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National Ethics Seminar 2005
26 November 2005
Medical Professionalism and Ethics
by Professor Dato' Mrs S T Kew, Master, Academy of Medicine of Malaysia
What is a profession? The Oxford English Dictionary defines profession as "any calling or occupation by which a person earns his living; a vocation in which a professed knowledge of some department of learning is used in its application to the affairs of others." A professional is "someone belonging to a profession, someone who is highly skilled in doing something." Thus a professional is contrasted with an amateur e.g. in the sports arena. We often use the word unprofessional to describe someone who lacks skills or competence, or someone who has the wrong approach or unacceptable behaviour.
Professionalism is defined as "a body of qualities or features as competence, skills, behaviour etc characteristic of a profession or a professional." In essence, it is an outward visible expression of our culture: it reveals our values, show what we stand for, and how we behave and perform. There has been a dearth of literature dealing with professionalism in medicine, and this topic is generally not taught in most medical schools. As a consequence, in a rapidly changing world, doctors may not have a clear understanding of what the public expects from its professionals. Most doctors do not fully understand the obligations they must fulfill to satisfy public expectations and maintain their professional status.
Doctors simultaneously fill two overlapping but distinct roles: the healer and the professional. For the healer role, the Hippocratic Oath serves as the foundation of morality in medicine. The professional role, on the other hand, needs the framework within which to organize and dispense the services of the healer. Professional status is used as a method of organizing the delivery of complex services. This status is granted by the state, and defined by laws in licensing, and in the charters and regulations of the various certifying bodies.
At the heart of every profession is a legally sanctioned control over a specialized body of knowledge, and a commitment to service. As the average lay person cannot fully comprehend the body of knowledge in medicine, society has granted the profession the right to self regulation. Autonomy is given on the understanding that professionals will put the welfare of both patient and the society above their own, and that they will be governed by a code of ethics.
In recent decades, the medical profession has been confronted by an explosion of technology, changing market forces, problems in health care delivery, and in a larger context bioterrorism and globalization. These changes threaten the values of professionalism. Doctors a re finding it increasingly difficult to meet their responsibilities to patients and society. Voices from amongst the medical profession in many countries called for a renewed sense of professionalism. These concerns led to the "Professionalism Project" of the European Federation of Internal Medicine, the American College of Physicians-American Society of Internal Medicine Foundation and the American Board of Internal Medicine Foundation. Two key consultants in the development of this project were Drs Richard and Sylvia Cruess of Canada. There was very broad international collaboration in this work that resulted in a document "A Physician Charter". This was published simultaneously in the Annals of Internal Medicine and the Lancet in 2002.
In the "A Physician Charter" three broad fundamental principles form the basis of medical professionalism:
These three fundamental principles form the ethical basis of physicians’ professional relationships: individually with patients and collectively with the public.
"A Physician Charter" referred to above listed 10 professional responsibilities. For convenience, these may be grouped under 3 headings:
One of these responsibilities is that of commitment to professional responsibilities. As members of a profession, doctors are expected to work collaboratively to maximize patient care, be respectful of one another, and participate in the processes of self-regulation: including discipline and remediation of members who have failed to meet professional standards. The profession should also define and organize the educational and standardsetting process for current and future members. Doctors have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance.
In the Malaysian context, we see the role of Malaysian Medical Council in the discipline and perhaps remediation of errant medical practitioners. Universities, Academy of Medicine, Colleges within the Academy, Academy of Family Physicians and Specialist Societies play important role, individually and collectively, in education and standard setting for undergraduates, post-graduates and practicing doctors. We need many more doctors to actively participate in these processes of self regulation.
