Physician, monitor thyself: professionalism and accountability in the use of social media

The recent report of the AMA Council on Ethical and Judicial Affairs (CEJA), "Professionalism in the Use of Social Media," describes the types of social media medical professionals use, outlines ways in which existing AMA policies address issues of online professionalism, and makes a list of recommendations for physicians to maintain online professionalism. CEJA recommends directed efforts towards educating physicians about the benefits and pitfalls of social media and, in particular, underscores the difficulties of maintaining professional boundaries in the digital age. In this commentary, we highlight issues introduced by the report and suggest some specific ways that the recommendations of the committee can be implemented by medical schools, residency programs, and practicing physicians.     

Sex differences in the professional orientation of first-year medical students

This article, presenting the findings from a 1975 survey of first-year medical students in the state of North Carolina, explores the relationship between students' sex and professional orientations considered relevant to current health care problems. The professional orientations concern four problem areas: (1) physicians' relationships with patients, (2) political and economic change in the medical profession, (3) the treatment of women physicians and women patients, and (4) geographic and specialty mal-distribution of physicians. Substantial sex differences are found for some professional orientations. As hypothesized, women orient more highly than men to humanizing physician-patient relationships, political and economic change in medicine, the problems facing women physicians and patients, and expecting an inner-city practice. Implications of the findings for health care and medical education are discussed.This report is based on the author's doctoral dissertation, Boys and Girls in White: Professional Orientation of the Student Physician Department of Sociology, Duke University, 1976. The author would like to express appreciation to Jim House for his continued guidance and encouragement as dissertation advisor.     

Religious Values in Clinical Practice are Here to Stay

Research to date has shown that health professionals often practice according to personal values, including values based on faith, and that these values impact medicine in multiple ways. While some influence of personal values are inevitable, awareness of values is important so as to sustain beneficial practice without conflicting with the values of the patient. Detecting when own personal values, whether based on a theistic or atheistic worldview, are at work, is a daily challenge in clinical practice. Simultaneously ethical guidelines of tone-setting medical associations like American Medical Association, the British General Medical Council and Australian Medical Association have been updated to encompass physicians’ right to practice medicine in accord with deeply held beliefs. Framed by this context, we discuss the concept of value-neutrality and value-based medical practice of physicians from both a cultural and ethical perspective, and reach the conclusion that the concept of a completely value-neutral physician, free from influence of personal values and filtering out value-laden information when talking to patients, is simply an unrealistic ideal in light of existing evidence. Still we have no reason to suspect that personal values, whether religious, spiritual, atheistic or agnostic, should hinder physicians from delivering professional and patient-centered care.

     

The Use of Narrative in Jewish Medical Ethics

Anne Jones has pointed out that over the last three decades, stories have been important to medical ethics in at least three ways: (1). Stories as cases for teaching principle-based medical ethics (2). Narratives for moral guides on what is considered living a good life (3). Stories as testimonials written by both patients and physicians. A pioneer in this effort, particularly in regard to using narratives as moral guides, has been the ethicist and philosopher Stanley Hauerwas. Heavily influenced by virtue ethics, Hauerwas believes that it is a person’s particular narrative tradition that provides one with convictions that form the basis of one’s morality. Befitting a Protestant theologian, he is particularly concerned with the Christian narrative. From a Jewish perspective, there has been much less written on the use of narrative in medical ethics. However, it is a mistake to think that narrative has little, if any, role in Rabbinic ethical decision making. The purpose of this article is to demonstrate the centrality of narrative in the thought of Orthodox Jewish decisors and the problems inherent in this methodology.     

