ethics? 7
UNIT 2: What is bioethics? 10
UNIT 3: Human dignity and human rights (Article 3) 13
UNIT 4: Benefit and harm (Article 4) 17
UNIT 5: Autonomy and individual responsibility (Article 5) 23
UNIT 6: Consent (Article 6) 27
UNIT 7: Persons without the capacity to consent (Article 7) 33
UNIT 8: Respect for human vulnerability and personal integrity (Article 8) 38
UNIT 9: Privacy and confidentiality (Article 9) 42
UNIT 10: Equality, justice and equity (Article 10) 46
UNIT 11: Non-discrimination and non-stigmatization (Article 11) 49
UNIT 12: Respect for cultural diversity and pluralism (Article 12) 53
UNIT 13: Solidarity and cooperation (Article 13) 56
UNIT 14: Social responsibility and health (Article 14) 59
UNIT 15: Sharing of benefits (Article 15) 65
UNIT 16: Protecting future generations (Article 16) 73
UNIT 17: Protection of the environment, the biosphere and biodiversity (Article 17) 77
Study Materials Cases Case 2: Conflict of interests
A seventy-six year old very wealthy woman is affected with mild dementia. Her children call on her
doctor complaining of her spending habits of giving liberally to members of a church cult, whom they
think are scheming to deprive her of her wealth. They are worried about their rights to her inheritance
and request from the doctor to declare her incompetent to manage her financial affairs. The doctor
dutifully advises his patient about the visit from her children and tells her that he does not think that a
psychiatric consultation is in order. The doctor himself is a member of the same church cult.
Readings Video/Movie Movie: 12 Angry Men
(1957, Director: Sidney Lumet)
12 Angry Men is the gripping, penetrating, and engrossing examination of a diverse group of twelve
jurors (all male, mostly middle-aged, white, and generally of middle-class status) who are uncomfortably
brought together to
CERTIFIED ON LINE COURSE
TAKEN BY ALL SEMESTER 4 STUDENTS
ALSO DONE BY CLINCIAL FACULTY (KPI)
2nd School of Medicine Retreat
5 April 2014
Executive Summary
Professionalism, Ethics & Medical Law
Presenter: Prof. Dato’ Dr N Sivalingam
Moderator:Prof. Dato’ Dr P Kandasami
DSN shared and took members through his comprehensive slides, and sought members’
comments on the topic.
He shared the value of E&P and how its was incorporated into the MBBS curriculum. He also
alluded to the broader perspective of including Biosafety and Medical Law to the curriculum.
The UNESCO Core Curriculum on Bioethics has been adopted and each of the 17 units of the
curriculum are to be delivered as the student goes through the clinical school.
All students have had been sensitized to the topics on Bioethics and there is a curriculum drawn
by the Community Medicine ( A. Prof Verasingam).
Discussion/Feedback
Dr Rohaizan viewed that professionalism should be imparted to medical students so as indude
quality care in the woking environment
A/P Sui Chen thought student should value the advantage of this important aspect and
incorporate into research. This aspect has been incorporated in all student research in the
clinical school. Currently students are expected to present and get approval from the Ethics and
Research Committee IMU.
Some members felt this personality trait should be embedded into students, nevertheless
framework on acquisition of concepts and knowledge as well as application of ethicas in the
clinical setting should be established. This should move smoothly as in the teaching of
integrated curriculum from early semesters to later semesters.
Members concurred it will be challenging as this attribute also depends on students’
background. Professionalism and good moral values should have been inculcated
into their upbringing. This is very much so in the Asian culture.t was acknowledged
that most departments are following UNESCO Bioethics Core Curriculum as
guidelines and references available in teaching and curriculum delivery. DSN
suggested the SOM should emphasize the need ti integrate various elements of P&E
inot the clinical curriculum apart from formal teaching as stated above. HOD should
assist in ensuring new faculty joining the SOM in both familiarizing and delivering the
curriculum on Bioethics.