Most doctors are deeply conscientious in discharging their professional responsibilities: through their own idealism, sense of service and self-discipline - literally self-regulation in their own practices. There are exceptions to this rule: some doctors are clinically inadequate, some cannot communicate, and some cannot relate appropriately to patients. The public has given the duty to the medical profession to regulate itself: making sure that every licensed doctor practices in accordance with the standards that it says are necessary, and where a doctor does not, to act promptly and decisively to protect patients from possible harm. This collective responsibility is also part of our professionalism. So professionalism has 2 limbs to it: one relating to our personal responsibility for our own competence, attitudes and conduct; the other relating to our collective responsibility, to which we must all contribute, to make sure that clinical teams and professional bodies function as they are expected to. This holistic view of professionalism goes with our claim to be a profession with all the privileges and status that attach to it. It is the essence of our part of the regulatory bargain with the public.
Professionalism is the basis of medicine's contract with society. Essential to this contract is public trust in physicians, and trust depends on the integrity of both individual physicians and the whole profession. This social contract demands of physicians to place the interest of patients above those of self, to set and maintain standards of competence and integrity, and to provide expert advice to society on matters of health.
Public has legitimate expectations of the medical profession: they expect safe, ethical practice from all doctors for all patients. The public has, from time to time, been critical of the medical profession: for its emphasis on remuneration, its failure to self regulate adequately, its apparent inability to address problems felt to be important by society, and the fact that the profession often puts its own welfare above that of both society and individual patients. These criticisms reflected the public opinion, and undoubtedly had an influence on the public perception of the medical profession.
It is a fact that most doctors wish to meet their obligations properly. To quote Kultgen, "Entry into the profession is a voluntary act, and most people who perform it are disposed to learn its ways and take its ideology seriously." Only a small minority of the profession is thought to be guilty of betrayal of trust, but the reputation of the whole profession suffers.
Public trust in the medical profession has been eroded by high-profile medical disasters, resulting from work of physicians with inadequate knowledge or skills. Trust has also been eroded because of well-publicized ethical failures in the financial sphere e.g. fraud in doctors billing insurance companies etc. However, there is this more subtle and widespread abuse of trust and departure from professional ideals arising from failure to recognize and manage conflicts of interest, especially in relationships with the industry. This headline in USA Today said it all: "Drug firms spend big bucks on doctors, get results!" Pharmaceutical marketing is big business: marketing drives formulary & prescription practices, sometimes in the wrong direction. Drug costs have risen rapidly & now exceed payments to the doctors in some countries. Higher drug costs may limit resources available for other components of healthcare. For the medical profession to survive as an independent, selfregulating profession, the issue of conflict of interest is important because the public, via the media, learns about marketing schemes, and public trust in the profession will be weakened.
General Medical Council - Good Medical Practice
GMC's Good Medical Practice is a national, patientcentred code of practice in Britain, tied to medical licensure to secure universal compliance throughout a doctor's career. It was designed from the outset to unify the profession around the basic duties and responsibilities of a doctor agreed between the profession and the public. It stands as the British standard of patient-centred professionalism. For individual doctors, it is a public affirmation of their values and standards. The code forms the basis of all aspects of registration and licensure: i.e. embedding into the professional life of every doctor. It ensures that all those joining the medical register attain the standards expected, that those on the register continue to practice in accordance with them, and that doctors who fail to comply are disciplined, placed under supervision whilst remediation is attempted, or if necessary removed from practice altogether. It also means imprinting "Good Medical Practice" onto the whole of medical education so that the system is capable of producing doctors with the desired qualities. Alongside the code, the most fundamental change has been the adoption of revalidation as a means of achieving virtually continuous re-licensure. Revalidation begins in 2005.
The CanMEDS Competencies
Royal College of Physicians and Surgeons of Canada RCPSC defines seven basic roles required of Canadian doctors, referred to as CanMEDS competencies. A diagram in the shape of a flower illustrates the elements and interconnections of the seven roles: medical expert as the central role, communicator, collaborator, health advocate, manager, scholar and professional as the other roles. The seven CanMEDS roles or competencies are integrated by doctors on a daily basis in practice. Besides the medical expert role, professional role is perhaps equal in importance.
