Medical Professionalism in a Time of the Covid 19 Pandemic and Beyond
Angeles Tan Alora
Dec 2022 DOI 10.35460/2546-1621.2022-sp02
The Coronavirus-19 (Covid-19) pandemic disrupts our medical world. There are substantial demands on our overstretched, understaffed, and under-resourced health systems. Physicians continuously adjust to “crisis standard of care” and new skills for on-line or face to face restricted practice. Physician health and well-being suffer stress, burn-out and moral injury. Many get sick and some die. They ask: “How should I behave as a medical professional in a time of the Covid-19 Pandemic and Beyond?”
This article explores medical professionalism: its meaning, its core values and challenges in the time of Covid-19. Its aim is to help doctors and medical students improve their professionalism, and mature into more dedicated physicians who derive joy and pride in what they do.
In 2005 the Royal College of Physicians defined medical professionalism as “a set of values, behaviors and relationships that underpins the trust the public has in doctors” .
Professionalism encompasses who doctors are, how they work, what they value, and how they view themselves.
Fig 1 Medical Professionalism
Professionalism is fundamental to good medical practice. It benefits patients, doctors, and health systems.
Medical professionalism commits to patient welfare and public health with the core values of excellence, service, humanism and solidarity [2,3].
Doctors have a primary responsibility to act for the patient’s welfare [2,4]. They protect, preserve and defend the life, health, integrity and dignity of the patient. These they do by providing quality patient healthcare and by being a patient advocate.
Provision of Quality Patient Healthcare
Basis for duty to provide healthcare
The duty to provide healthcare is based first on our shared humanity. Members of the human community have a Duty of Easy Rescue: to aid others in great need when one can do so at minimal risk to oneself. In addition, the duty to provide healthcare is based on the physician’s trust relationship with patients. This covenant of trust arises first on the reciprocal obligation of physician to society: the community supported the physician’s learning and provides them special privileges. Second, the covenant arises from the physician’s possessing special abilities. This trust relationship obliges physicians to take greater than the minimal risks required by our shared humanity.
The Philippine College of Physician’s Code of Ethics states: “The internist must provide appropriate service and care to patients irrespective race, age, gender, disease, disability, sex orientation, social standing, creed or political affiliation or ability to pay”.
Characteristics of quality patient care
Quality healthcare is competent: scientifically and ethically sound, holistic and attentive.
Competence is when a physician, given a patient, is aware of the need to act, obtains relevant information, integrates updated research evidence, local experience, patient/community/physician values and context in deciding what to do, can do what should be done and chooses to do it.
Competence is also not doing what one should not do. The competent physician recognizes futility and acknowledges proportionality. When no benefit will result or when risks or burdens outweigh the benefits of a particular test, drug, procedure or referral for the specific patient, he does not use it.
In many countries, the battle against Covid-19 has provoked medical schools to speed up their graduation process, and push students out of classrooms into clinical practice . In the Philippines, the Department of Health called for volunteers, regardless of experience or readiness (including fresh graduates without certificates of registration from the PRC ). The impact of such measures on the provision of competent care has not been reported. Supervisors have the responsibility to ensure quality healthcare is provided and patients are not harmed.
Quality Healthcare is holistic. It cares for the whole patient: body and spirit. The physician listens to the patient’s doubts, fears and anxieties, then clarifies and reassures. He prays with and for his patients.
Quality healthcare is attentive. The physician is physically present when needed. The fear of getting infected, bringing the infection home, or the lack of health-team support are not justifications for negligence or abandonment during the pandemic.
The holistic and attentive aspects of healthcare underscores the role of doctor as a healer, more than just a curer; a great more than a good doctor.
Limitations to providing patient care
The duty of the physician to provide quality patient care is not absolute. Limits are set both by what can be done and what ought to be done.
Limited resources in a pandemic do not allow a physician to admit a patient into the hospital where there is no space for the patient. Neither can the physician provide a respirator if there is none.
Ethical principles and physician’s conflicting duties to self and others define what ought to be done.
