Professionalism and Communication in Medical Practice

Himanshu Pandya

E thical and legal principles, professionalism and professionalism to facilitate deliberations on the subject as
communication are linked to each other. Whereas ethical well as teaching and evaluation of trainees and physicians. A
and legal principles inform professionalism, communication medical student begins the process of becoming a professional
skills are used to express professionalism. This chapter will from the day he enters a medical school. Being a professional
discuss the scope of professionalism and communication in means internalizing and adhering to a set of values, behaving
today’s medical practice and review current concepts on according to standards that define acceptable medical
teaching and evaluation of these competencies. practice. The word profession is derived from profess which
means ‘to proclaim something publicly. Physicians profess two
PROFESSIONALISM things: to be competent to help patients and to have patients’
Introduction best interests in mind. Such commitment invites trust from
Though professionalism has become a buzzword in medical their patients. Behaviors that are common to several proposed
education literature, training in professionalism occurs to definitions and discussions on professionalism include the
a large extent through role modeling and socialization. The following, however a detailed discussion of these attributes
culture of institution and socioeconomic factors are the is beyond the scope of this article5,6,7,8.
forces which have significant impact on professionalism and  fiduciary obligation
are beyond control of an individual doctor. Helping future  responsiveness to societal needs
and current doctors meet professional standards should be  empathy
one of the key mission objectives of any medical education  respect for others
endeavor. The need to teach and evaluate professionalism  accountability
in a formal manner has arisen out of recent concerns  commitment to quality and excellence
about physicians’ conflict of interest and evidence that  ability to deal with ambiguity and complexity
certain behaviors during training are linked to future loss of  reflection
licensure for issues related to professionalism1,2. This view is
advocated by medical schools, graduate education programs Professionalism: how to teach it
and professional bodies. Regulatory bodies have also issued Though principles of professionalism can be articulated at the
practice guidelines explicitly outlining professional duties level of institution and educational program, the teaching of
of physicians3,4. Students, recent graduates and practicing professionalism is best done in real life situations. Such a strategy
doctors are expected to understand, internalize and also takes care of hidden or informal elements of curriculum.
demonstrate professionalism. Some strategies to teach professionalism are detailed here.

Defining professionalism Courses: Most medical schools offer courses on clinical skills
Educators and regulatory bodies have tried to define that include ethics, doctor-patient relationship and moral
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reasoning 9,10,11,12. Course can be taught in non interactive Professionalism can be evaluated formatively or summatively,
lecture format, however problem based or team based be targeted at educational ends or accreditation, be used
learning allows to teach content using the process that needs measure the effects of educational program, or to reward
to be taught. Such teaching methods require students to individuals or promote practices in an institution. Since
be collaborative and accountable, attributes important for professionalism is context specific and its manifestations are
developing professional attitudes and behaviors needed for in actions and behaviors as well as attitudes and motivations,
multidisciplinary care of complex patients 9. Some educators its evaluation should be done in longitudinal fashion, by
have used literature, art and film to teach professionalism. different methods and across different contexts.
Students are able to see and feel patient’s perspective
during these efforts, thereby developing empathy and Evaluation by supervising faculty: Faculty supervisors may
respect. witness behaviors of trainees in interaction with patients,
peers and staff. They may have the opportunities to observe
Role modeling and mentoring: Trainees model their trainees over time and in different clinical contexts.
behaviors on those who they see around them through
process of emulation and socialization. Mentoring is more Incident reports: Faculty document notable professional or
formal relationship in which a senior and established unprofessional incidents that they observe in trainees over
member of a community advises a specific trainee regarding longer periods and across more contexts. Several reports
personal and professional growth. Role modeling occurs on over time and in aggregate may detect trainee traits that
day to day basis and does not have the length and intensity are generalizable.
of mentoring relationship. Modeling may go unnoticed
without explicit discussion. For example a physician may Peer assessment and 360° evaluations: Peers, since
model behavior like washing hands to teach importance of they are at same level of training or experience, and they
preventing nosocomial infection, yet a student may interpret have longer and more intimate exposure to each other,
this as physician’s concern about contracting disease. may offer unique perspectives in humanistic attribute
and collaborative behaviors. Peer evaluation can take the
Reflection: Reflection provides trainees opportunities to form of rating forms, nominations, rankings or qualitative
generate insight into how they perceive themselves and assessment, can be required or voluntary, anonymous or
their roles. Since trainees may have limited practice in self signed. Developing assessment with peers is recommended.
assessment it is better if reflection is structured and involves Most acceptable form of peer assessment is anonymous
the assistance of faculty. Reflection should take the form and formative. In addition to assessments from faculty and
of small group discussions, essays, journals, or portfolios. peers, 360° evaluations also add elements from patients,
Trainees can draw upon their own experiences or can reflect nursing and ancillary staff. These perspectives enhance
on scenarios provide to them. evaluation process and offer unique perspectives on qualities
like compassion, respect for others, cultural awareness and
Service learning: Medicine has at its core a service ability work in teams.
endeavor. Trainees may not get to participate in this
central activity of medicine. The way medicine is currently Portfolios: The portfolio operates on the theory that
taught is too focused on aspects of biomedical knowledge reflection on experience can result in deeper and more
and procedural skills and therefore may not promote a permanent learning. Reflecting on experience and
sense of duty amongst trainees. The informal or hidden documenting the reflection, could be useful method of
curriculum has the potential of devaluing central elements promoting mindful practice. Experienced faculty members
of professionalism like compassion and respect in favor of should serve as mentors and reviewers of portfolio.
efficiency and expediency. Service endeavors led by trainees
help fill this large gap in professional education. Promoting a culture of professionalism
For any efforts to teach and evaluate professionalism to be
Professionalism - how to evaluate it successful, they must occur within a institutional culture
Key regulatory and educational bodies internationally and that reinforces the fundamental messages of the educational
across the continuum of medical education have called for endeavor. Educational efforts will be more successful if
increased attention to the measurement of professionalism. educators take into consideration the cultural factors and
546 Medicine Update-2011