RCPSC defines professionalism as the skills, attitudes and behaviours expected of individuals during practice. It includes the following concepts: maintenance of competence, ethical behaviour, integrity, honesty, altruism, service to others, adherence to professional codes, justice, respect for others, and self-regulation. RCPSC takes the approach that the concepts, ideals, and responsibilities of professionalism can be taught and that learning and adoption of these can be evaluated. Teaching and learning require specific objectives: and that evaluation should be specifically directed at the learning and accomplishment of these objectives.
As a profession, by and large, we still enjoy the trust and confidence of the public in this country. We learnt lessons how this trust can be weakened. As a professional organization re p resenting the medical specialties in this country, we need to spell out our commitment to professionalism and ethics. We need to sustain and build on the public trust we still enjoy in order to continue to self-regulate. To this end, we need to ensure the ethical integrity of individual practitioners and that of the whole profession.
We have had two national ethics seminars before, result of collaboration between Ministry of Health and Academy of Medicine. This is our third National Ethics Seminar. We have had discussions on some of the issues arising from the three fundamental principles of professionalism. May we now endorse and adopt the "A Physician Charter" in a more formal manner, and be more explicit in our commitment to professionalism and medical ethics? The Academy of Medicine has an important role in enhancing the standard and quality of health care through education and continual professional development of our members and fellows. The Academy also has a role in postgraduate and higher specialist training, in ensuring that doctors and specialists are not only knowledgeable and skillful, but are competent in other important and related roles.
This article is based on the following publications:
National Ethics Seminar 2005
26 November 2005
The Teaching of Medical Ethics: How Relevant
by Dato' Dr Sivalingam Nalliah FROG, FAMM
Department of Obstetrics and Gynecology, International Medical University, Seremban, Negeri Sembilan
The tenets of professionalism and ethics in Medicine are based on the principles of beneficence, non-mlaficence, respect for autonomy of the patient and justice in health care (i.e. principle of fairness and loyalty). For centuries the learning of medical ethics rather than its teaching has been implicit (in instructional medicine). Where medicine has been learnt in institutions, the teaching of medical ethics remained hidden within the medical curriculum. The master physician imparted his wisdom and the analytical approach to solving the mysteries of organic and psychological disease gingerly referring to ethical components of professionalism and ethics of medicine.
Over the last decade there has been a uniform resurgence of enthusiasm both in the West and the East, in making the teaching of medical ethics and professionalism explicit. Professional bodies like the American Board of Internal Medicine and its European counterpart have drawn, what should appropriately be called the Patient's Charter where the physician re-looks at the tenets of professionalism with him playing an advisory role. The General Medical Council (UK) regularly reviews the medical curriculum and emphasizes the need to make the teaching of professionalism and ethics explicit (see Tomorrow's Doctor - GMC).
WHY HAS TEACHING OF MEDICAL ETHICS BECOME RELEVANT?
Clearly several factors have contributed to the teaching of professionalism and ethics becoming an important component of the medical curriculum. There is general consensus among educationalists that too much core knowledge has to be mastered without developing the skills and appropriate attitudes for the practice of medicine. The medical discipline is now more accessible to those intending to become doctors. This is a welcome development. However, there is a change from Medicine being a 'calling' to that of a career. Justifiably, with a large financial commitment by parents, one cannot deny the need to reap the benefits of such a heavy investment! This should not be seen as a barrier to professionalism and ethics, however. Several other factors have been implicated as barriers (other than parental expectations) including the withering of the master physician who is not within easy reach of large number of medical students in the present environment where medicine is taught through distributed learning approaches and the electronic media. Specialization and sub specialization has made it possible for medicine to be fragmented into organs and systems for closer scrutiny by the latter at the risk of a holistic approach. The foundations years are vital for imparting the art of medicine where skills in communication and information gathering will nurture the student to sustain an analytical mind to solving the source of ailment without sacrificing the finer elements of the art e.g. community needs, patient autonomy and primacy of healthcare. Medical technology has proliferated rapidly contributing to sophistication and diagnostic accuracy. This, however, has not developed without risk of being a barrier to ethics and professionalism. Compartmentalized care by sub specialists as organs of the patient are 'processed' by technological gadgets both in the laboratory and the clinic setting has contributed to issues questioning the very tenets of professionalism and ethics. Justice in healthcare has to be seen to be carried out through appropriate use of technology without sacrificing ethics. Medical intervention may be construed as unnecessary if one looks at favorable outcomes alone. Medical advice, medical procedures (invasive and non-invasive) and the use of drugs are common medical interventions which are often indicated and warranted. The good of medical intervention is to make it appropriate, efficacious and scientifically acceptable (evidence based). Inappropriate interventions are not acceptable. Extreme examples of inappropriate medical interventions would be the use of high does chemotherapy for breast cancer followed by bone transplantation and ventilator support for cardiac arrest in multiorgan failure.