Re-Visioning Medicine

Studies suggest that medical students and physicians have higher rates of anxiety, depression, and suicidal ideation than their peers in the general population. Some authors have suggested that medical culture perpetuates these problems by erecting “barriers to treatment,” preventing students and physicians from getting the help they need. Here, the author begins a broader examination of the potential role of culture by examining the myths and symbols that form the basis for medical culture and the medical self-image. The author argues that a medical self-image based on a de-contextualized medical mythology, the Asclepius myth, results in a sense of professional identity that is unbalanced, dehumanized, and characterized by unattainable expectations. The outward expression of this medical self-image, the medical culture, is often a-relational, unhealthy, stressed, or even toxic. The author suggests some ways of re-modeling medical culture, including its rituals and symbols, and medical education in ways that incorporate what is currently kept in its shadow.     

Vertical integration in medical settings: A brief introduction to its potential effects on professional psychology

Vertical integration in medical settings typically involves the merging of independent physicians, physician groups, and hospitals to render an organized health care network. Such systems are considered to be vertical, as they may allow for a seamless continuation of services throughout the range of needs a patient may require. Mergers often result in the redefining of professional services offered in the acquired facility or across the network. As such, mergers have the potential of adversely impacting psychological practices. Professional psychology needs to take a proactive stance in this changing health care landscape. Research regarding empirically validated treatments and effects of psychological interventions on overall health-care costs needs to be properly disseminated to health care administrators to assure their knowledge of the utility of psychological services in the medical setting. Training psychologists to assume leadership positions in health-care institutions, gaining representation on hospital staff boards, and linking psychologists and physicians through collaborative training, to provide improved care, may allow for psychology to influence health care delivery.     

Towards a Confucian Virtue Bioethics: Reframing Chinese Medical Ethics in a Market Economy

This essay addresses a moral and cultural challenge facing health care in the People’s Republic of China: the need to create an understanding of medical professionalism that recognizes the new economic realities of China and that can maintain the integrity of the medical profession. It examines the rich Confucian resources for bioethics and health care policy by focusing on the Confucian tradition’s account of how virtue and human flourishing are compatible with the pursuit of profit. It offers the Confucian account of the division of labor and the financial inequalities this produces with special attention to China’s socialist project of creating the profession of barefoot doctors as egalitarian peasant physicians and why this project failed. It then further develops the Confucian acknowledgement of the unequal value of different services and products and how this conflicts with the current system of payment to physicians which has led to the corruption of medical professionalism through illegal supplementary payments. It further gives an account the oblique intentionality of Confucian moral psychology that shows how virtuous persons can pursue benevolent actions while both foreseeing profit and avoiding defining their character by greed. This account of Confucian virtue offers the basis for a medical professionalism that can function morally within a robustly profit-oriented market economy. The paper concludes with a summary of the characteristics of Confucian medical professionalism and of how it places the profit motive within its account of virtue ethics.     

Voices from the Front Lines: An Analysis of Physicians’ Reflective Narratives about Flaws with the ‘System’

Physicians often express frustration with the ‘system’ in which they work. Over time, this frustration may put them at risk of burnout and disengagement, which may impact patient care. In this study, we aimed to understand the nature of the system flaws that physicians identified in their published narratives and to explore their self-representation as agents of change. We reviewed all reflective narratives published in four medical journals (NEJM, JAMA, CMAJ, Annals IM) between January 2015 and December 2017 (n?=?282). By consensus, we identified those that addressed system flaws (n?=?87). Using content and narrative analysis, we analyzed the types of flaws and the physicians’ orientation to the flawed system. We identified seven recurring system flaws—five related to medical culture: failures of communication, erosive impact of the hidden curriculum, inadequate health advocacy, frenzied pace of work, and experience of stigma. Less frequently, physicians’ narratives also exposed limited and disparate healthcare resources and restrictive institutional practices as impeding patient-centered care. Physicians expressed agency to create change foremost when writing about flaws related to medical culture. While physicians are challenged by system flaws, they strive to practice in ways that do not succumb to them. We saw tension between the elements outside the physician’s control and those within it. This tension becomes a source of distress when the compromises that emerge from system flaws move physicians away from the values that define their professional identity.