use them to inform the curriculum. The informal or hidden safe manner. There is evidence that, though effective
curriculum, which is to an extent decided by institutional communication improves patient outcomes, doctors are
culture, is a powerful teaching force. Educators must not all ideal communicators and skills of communication
keep in mind this force while teaching and evaluating can be learned14.
professionalism.
In medicine, communication skills are needed,
Potential threats to teaching and learning of professionalism  for forming and maintaining relation
within an institutional culture may include:  to gather and share information
 lack of shared definition of professionalism  to gain informed consent
 lack of consequences for trainees and faculty who engage  to support problem solving
in unprofessional behaviors  to provide reassurance
 lack of recognition for those who exemplify professionalism  to alleviate distress
 the fast pace and intensive nature of clinical medicine  to make best evidence-based decisions
that encourages reflexive as opposed to reflective
thought and action Communication skills in medicine includes interaction,
 the brief and episodic nature of interactions between doctor and patient, between colleagues and with
between faculty and trainees, that gives faculty too other health professionals. A variety of media influence the
few opportunities to observe trainees and model development communication in health care and they include
professionalism written patient records, telephones and electronic written
 the selection process for trainees and faculty as well as communication like e-mails and text messages.
promotion of faculty may not include professionalism
Why are communications skills important?
There are a number of ways to address these threats. It is well known that patients prefer clinicians who are
Institutional or programmatic recognition of importance of warm and compassionate, listen to their patients and ask
professionalism is the first step. Health care institutions can relevant questions. Effective communication is a product
instill professionalism by operationalizing and implementing of appropriate knowledge, skills and attitude. Doctors who
innovations at the institutional level that promote empathy, communicate well are more likely to,
respect and accountability.  make an accurate diagnosis especially with regards to
problems with psychological element or psychiatric
Challenges to professionalism in developing world conditions
In India and some other developing countries, doctors have  have their patient manage their medications better
been traditionally greatly trusted. However ‘my doctor  have better outcomes
knows what is best’ type of trust is giving way. Some of the  be safer
unprofessional facets of health care in developing countries  encounter fewer malpractice claims
are unethical advertising, fee splitting and other incentives
to lure referrals, doctors’ tendency to prescribe expensive Communication models
and irrational drugs, fetal sex determination tests etc 13. Although a number of models of communication for clinical
practice have been described, the Calgary Cambridge
CLINICAL COMMUNICATION approach has become well established as generic guide
What are communication skills? to consultations15. All models emphasize the importance of
The word ‘communicate’ comes from the Latin to impart, understanding not only the patient’s disease process but
to share. Communication is about how doctors and patients also their thoughts, beliefs, feelings and expectations. The
interact with each other in search for mutual understanding basic elements of a successful consultation include,
and shared solutions to problems. Communication lies at  initiating the session
the heart of medical practice and is becoming increasingly  building relationship
important in present times. Given the complexities of  arranging the consultation
health care, with involvement of larger health care teams  gathering information
and increasing number of available therapeutic options,  explanation and planing
it is essential that all communication is carried out in a  closing the session
 Medicine Update-2011 547

More advanced communications skills are required for areas Simulations: Simulated consultations can be created using
such as, members of teaching team, volunteer patients or professional
 breaking bad news actors. Simulations can be developed in different settings
 dealing with anger like out patient consultations to ward or community where
 language and cultural differences communications with patients, colleagues and other health
 communication through and interpreter care professionals can be observed.
 where there are medical problems such as dementia
Role play: Students themselves can take the role of patient
A useful statement from UK medical schools has provided the and doctor to carry out simulated consultation. Students are
content of undergraduate clinical communication curricula16. able to understand the patient’s perspective while learning
communications skills through role play.
Core concepts in teaching communication skills
Communication skills are used in daily practice and therefore Observation: An experienced tutor can write observations
teaching them will be more effective if it contains practical during an encounter of a student with real or simulated
experience and feedback along with theoretical material. patient for accurate feedback later on.