THE CHARACTERISTICS OF THE MEDICAL PROFESSION
The World Medical Association (WMA) through several of its declarations and the International Code of Ethics, allude to the duty of the physician being to promote and safeguard the health of people. The physician shall act only in the interest of the patients' interest. The characteristic of the profession is such that success is measured by more than the amount of financial returns through selfregulation and autonomy in clinical decision making.
The media has addressed the waning of professionalism in the medical profession time and time again. The Prime Minister of Malaysia addressed the need for professionalism and high integrity among workers after he declared the National Inte grity Day (4 November 2005). Bridget Menzes, a weekly column writer in the New Sunday Times referred to greed among physicians leading to increased health costs and the eroding of values affecting professionalism in medicine. She ends her column by pleading for the need for the establishment of a value system in medicine (NSTP 14 June 2003).
Ahiruddin Attan wrote in Sunday People (NSTP-13 Nov 2005) about the suspension of 100 doctors by FOMEMA (Foreign Workers Examination Monitoring Agency). He went on to add 'doctors deemed to be joining the rogues' gallery in droves' and 'how do we keep society's faith in the respected profession?' He went on to add that doctors are selling medical chits to lazy workers for a few ringgit. Although this suspension was lifted at a later date, damage has been done though initial adverse publicity.
CLINICAL MEDICINE: TEACHING THE ART AND SCIENCE
Clinical medicine confronts the student of medicine with the need for development of empathy, compassion, sensitivity, reality, sympathy and involvement. Few professions require skills and attitudes against a very high value system like the medical profession and the need to maintain integrity against several barriers of professionalism requires the instillation of a value system. This has been realized by the profession and there has been an emphasis to return to the core moral values and behavior that typify the medical profession by making teaching of ethics explicit through efficacious teaching - learning methods. William Osler refer red to Clinical Medicine as a science of uncertainty and art of probability. The task of the clinician is to reduce this uncertainty by gathering data on the ailment, applying his medical knowledge and clinical reasoning so as to propose a plan to meet the patient's needs. Such an approach amounts to clinical judgment (the art of medicine), a component that can be effectively imparted by the medical teacher through a period of apprenticeship, an activity that emphasizes the personal side of medicine i.e. effective communication, commitment to patient's interests admits muticulturism and social inequality.
The art of medicine has been seen to be a rather complex process but more recently it has been scientifically approached to be effective and valuable through clinical epidemiology and evidence based medicine. Disciplines like clinical biostatistics, clinical epidemiology and decision analysis can be used to evaluate the quality of the physician who makes appropriate clinical judgment and recommendations.
Medical proponents are convinced that clinical medicine as a science, can be taught in the formative years of medical education through problem based learning, task based learning and portfolio development.
MORAL ISSUES IN CLINICAL MEDICINE
The advances in understanding of medicine have introduced new technology which places the practicing clinician in a situation where moral values are tested against conventional te a ching and societal values. This is complicated by the disparity that exists in society which is influenced by cultural views, religious beliefs and medical possibilities. Without basic knowledge of medical ethics and a period of apprenticeship, the physician will find himself working in conflict with society.