All , members agreed that delivering P&E curriculum should be both formal or nonformal teaching. Various teaching methods including reflective writing and narrative
medicine were presented and spelt out in the slides.
It was reiterated that the contents of E&P should include :
Bioethics
Medical Law
Professional Development of students and faculty
Social Responsibility though community service
Humanism, cultural diversity and literature
Patient Safety
360 degree Student Feedback based on portfolios maintained by the student would an
effective assessment mode.
Conclusion
The IMU has incorporated and integrated the teaching of Bioethics and Professional
Practice in all programs as part of the transformation process.
Resources
http://elearn.imu.edu.my/course/view.php?id=567
Ethics and Professionalism for Clinical School
http://elearn.imu.edu.my/course/view.php?id=393
Some examples of Case Summaries
Objectives:
“
Professionalism and ethics in the new
medical curriculum
To educate and train students to become
physicians with high levels of competence,
compassion and moral integrity
”
Assessment
Ethics and Professional activities in Phase 1 Medical
Contents: Sem 1-5
SEM 1
SEM 2
SEM 3
SEM 4
SEM 5
T/L activities
Themes
PPD workshop
Professional Values, Reflective writing
CSU
Communication skills
Community Oriented Project
Team work /communication
PBL
Team work/ behaviours
Plenary
Introduction to ethics/Consent
Clinic Visits/CSU
Communication/Teamwork
Plenary
Confidentiality/End of life issues
PBL
Team work/ behaviours
Clinic Visits/CSU
Communication/Teamwork
Plenary
Reproductive ethics
PBL
Team work/ behaviours
Clinic Visits/CSU
Communication/Teamwork
Completion of Norwegian ethics module
Knowledge /application of ethics
PBL
Team work/ behaviours
Community Medicine Survey
Teamwork/Timeliness/communication
Ethics of research
CSU
Ethical case scenarios
Hospital Posting
Reflective portfolio/Case summary
PBL
Team work/ behaviours
TOPIC
Mode of Delivery
Assessment
Feedback
Autonomy and
Confidentiality
Plenary/ Clinic visits
MCQ
Class discussion
Fitness to practice
Medical Act 1979
Plenary
MCQ
Class discussion
Plenary/case studies
MCQ
Class discussion
End of life issues
Plenary
MCQ
Class discussion
Relevant topics)
PBL
Death Dying and
Killing
Criminal Procedure
Code
TOPIC
Mode of Delivery
Ethical and legal
consideration in
terminations of pregnancy.. Plenary/Debate
Criminal Procedure Code
Legal and ethical issues in
antenatal screening and
family planning
Plenary
Consent in Minors and
mentally challenged Child Plenary
Protection Act 1991/ Mental
Health Act
Relevant topics
PBLs
Assessment
Feedback
MCQ
Class discussion
MCQ
Class discussion
MCQ
Class discussion
TOPIC
Mode of Delivery
Assessment
Feedback
Ethical and legal
considerations in medical
Plenary
research
MCQ/ Practicum in Sem 5
Class discussion
Legal and ethical issues
In accessing health care
Ethics of screening
MCQ/SAQ
Class discussion
MCQ/SAQ
Class discussion
Plenary
Duty of Care/ Standard of
Care/ Negligence
Plenary/Case studies
Relevant topics
PBL
Assessment
Topic
Professionalism
Duties of doctors
Professional Code of
conduct..MMC guide lines
Introduction to medical
ethics Physician
misconduct
Autonomy and Consent/
Standards of practice
Relevant Topics
Mode of Delivery
Assessment
Feedback
workshop /role playing
reflective writing.