A physician may refuse to treat a Covid patient for ethically defensible reasons. Examples include when the care requested is contrary to the physician’s value such as requests for futile or non-standard care; when more capable physicians are available; when harms outweigh benefits as when risk to the physician outweighs benefit to the patient. Refusal does not end with saying “Sorry”. The physician explains to the patient/family the reason for the refusal and offers the patient the appropriate alternative in a timely effective manner. He also continues to be a patient advocate and supports healthcare in other ways.
A physician promotes patient integrity and dignity by being an advocate for all patients, both present and future.
The physician empowers patients to be self-carers. He provides accurate information regarding disease, tests and treatment. He educates towards critical decision-making: how to weigh benefits/burdens in line with personal goals, values and obligations, and apply the principle of proportionality. He involves patients in management plans. He explains the pros and cons of specific actions, including their financial and spiritual implications, provides time for questions and reflection, then obtains free consent before acting.
The physician protects patient safety. Medical “errors” are mostly preventable. The physician works towards a “just culture” that demands high standards of care and expects accountability from both the health system and the individuals involved.
Doctors commit to the second responsibility of seeking the welfare of society: the common good. This duty is based on their membership of society and is achieved by promoting public health.
The physician participates in public health programs like vaccination. In public fora, the physician educates the public, regarding healthy living and prevention of disease. He corrects mis-information and disinformation regarding tests, wonder drugs and miracle cures. He is a good steward: using limited resources optimally and distributing benefits and burdens fairly. He is involved in policy creation/advocacy for a healthy environment including tobacco, alcohol, climate change issues. He finds alternative ways to fill gaps of the healthcare system.
Many measures done to contain the pandemic (converting public buildings to isolation centers, etc.) are temporary. Healthcare maldistribution is part of the larger national socioeconomic inequities . The physician promotes social justice by advocating effective permanent measures directed to lift the underprivileged and vulnerable before, during and beyond the pandemic.
In seeking patient welfare and public good a physician possesses the core moral values of excellence, service, humanism and solidarity.
Excellence is the quality of being outstanding or extremely good or at least, the best of oneself. The excellent physician has competence and integrity.
Competence requires knowledge, skills and attitudes to perform the physician’s duties of providing patient care and participating in public health. The many on-line learning activities: webinars, postgraduate courses, scientific meetings update knowledge. Health institutions and professional organizations offer programs for physicians to improve manual skills. Developing the right attitudes of patient welfare and common good before self, lifelong learning with a commitment to evidence-based practice needs strong support from colleagues, health institutions and professional organizations.
Integrity is “a virtue consisting of soundness of and adherence to moral principles and character and standing up in their defense when they are threatened or under attack. This involves consistent, habitual honesty and a coherent integration of reasonably stable, justifiable moral values, with consistent judgment and action over time” .
An honest physician does not bear false witness against a colleague, does not provide false data in a medical certificate or up-case a medical claim.
The coherence of his moral values with his judgment and his action is reflected as he walks the thought, does what is right for the right reason. In relating with patients, research participants, colleagues, institution and pharmaceutical industry, the physician with integrity avoids conflict of interests.
He chooses a particular action primarily because it serves the patient’s best interest, not his own. Referrals are made to provide better patient care and not to reduce physician responsibility, reduce physician stress or provide earning to a colleague.
Professional fees are fair compensation for service rendered. They provide the physician with a comfortable and secure life but never lavish living.
Tests/procedures/treatment purely for “academic” reasons are not done. When trainees “practice” on patients, supervising physicians must ensure that the “practiced” test/procedure/treatment is scientifically and ethically justifiable as for the patient’s good, supervision is intimate to protect patient from harm, the patient knows and agrees to have someone in-training do the test/procedure/management and the patient is not charged a fee for the test/service.
When human participants are involved In research, the physician-researcher ensures clinical equipoise, protects the participants from harm, benefits them, obtains their free and informed consent and selects, recruits, and assigns them fairly.