Theoretical material: Clear hand outs of the model used Recording: Students an record their consultations with
accompanying regular lectures, seminars or web-based real or simulated patients which they can take to their
material can provide clear directions to students about their supervisors for constructive feedback. Videos allow students
progress in the curriculum. It is also essential to identify to analyse their body language and eye contact.
specific instructional objectives for a communication skills
session or a module. This helps standardization of sessions and Remote observation: Encounter of student with a patient
gives signposts to the students in their journey of learning. can be captured by video camera linking the recording live
to a room of observers.
Practical experience: Practical experience can be imparted
in several formats-under supervision with real patients Providing experience for specific communication skills
on wards, outpatients setting or in primary care, or with There are number of special situations which require further
simulated patients in more controlled environment. Initially training
experience is directed at core skills of communication, to  breaking bad news
be followed by more difficult and complicated situations.  dealing with distressed patients who are angry or upset
It is also essential to provide opportunities for analysis and  dealing with ethical dilemmas like confidentiality
discussion of experiences. For any audio or visual recorded  dealing with patients who have communication
communication skills session key issues to be taken care difficulties through sensory impairment
of include consent of the patient, setting ground rules  communicating across language or cultural differences
with the learner and giving constructive feedback to the  communicating through an interpreter
learner. Effective feedback is the cornerstone of effective  giving life style advice
communication skills learning and needs to be clear, regular,  communication with colleagues
balanced, specific and objective.  communication in acute or emergency setting
 teaching
Methods for delivering communication skills teaching  dealing with media
Medicine is a knowledge based profession and when you  communicating using telephone
are unfamiliar with information, it is a daunting task to be  using written communication
learning how to share information. Communication skills  recording an interaction with patient or colleague in
teaching sessions are more productive if learners have prior medical records
underlying knowledge.
Students are only able to observe experienced doctors
Demonstrations: Recorded consultations either real or simulated handling such situations. However real learning comes from
in diverse settings can be used during lectures, discussion groups trying out yourself and hence simulations and role play are
or seminars to help students learn core concepts. the methods which can be employed.
548 Medicine Update-2011

Assessing communication skills Concerns about eroding values of practitioners and trainees,
Assessment can be used to focus on learning in addition to expression of public dissatisfaction with medical care, and
measuring competence. threat to primacy and autonomy of medical profession
all have contributed to renewed look at professionalism.
Continuous self assessment: Ideal assessment of Planning and implementation of medical training in
communication skills requires evidence about all aspects of professionalism and its evaluation requires careful attention
communication throughout a clinician’s practice. to educational structures and cultures. Whereas medical
education focuses on observable behaviors and outcomes,
Formative assessment: Feedback on student’s performance professional identity is complex matter involving inner
can be given using direct observation or recording. processes like feelings, attitude and beliefs. Educators face
the major challenge of ensuring how trainees internalize
Summative assessment: Assessment of communication skills these lessons so that their claims to expertise and service
can be part of objective structured clinical examination are authentic ones.
using simulated patients for standardized consultation.
Standardized instruments for assessing communications Knowledge by itself is insufficient to make an effective
skills can be either used or further refined in different doctor as doctors need to communicate with patients,
settings17. colleagues and staff. Effective communication skills can be
taught. Basic communication skills can be taught effectively
Teaching the teacher by using standard communication model in small groups or
Communication skills teaching requires sensitive and one-to- one situations. Effective teaching methods may
dedicated teachers who are excellent communicators involve role play, simulated or real patients with either
and role models. It is important that those who teach recording or direct observation used to support feedback to
communication skills are themselves adequately trained and to student. Teachers of communication skills should be well
experienced in the teaching methods being used. trained and themselves be role models. Good communication
Summary skills are central to practice of medicine.
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FURTHER READING
1. Stern DT (Ed) Measuring medical professionalism. Oxford University 4. Martin D. Martin’s Map: a conceptual framework for teaching and
Press. New York. 2006 learning the medical interview using a patient-centred approach.
2. Wear D, Bickel J (eds) Educating for professionalism: creating a Med Educ. 2003 Dec;37(12):1145-53.
culture of humanism in medical education. University of Iowa Press, 5. Dowell J, Dent JA, Duffy R. What to do about medical students with
Iowa City. 2000. unsatisfactory consultation skills? Med Teach. 2006 Aug;28(5):443-6.
3. Brown J. How clinical communication has become a core part of
medical education in the UK. Med Educ. 2008 Mar;42(3):271-8.