On line
Plenary
MCQ
Class discussion
Plenary
MCQ/SAQ
Class discussion
Plenary
MCQ/SAQ
Class discussion
PBL
Discussion
ASSESSMENT AND DELIVERY
Semester 6-10
• MULTIMODAL
• EACH UNIT IS INCORPORATED INTO EACH ROTATION (
SEM 6-10)
• LOG BOOK: Attributes ( 360 degree )
• EOP and EOS : clinical exams and summative ( OSCE/MEQ)
• SEMESTER 10:
• ONE DAY SEMINAR ON MEDICAL LAW AND PROFESSIONALIMS
• HALF DAY : DEBATE ON BIODIVERSITY AND HEALTH WITH
EXHIBITION ( DEPT OF SCIENCE AND ENVIRONMENT)
• PORTFOLIO : ETHICS AND PROFESSIONALISM ( EACH OF 5 /10
PORTFOLIOS
The expanded curriculum
The expanded curriculum
ETHICS
BIOETHICS
PROFESSIONALISM
& PROFESSIONAL
PRACTICE
PATIENT
SAFETY
MEDICAL
LAW
SOCIAL
RESPONSIVENESS
AND SOCIAL
RESPONSIBILITY
Medical law
Medical Law: http://elearn.imu.edu.my/pluginfile.php/37921/mod_resource/content/1/Professionalism_Medical_Law_list.pdf
Malaysian Medical Act 1971: http://www.mma.org.my/Portals/0/medical%20act%201971.pdf
http://elearn.imu.edu.my/course/view.php?id=567
Patient Safety
Anaesthesia: http://elearn.imu.edu.my/mod/page/view.php?id=10328&inpopup=1
Scholarship
Workshops on Bioethics and SOM retreat
Conferences
Presentation & Publication
1st and 2nd Bioethics Conference
Research and Publications
The environment
Conducive and Safe
Embed core values to
activities
Teaching &
Learning
Recruitment
Research
Healthcare
Individual’s
Development
Get-together
events
SOPs
IMU Social
Responsibiliti
es Activities
Mentoring
System
Social Media
Guidelines
Evaluation
Handbook
Posters
E-bulletin
Videos
Website
(Social Media)
General guidelines
on ways to embed
core values to the
activities
Articles on
core values
Success Stories and
Role Models
International Medical University
Ethics and Professionalism Working
Group – Summary of Initial Meeting on
2nd May 2013 and Minutes of Meeting
for 17 th May 2013
Date of Meeting
Time
Venue
Name of Meeting
Attended by:
2nd May 2013
4.00 p.m. to 5.30 p.m.
MR 2, IMU Bukit Jalil
IMU Ethics and Professionalism Working Group Meeting
Tan Sri Dato’ Dr. Abu Bakar Suleiman (ABS)
Prof Dato’ Dr Sivalingam Nalliah (SN)
A/Prof Dr. Verasingam Kumarasamy (VK)
A/Prof Dr. Muneer Gohar Babar (MB)
A/Prof Dr. Nazimah Idris (NI)
Dr. Haider Abdulameer Al-Waeli (HA)
Syed Imran Ahmad (SI)
Wong Chin Hoong (WCH)
Apologies:
Prof Dr. Winnie Chee (WC)
Sheba DMani (SD)
Social accountability
Obligation of medical schools to direct education
• Education
• Research
• Service activities
• Towards addressing priority health concerns of the
community, regions and nation they mandate to serve
• Need to be jointly addressed by government healthcare
organizations, health profession and public
Boelen C, Heck JE Defining and measuring accountability in medical schools Geneva
WHO 1995 (WHO/HRH/95.7
)
IMU Cares in Clinical School
Elderly Homes IMU Cares Project
Kampung Sebir, Kampung Project
Flood Relief Project – Kuala Krai, Kelantan
Promoting Adolescent Health Project
Sem 10 Kampung Projects
Inauguration speech by Guest of Honour –
MP- Batu Pahat
Batu Pahat Kampung Parit Lapis Project
30MAY2014
IMU and IMC students promote Adolescent
Health in Kuala Pilah
CHALLENGES
SWOT ANALYSIS BY COMMITTEE ON ETHICS AND
PROFESSIONAL PRACTICE
SWAT Analysis(2013): Issues
Assoc. Prof Verasingam
1. Culture of organisation:
Transparency (PMS placement),/ Dress Code some faculty are poor role models.