The physician works with rather than against his colleagues, seeking to complement rather than compete, support rather than find fault.
He is loyal to his institution living its mission and protecting its name.
When pharmaceutical industry representatives offer the physician gifts, food and various forms of “return-to-practice support”, he asks “For what and for whom?”. He refuses benefits given in exchange of his prescriptions/endorsements or for his personal individual use.
Service is giving to others or to a larger purpose without selfishness or self-interest. It is performing a task without expecting anything in return, it is self-forgetfulness. Service relates to altruism- the selfless concern for well-being of others as against self-preservation.
The physician serves those in need, and those who serve/will serve those in need.
Serving those in need
The physician serves those in need by contributing to safe, equitable and efficient healthcare. He heals as best he can, even if the patient has nothing to pay, no learning to offer or no information to add to his research. Need is the patient’s claim. For patients who are afraid to come or who cannot afford to come, he becomes a mini call center, a virtual out-patient department, using digital technology to listen to questions, doubts, and complaints; to allay fear and guide decisions. He avoids adding burdens of his patients: no midnight or early morning rounds that prevent the patient from restful sleep; only absolutely justified expensive technology/compassionate drugs; no professional fees for patients managed by referred-to physicians. The physician transforms his work from a job to a gift.
Serving those who serve those in need
The physician serves those who serve those in need by supporting his front-line colleagues. These colleagues expose themselves, even risk their lives, to situations where others are not willing to go, to do tasks others are unwilling to do. They experience higher workloads, psychological distress, shortage of personal protective equipment, social exclusion/stigmatization, lack of support, and improper management . They are vulnerable, anxious of bringing home the virus and weary from their pleas for justice. Only their faith in God, dedication to their profession and the mutual support from colleagues strengthen them to face these difficulties.
The physician cooperates in preventive control policies to reduce their risks. He volunteers to take over some of their duties so they can care for Covid-19 patients: activities like public health vaccination programs, training of the juniors, interns and students. He uplifts their flagging spirit by bearing witness to their problems and by joining their fight for a just healthcare system
Humanity is seeing the other as a fellow human being who feels, suffers, and needs help. The physician is neither forgetful nor indifferent of the increased burdens that has accompanied the pandemic. He expresses his attention through empathy and compassion to the marginalized and the wounded spirit..
The Covid-19 pandemic has disproportionately affected the marginalized in our society. The poor cannot stay home if they must go out to earn their daily living, they cannot isolate if they live in only one room and cannot maintain proper ventilation if they have no window. The privileged can. The physician acknowledges these inequalities. He is sensitive to the feelings of the poor and does not repeat statements like “we are all in this together”. He does not display on social media pictures of beach vacations, parties, travels abroad and similar activities only the rich enjoy. He lives simply and shares his resources- to whoever and whenever he can.
The wounded spirit
Self-preservation and infection precautions are critical to reduce the spread of Covid-19. By their very nature however, they are “isolating”, create a more distanced approach  and wound the spirit. The physician seeks solutions to mend these wounds.
The physician hears the cries of the dying intensive care unit (ICU) isolated patient separated from her loved ones, unable to have her family come near, to say “I love you” or “goodbye”. He is resourceful in crafting ways to connect patient and family through the phone, or whatever on-line platform he can make available. He becomes a proxy family member who holds the patient’s hand or spends a few extra minutes at the foot of her bed to “be near”.
He feels the anxiety of the hearing and visual impaired older person, lacking manual dexterity, trying to make sense of technology and challenged to use telemedicine or receive no healthcare. He spends additional time explaining how teleconsultation works, guides her through the process and puts her at ease. He waits patiently as she tries to cope. Many reminder mnemonics such as ICARE or AIDET are particularly useful heuristic tools .
He listens to the frustrated families of critically ill patients refused admission or refused resuscitation. He explains the reasons why their wishes were not granted, how policies reduce spread of the disease and protect all, how everyone is doing their best.