Reproductive technology saw IVF being introduced in the 1980's with rapid advances in reproductive technology which remains difficult to contain within the context of cultural and religious values. Surrogacy and gamete donor ship has introduced confusion and conflicts. A sexual reproduction (reproductive cloning) has become a reality albeit with inherent risks to health and social relationships. Transplantation procedures are a reality we are contending with but that which requires high ethical responsibilities and regulation.
The culture of death is now being reviewed in the context of scientifically defining this finite event. Ethical involvement cannot be avoided when dealing with the terminal patient. The latter is expected to die from a specific disease despite appropriate treatment in a relatively short period ranging from days to months. Medical ethics can be addressed in these situations such that treatment can be realistic based on medical evidence as we will continue to encounter the overly pessimistic and the inappropriately optimistic physician managing such patients.
Ethical issues at the end of life have seen physicians playing vital roles to make life comfortable and death dignified. However, ethical issues will arise when death is facilitated with introduction of both active and passive euthanasia (killing and allowing dying). Assisted suicide invariably evokes emotion and controversy. Physicians have to avoid playing GOD when faced with informed demand for 'non-beneficial treatment' and be able to handle issues related to such demands and wishes.
GENETICS AND MORALITY
The implications of prenatal and diagnosis have had severe impact on moral values and human right to life. Human genetics has been said to be a science of inequality, of human particularity and diffe rences. Disease like Huntington's chorea and major thalaseemia has life-long implications on off-springs. One will then question if parents with such conditions be denied the right of having children of their own. Such views will have an immeasurable impact on the Human Genome Project. Moralists have questioned the assimilation of evidences derived from such projects and studies used to create political. legal and moral inequalities. Health insurance, which used to be a system based on community rating has met new challenges as we see the shift to an expected claims or experienced based rating! Clearly, community rating does not consider pre-existing conditions but the availability of genetic testing and predictive possibilities of medical technology presents new challenges in our society.
ETHICAL ISSUES IN CLINICAL RESEARCH
Research in Medicine presents ethical issues with regards to obtaining grants for medical research, recruiting subjects who give informed consent and the need for review of study protocols by competent and independent regulatory bodies. Inspite of the presence of such procedures we hear about breeches in ethics. Research done on vulnerable populations like the pediatric group and prisoners need continued scrutiny of study protocols. The continued surveillance of research over a period of time so that it may be stopped in the event unacceptable adverse events is reported (the use of combined estrogen-progestogen hormone replacement therapy and breast cancer in WHI study) is of utmost importance. Evaluating the outcome of research alone presents problems at times as one uses statistical arguments (inductive) in attempting to establish relationships with some probability. Herein lays the importance of designing appropriate methodology when the sample population is drawn.
MEDICAL ERRORS IN CLINICAL MEDICINE
Safety in medicine is described as freedom from accidental injury while errors are failure of planned action to be completed as intended or use of a wrong plan to achieve a desired aim. The implications of medical errors are related to huge financial and personal costs. Errors may come about because of a system failure or due to an error in judgment. Incompetence should not be an argument to justify errors in medicine. The ethics surrounding errors in medicine are multifaceted but need to be addressed squarely. It would be prudent to highlight such issues to all concerned as that due to incompetence or remediable ignorance constitutes serious breech of the physician's clinical and ethical responsibility. Some 44000 - 98000 Americans are said to have died due to medical errors. Medical errors produce ethical problems related to truth telling.
WHAT CAN BE DONE IN TEACHING ETHICS?
It is now clear that imparting core knowledge in the medical curriculum is not adequate for complete training of the doctor. The need to acquire good clinical skills and to maintain high ethical standards require the teaching of medical ethics to be explicit in the medical curriculum. The practice of medicine has been the subject of legislation and litigation. There is a notable increase in the volume of litigation and a consequent increase of regulation in medicine. However, this approach will not be adequate to define the characteristics of the profession in instilling a value system incorporating all the tenets of professionalism and medical ethics. Healthcare providers will continue to learn about the ways laws and ethics interact, identifying potential legal issues and be clear as to how and where to seek legal guidance when the need arises.