     

Professional Autonomy and the Normative Structure of Medical Practice

Professional autonomy is often described as a claim of professionalsthat has to serve primarily their own interests. However, it can also beseen as an element of a professional ideal that can function as astandard for professional, i.e. medical practice. This normativeunderstanding of the medical profession and professional autonomy facesthree threats today. 1) Internal erosion of professional autonomy due toa lack of internal quality control by the medical profession; 2)the increasing upward pressure on health care expenses that calls for ahealth care policy that could imply limitations for the professionalautonomy of physicians; 3) a distorted understanding of theprofession as being based on a formal type of knowledge and relatedtechnology, in which other normative dimensions of medical practice areneglected and which frustrates meaningful communication betweenphysicians and patients. To answer these threats a normative structureanalysis of medical practice is presented, that indicates whichprinciples and norms are constitutive for medical practice. It isconcluded that professional autonomy, normatively understood, should bemaintained to avoid the lure of the technological imperative and toprotect patients against third parties' pressure to undertreatment.However, this professional autonomy can only be maintained if members ofthe profession subject their activities and decisions to a criticalevaluation by other members of the profession and by patients and ifthey continue to critically reflect on the values that regulate today'smedicine.     

Developing the Good Physician: Spirituality affects the development of virtues and moral intuitions in medical students

The Project on the Good Physician is a national longitudinal study of moral and professional formation of American physicians over the course of medical training. The purpose of this paper is to examine the processes by which spirituality influences the development of three virtues (mindfulness, empathic compassion, and generosity) in medical students as mediated by the moral intuition to care/harm, as well as make predictions as to how this type of study could be generalizable to other populations. Study participants were 563 medical students recruited by the University of Chicago from 24 medical schools across the U.S. (54.7% male, 57% white) who completed measures assessing virtue formation 9 months apart. Path analysis of a cascade model showed that spirituality (but not religiousness) was directly and indirectly related to change in the virtue empathic compassion, and also indirectly related to change in the virtue generosity. Moreover, the moral intuition to care/harm partially mediated the association between spirituality and the virtues of empathic compassion and generosity (but not mindfulness).     

False dawns,bleak sunset: the Coalition Government's policies on career guidance

ABSTRACT

The Coalition Government's policies on career guidance are analysed. Its rhetorical concern for career guidance provision is based largely on its support for social mobility, and its recognition of the role of career guidance in moving towards a demand-led skills system. Initial policy statements affirmed its intention to establish an all-age careers service, to revitalise the professional status of career guidance and to safeguard the partnership between schools and external provision. But these policies have been undermined by its commitment to school autonomy and to public expenditure cuts, exacerbated by indecision and delays due to difficulties in resolving the tensions within its policies. The result is a significant erosion of the all-age vision, and a likely major reduction in the extent and quality of careers help for young people.     

The Role of Virtue in Xunzi’s 荀子 Political Philosophy

Although there has been a resurgence of interest in virtue ethics, there has been little work done on how this translates into the political sphere. This essay demonstrates that the Confucian thinker Xunzi offers a model of virtue politics that is both interesting in its own right and potentially useful for scholars attempting to develop virtue ethics into virtue politics more generally. I present Xunzi’s version of virtue politics and discuss challenges to this version of virtue politics that are raised by the Legalist thinker Han Fei. I show that not only is Xunzi’s virtue politics capable of surviving the challenges raised by his contemporary, he offers an account that is in many ways both attractive and plausible, one that may usefully be brought into conversation with contemporary visions of virtue politics.     

The Death of Us

An unconventional and provocative overview of the mental health culture in the first decade of the new millennium is offered as a springboard for reflection and widespread conversation. The author identifies five areas of concern. Destructive infighting, rejection of the medical model, the erosion of talk therapy, financial complications, and the impact of the insurance industry on mental health are noted for having negative influences on the quality of the services mental health providers rendered.     

What does the character of medicine as a social practice imply for professional conscientious objection?