Other organizational processes involving students need to be reviewed in light of
transparency and ethical issues.
2. Assessment:
Inadequate
3. Plenaries : Not effective in modulating professional behaviours, small
groups discussion are better.
4. Common definition of Professionalism across board.
The course will be conducted as a vertical strand running along all the semesters
 Lecture
 PBL / TBL
 Case scenarios (EBM and ethics)
 Seminars
 Workshop
 Portfolio (elective)
The course will be further strengthened during the health clinics visits programme where the
students will be asked to study the organization of the health centre and the role and responsibility
of the staff at the health centers. A research project will also be given to the students to implement
what they have learnt during the lecture sessions. The details of the workshop and seminars will be
developed during the rotations week as part of the rotation slots in Community Medicine. Some of
the sessions are covered during the health issues week. If approved the details of the
implementation of the programme will be worked out.
SWOT analysis on the teaching of ethics and
professionalism (E/P) in Phase 1 (SEM 1-Sem
5) in the medical curriculum.
Strength
Admission Interview before
admission
Weakness
Opportunities Threats
Unable to
discriminate
students with
potential
behavioural and
ethical problems
Interviews here
seem to be more
of a marketing
/public relations
exercise rather
than a
discriminating
one
More stringent
interviews.
Suggestions
In a competitive Interview process need to be
business
reviewed to weed out potential
environment
unethical students
To reveal data
deficiency in
how many
moral decision
students were
making may
rejected on
take a back
interview (if any) seat
How Patient Safety and Medical law has
been incorporated into the curriculum.
Are the topics on Ethics and
Professionalism only delivered by CM
faculty?
Current situation
Suggestions/ comments
Pt safety and Medical Laws are
incorporated into relevant plenaries on
Medical ethics
2. Elements of professionalism,
medical ethics and patient safety are
incorporated into
the PBL and CSSU
Adequate theoretical input
All the plenaries pertaining to Ethics and
professionalism is being delivered by CM
staff in phase 1 except in the Forensic
module some are delivered by Pathology
dept. (Dr. Vasu)
Elements of professionalism are
Do we incorporate aspects of
incorporated in PBL and CSSU for medical
professional practice in CSSU and PBL?
students at varying degrees and is faculty
dependent. Some are strict some are not
Assessing learning in Professionalism
and Ethics in Phase 1 (Sem 1-5)?
No assessment structure based on
behavioural attributes in PBL and CSSU
A few OBA in the theory exams. Sometimes
Air topics is given based on specific ethical Generally inadequate. No assessment of
issues. Completion of Norwegian Medical
behavioural attribute is being measured.
Ethics online course
Curriculum
Strength
Weakness
Opportunities Threats
Organized
curriculum with
learning
outcomes and
competencies
Spread
throughout the
curriculum
Not much
coordination
between
various
departments
conducting
teaching and
professionalis
m activities.
Many activities
are undertaken
where
professionalism
and ethics can
be incorporated
in a formal
manner
Suggestions
Lack of staff Process of coordination
to undertake need to be inbuilt in the
the extra load curriculum
may scuttle
any plans for
efficient
coordination
References:
1. Code of Professional Conduct, Malaysian Medical Council, 1986
2. Teamwork, Ministry of Health, Malaysia, 1996
3. Medical Professionalism in the new Millennium: A Physician Charter,
2003. ABIM foundation, ACP- ASIM Foundation& European Federation
of Internal Medicine
4. SR Cruess, RL Cruess: Professionalism must be taught. BMJ 1997;
315:1674-1677
5. Yadav H. Hospital Management. University Malaya Press. 2006
6. Bioethics and Professionalism for Stakeholders: booklet for the IMU
Acknowledgement
Input from Members of the Committee on E&P
Dr Wong Chin Hoong ( Family Medicine)
Community Medicine Dept ( A.Prof Verasingam & Prof Yadav)
Sharifah Sulaiha
Tan Sri Abu BAKAR Sulaiman