There is now a dire need to not only impart core knowledge but to focus on building skills to identify patte rns of reasoning and to distinguish between objective statement of facts (description) and inference (conclusion). This can be done through a method of critical thinking. The latter will involve learning how to monitor though processes of evaluating own thinking, attempting to inter-relate to improve thinking. Self-assessment and reflections are useful tools the student should use to appreciate clinical findings. Barriers to critical thinking include accepting unreflectively cultural or social norms or attitudes towards certain persons and accepted obedient attitudes without question authority in the clinical setting. The student picks up bad habits of thinking is these issues are not clearly addressed form the beginning.
The medical profession, in the new millennium is moving towards a new dimension where he will play the role of advisor subscribing to the concepts of patient autonomy, social justice in health care and primacy of patient welfare. The teaching of medical ethics will have to be explicitly enshrined in the medical curriculum as they are relevant to the practice of modern medicine. Medical teachers are being sensitized to this concept. The role of the teacher - mentor is now a reality in identifying the gaps that exist in the medical c curriculum with regards to ethics so as to rectify deficiencies in the education process. Changes in the health care system present new challenges and other developments like alternative medicine and technological advances will continue to present ethical problems to be resolved. The master physician will now have a bigger role in taking on the expanded task of medical education and medical ethics.
Report from the College of Pathologists
by Prof Cheah Phaik Leng, Honorary Secretary
COUNCIL 2004 - 2006
|PRESIDENT||Professor Looi Lai Meng|
|VICE-PRESIDENT||Professor Cheong Soon Keng|
|SECRETARY||Professor Cheah Phaik Leng|
|TREASURER||Assoc Prof Datin Noor Hamidah Hussin|
|COUNCILORS||Dr Halimah Yahaya
Dr Leslie Lai
Professor Nor Hayati Othman
Dr Abdul Karim Tajudin
Professor Parasakthi Navaratnam
2005 saw the College of Pathologists (CPath) involved in many activities and the year has been particularly fruitful and meaningful.
HIGHLIGHTS OF COLLEGE ACTIVITIES FOR 2005
Accreditation is an important means to ensure competency and quality of the services provided by medical testing laboratories. On 14 December 2004, the Department of Standards Malaysia (DSM), the national standards and accreditation body for Malaysia, through its collaborative effort with CPath, successfully launched MS ISO 15189: 2004 (Medical laboratories - particular requirements for quality and competence). This Malaysian Standard adopted the International Standards ISO 15189, which is the recognized accreditation standard for medical testing laboratories. As DSM is signatory to the International Laboratory Accreditation Cooperation (ILAC) and the Asia Pacific Laboratory Accreditation Cooperation (APLAC), accreditation will allow mutual recognition in other joint signatory countries worldwide.
Since its launch, accreditation under MS ISO 15189 has seen resounding response from medical testing laboratories in Malaysia, with many currently seeking accreditation. CPath continues to support the accreditation scheme and plays the role of advisor to DSM on professional issues pertaining to the accreditation standards. Members of CPath are actively involved in the various tiers of governance of the accreditation process and also serve as DSM's technical and lead assessors.
CPath has also prepared 6 Guidelines for Good Laboratory Practice:
As a further effort to help laboratories understand MS ISO 15189: 2004 and prepare for accreditation, CPath conducted a training course entitled "Understanding ISO 15189" in April 2005. Mr Phil Barnes, the Program Manager for Medical Laboratories, International Accreditation New Zealand (IANZ), one of the first accreditation bodies to adopt ISO 15189 for accreditation of medical testing laboratories, served as the main resource person. The event was oversubscribed with over 80 registrants.
2. QUALITY ASSURANCE
CPath's commitment to quality laboratory medicine practice has also been extended to strengthening its Laboratory Quality Assurance (LABQAS) program. LABQAS, run with the Malaysian Institute of Medical Laboratory Science (MIMLS) has become increasingly popular with the local medical testing laboratories and it is the hope that most Malaysian and regional medical laboratories will choose LABQAS as their mainstay external quality assurance program in the future.