He tries to put himself in the shoes of the distressed resident unable to do what he thinks he should be doing, the pressured admission officer “forced” to give in to a superior demanding special treatment for a relative. He assures them that doing one’s best is all the Lord expects; bad things will happen and finding meaning and lesson may make it good.
The guiding principle in being humane is caring and showing that one cares. It is being trustworthy to tell the truth and do what is right consistently It is replacing cruelty with kindness and empathy, reaching out and listening.
Solidarity is an attitude of teamwork with others: one of collaboration, respect, mutual support, belonging, commitment, and sacrifice. It is how we understand and enact our collective responsibility to and relationship with each other.
On an international level, the scale and severity of the Covid-19 outbreak made countries work in a spirit of solidarity. – political solidarity, technical solidarity and financial solidarity . COVAX is an attempt to achieve equitable distribution of vaccines globally.
On a national level key groups of leaders such as politicians, public health experts and scientists work together to craft the nation’s response efforts. The Inter-Agency Task Force for the Management of Emerging Infectious diseases has the immediate priority to contain the epidemic. at the same time responding to its socioeconomic impact. Addressing social and economic inequalities, to reinforce equity, maximize protection for vulnerable groups and the medical workforce requires strong and sustained national solidarity.
On an individual level, the physician expresses solidarity with his colleagues and the community
Solidarity with colleagues
The physician witnesses and role-models professional behavior for colleagues to follow. He cares for his health, both body and soul. Physically, he eats proper food, exercises and rests. He is not seduced by how much he can earn, so that he works too long or travels too far, but makes time for rest, family, and friends. Spiritually, he recognizes his dependence on God and prays. He is careful of the slippery slope that starts with undeclared income, plagiarized research reports, minor indiscretions, rationalized as “pakikisama”, “palakaran” or obeying orders and slips into fraudulent medical certificates and testimonies, commissions for prescriptions or referrals, solicitation of patients, unnecessary procedures for increased charges, excessive professional fees, even sexual harassment and bullying.
He is a responsible and reliable team member. He is not absent from work so as not to overwork those present, does not abuse power, not criticize colleagues in public. He listens to, values, and obeys policies and living guidelines made by expert colleagues. The physician does not grab every opportunity to promote his self-interests, but sometimes allows a colleague to “seize the day”.
The physician aids in maintaining established professional standards by sharing expertise through health professions education programs. He instructs, guides and supervises trainees. He creates partnerships to enhance and expand both undergraduate and postgraduate learning. He creates more teaching modules and distance learning tools.
Although he accepts that everyone has shortcomings, he does not tolerate incompetence or unprofessional behavior. Instead, he calls attention to misbehavior through legitimate process without resorting to gossip or scandal.
Solidarity with the community
The privileged positions of a physician in the community provides special benefits. People give way for him. Still, he respects everyone as his equal. He follows the line and never jumps the queue. He does not push his weight around. He does not bully, but respects; not exploit, but encourages; never talks down to someone lower in the socioeconomic hierarchy.
When community members have laments, the physician hears them, sees them, shows them their worth. He guides them to bring out their best explaining what they can and should do and what they can and should be. He teaches them to use their conscience as their guide. He empowers them to unite, restore their personal dignity and work for the common good; to speak and act against dishonesty, injustice and corruption, for a morally defensible, transparent and consistent governance, if not for themselves, for their children and grandchildren.
The physician prays for transformation: for leaders who seek the common good more than self-interest, who are wise not deluded, for citizens who are generous, not greedy; empowered, not lukewarm and for physicians who are compassionate rather than detached, involved more than isolated .
The extraordinary and unique times challenged us to rethink, refocus, revise, and transform, to do what must be done, to fight for what must be. We must make the pandemic a positive game change, find our “marketplace” where despite difficulties, pain and sorrow, we can heal, teach, inform and empower with excellence, humanity, service and solidarity, where we can model the nobility of our profession and our person. The disruptions brought by Covid-19 are temporary, but we must maximize indefinitely the gains in professionalism to benefit our patients, our people and ourselves.
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