The dispute over professional conscientious objection presumes a picture of medicine as a practice governed by rules. This rule-based conception of medical practice is identifiable with John Rawls’s conception of social practices. This conception does not capture the character of medical practice as experienced by practitioners, for whom it is a sensibility or “form of life” rather than rules. Moreover, the sensibility of medical practice as experienced by physicians is at best neutral, and at worst hostile, to the demands of those who would override physician conscientious objection to the provision of currently contested services. That being so, calls for overriding physician conscientious objection are much more demanding of the medical profession than they appear in light of Rawls’s view. As such overriding may entail the forcible transformation of medicine’s form of life, the author contends that it would be more prudent to provide contested services by circumventing the medical profession than by compelling it.     

The Spirituality of Compassion: A Public Health Response to Ageing and End-of-Life Care

SUMMARY

The recent revival of interest in spirituality in later life marks a significant step forward in the person-centred care of ageing people. The benefits will, however, be of limited value if we do not attend to the settings in which spirituality is to be lived. In contemporary society many aged people are located in environments unsympathetic to spiritual belief and practice. Health care settings focus on professionally-assessed physical needs and are dominated by concerns about the cost of services. The national social policies that direct health care services and less directly shape older people's place in contemporary society are strongly influenced by globalised neoliberal economic policies characterised by individualism, competition, and greed. For robust and viable spirituality to develop at the individual level we need compassionate social policies that support interdependence within communities and between nations.     

The Impact of Economic Globalisation on Health

The analysis of the impact of economic globalisation on health depends on how it is defined and should consider how it shapes both health and health policies. I first discuss the ways in which economic globalisation can and has been defined and then why it is important to analyse its impact both in terms of health and health policies. I then explore the ways in which economic globalisation influences health and health policies and how this relates to equity, social justice, and the role of values and social rights in societies. Finally, I argue that the process of economic globalisation provides a common challenge for all health systems across the globe and requires a broader debate on values, accountability, and policy approaches.     

The Religious and Social Principles of Patients’ Rights in Holy Books (Avesta, Torah, Bible, and Quran) and in Traditional Medicine

Health protection and promotion in healthy people and restoring patients’ health have been the most important themes in medicine and health throughout our history. Therefore, discussion of different aspects of patients’ rights includes implementation of these objectives by the medical community, including physicians, nurses, pharmacists, etc., and the people in charge of health affairs. The principal objective of our research is the study of medical ideology and the approaches of our ancestors in relation to different aspects of patients’ rights. To study the different ideologies of traditional medicine in relation to patients’ rights, appropriate data were extracted from the original resources of traditional medicine and from religious books. By means of library research we studied these resources in addition to electronic versions of the Alhavi book (by Rhazes), the Kamel-al-Sanaah (by Ahvazi), the Canon of Medicine (by Avicenna), the Zakhireye Khawrazmshahi (by Jorjani), the Avesta, the Torah, the Bible, the Quran, and many other resources, and, finally, after searching, gathering, and encoding the findings, analyzed them qualitatively for thematic content. The holy Avesta book clearly insists on the competence of physicians and setting the appointment fee in accordance with peoples’ income. The Old Testament (holy Torah) warned government officials who did not observe patients’ rights. In the four gospels (holy Bible) the importance of treatment and taking care of the patient is stressed. After the emergence of Islam, medical students, before beginning the principal courses, had to study Islamic jurisprudence, ethics, logic sciences, natural sciences, geometry, astrology, calculus, and similar courses so that after purifying their soul they could enter the saintly profession of physicians. The holy Quran refers to saving the life of a human irrespective of social class, race, and religion, and insists on exemption of patients from physical activity, including the physical aspects of prayer. In these resources, some warnings are offered in relation to fake drugs, the lack of awareness of some physicians, the need for complete preparedness of medical society, and the need to manufacture appropriate drugs and offer a suitable medical service. This information is to familiarize medical and health authorities and persons receiving health services. According to the evidence available about traditional medicine, there was no specific difference between public and professional ethics, public and professional rights, or rights and ethics—ethics were no different from rights nor rights from ethics. So ethics are similar to the soul in the body of rights, and rights are similar to the litter of ethics, and they have developed in parallel with each other. Traditional medicine is community-based and preservation of the health of healthy people is given priority over the treatment of patients; there is insistence that “health rights” has wider scope than “patients’ rights”. It can be stated that health rights in Iran both before and after the emergence of Islam have been based on guidance from divine religions, observation of humanist ethics, passing suitable courses in the basic sciences, and an introduction to the practical piety of our ancestors, in addition to the syllabus of medical and health education.     