3. SCIENTIFIC ACTIVITIES
Visit of Professor Looi Lai Meng, the President,
to the Desmond Tutu HIV Centre in South Africa
4. MALAYSIAN JOURNAL OF PATHOLOGYl
The official and peer-reviewed journal of the CPath has entered its 27th year of publication. This journal is listed on the Index Medicus and can be accessed through the Medline online database.
5 . 24th WORLD CONGRESS OF PATHOLOGY AND LABORATORY MEDICINE: 20 - 24 August 2007 (WASPaLM 2007)
Preparations for WASPaLM 2007 are on schedule and have accelerated over the past few months. One of the most major events on the international Pathology scene, the World Congress is expected to bring Pathologists from all over the world to Kuala Lumpur in 2007.
CPath records its congratulations to Professor Looi Lai Meng, the President, on being conferred Fellowship of the Academy of Medicine of Singapore at the 39th Singapore-Malaysia Congress and the Celebration of 100 years of Medical Education in June 2005 and Honorary Fellowship of the College of Pathologists of South Africa in October 2005.
Clinical Competence & Specialist Register
Professor Boo Nem Yun, President of College of Paediatrics, Academy of Medicine of Malaysia
Clinical competence encompasses the cognitive (knowledge), psychomotor (clinical skills) and effective (emotions, values and attitude) aspects of the medical profession. It is recognized as the most important attribute of a good doctor. Via the internet, one can find many reputable medical schools, and specialty and sub-specialty bodies publishing detailed documents on the minimal standards of clinical competence expected of their graduate and postgraduate doctors. Indeed, international congresses have been organized in recent years by medical educationists to look into ways and means in improving training and assessment of clinical competence.
In Malaysia, it has been proposed that the minimal criteria for registering a medical practitioner as a specialist or sub-specialist in the Malaysian Specialist Register should include not only possession of a recognized basic medical degree and postgraduate degree, minimal duration of training required, and logbook documentation of minimal number of various procedures and types of patients treated by the applicant, but also evidence to support attainment of minimal standards of clinical core competency expected of a specialty or subspecialty. To that end, it is of paramount importance that the minimal standards of core clinical competence expected should be clearly spelt out to assist the process of vetting applicants. Furthermore, these clearly stated standards can serve as learning outcome objectives for young doctors undergoing training in their respective fields.
For specialists such as physicians, psychiatrist and pediatricians whose primary mode of practice is predominantly non-invasive in nature, assessing their level of core clinical competence include more than just examining their logbooks of procedures and the number of various types of patients they have seen. The clinical competence of a doctor should be assessed while he/she is performing procedures or clinical practice by observers to determine whether these are carried out independently, consistently, effectively and at a level expected of the respective specialty. Assessment of clinical competence can therefore be done either by his/her supervisors or peers based on clearly spelt-out criteria, or via standardized clinical examinations. Conducting clinical examination, however, involves a lot of logistic, financial and management problems, and is not favored by all specialty and subspecialty credentialing bodies in Malaysia.
In designing assessment forms on clinical competency, two important elements should be included: user-friendliness and clarity of the areas to be assessed. In Neonatology, for example, 13 areas of core clinical competencies of the applicants (such as the ability of the applicant to carry out cardio-respiratory intensive acre competently, management of congenital anomalies and genetic diseases, and communication skills and counseling) are to be assessed by the supervisors or referees. The credibility of this mode of assessing clinical competency, however, relies heavily on the honesty and integrity of the assessors.
40th Malaysia-Singapore Congress of Medicine
|THEME:||"Coming to Terms with Acute Care Medicine"|
|DATE:||24 to 27 August 2006|
|VENUE:||Sunway Pyramid Convention Centre Selangor, Malaysia|
19 Jalan Folly Barat, 50480 Kuala Lumpur
Tel: ( 6 0 3 ) 2093 0100, 2093 0200
Fax: (603) 2093 0900