Medical tourism in india: perceptions of physicians in tertiary care hospitals

Senior physicians of modern medicine in India play a key role in shaping policies and public opinion and institutional management. This paper explores their perceptions of medical tourism (MT) within India which is a complex process involving international demands and policy shifts from service to commercialisation of health care for trade, gross domestic profit, and foreign exchange. Through interviews of 91 physicians in tertiary care hospitals in three cities of India, this paper explores four areas of concern: their understanding of MT, their views of the hospitals they work in, perceptions of the value and place of MT in their hospital and their views on the implications of MT for medical care in the country. An overwhelming majority (90%) of physicians in the private tertiary sector and 74.3 percent in the public tertiary sector see huge scope for MT in the private tertiary sector in India. The private tertiary sector physicians were concerned about their patients alone and felt that health of the poor was the responsibility of the state. The public tertiary sector physicians’ however, were sensitive to the problems of the common man and felt responsible. Even though the glamour of hi-tech associated with MT dazzled them, only 35.8 percent wanted MT in their hospitals and a total of 56 percent of them said MT cannot be a public sector priority. 10 percent in the private sector expressed reservations towards MT while the rest demanded state subsidies for MT. The disconnect between their concern for the common man and professionals views on MT was due to the lack of appreciation of the continuum between commercialisation, the denial of resources to public hospitals and shift of subsidies to the private sector. The paper highlights the differences and similarities in the perceptions and context of the two sets of physicians, presents evidence, that questions the support for MT and finally analyzes some key implications of MT on Indian health services, ethical issues emerging out of that and the need for understanding the linkages between public and private sectors for a more effective intervention for an equitable medical care policy.     

Women in Computing: The Role of Geek Culture

Abstract

Synthetic biology is a field in-the-making: a loosely defined amalgamation of diverse disciplines, institutions and practices. Where some practitioners identify as scientists, others consider themselves engineers; while some extol the simplicity of standardised biology, others dismiss it as counterproductive. Three different communities in synthetic biology (epistemics, sceptical constructors and committed engineers) can be distinguished by way of their intentions, practices and promises. Synthetic biologists’ promises shape policy-makers’ expectations, which in turn shape institutional arrangements. These institutional arrangements then influence practitioners’ promises in an iterative fashion. In both the USA and the UK, ‘committed engineers’ have succeeded in gaining support for an engineering-based and industry-centred vision of synthetic biology, which promises applications and economic growth. This group's intentions and promises have influenced policy-makers’ expectations, which, in turn, have driven the major institutional developments in synthetic biology in the two countries. However, while the promises of the economic potential of this vision of the field have been embraced at policy levels, other aspects of this vision, such as the importance of enabling infrastructure, are often overlooked. In a sense, committed engineers’ promises and rhetoric have been too successful, because they have overshadowed the institutional and infrastructural developments needed to make them a reality.     

Ethical Challenges for Military Psychologists: When Worlds Collide

Despite the mental health needs in the military and improved access to military psychologists, many in need do not seek psychological services. The military policies, culture, and environment pose considerable barriers to help seeking. In turn, military practices often conflict with the psychologist’s professional ethics, leading to a range of ethical dilemmas including multiple relationships, multiple agencies, and limited confidentiality. To address ethical concerns and encourage service members to seek mental health services, this article proposes maintaining an understanding of military rules, law, and professional ethics; identifying multiple relationships and establishing boundaries up front; and collaborating with the patient in disclosures of information.