Consultation Skills - Demonstrating professionalism

Professional skills, such as calmness under pressure, are attained through training.

An angry patient may bring questions of professionalism to the fore (Photograph: SPL)
An angry patient may bring questions of professionalism to the fore (Photograph: SPL)

Being a professional is probably not something most doctors think about: it is just intuitively done, on the job, as it were.

But I would argue that there is merit in thinking about why and how what we do as GPs demonstrates professionalism, particularly during the years leading up to the certificate of completion of training (CCT).

The Royal College of Physicians has described medical professionalism as a 'set of values and behaviours' that underpins a patient's trust in a doctor.1 That kind of definition has spawned many lists of values and behaviours that GPs can read and reflect on. Essentially, those lists describe qualities, such as honesty, integrity, respect for patients and altruism and so on, in varying degrees of detail.

External morality
Being a medical professional is about what you might do in the care of patients, but it is also about what you are.

This distinction was usefully articulated by Charlotte Paul in a review of some headline adverse cases in 2000. What she called an 'external morality' of medicine was that imposed on practitioners from outside the profession: the regulators.

That was all very well, but did not work unless doctors could muster a strong 'internal morality' to interpret the external rules within which they had to operate. Both these moralities, she argued, had to run together to engender trusting relationships with patients.2

So how do we learn the qualities that make these trusting relationships happen? Perhaps those qualities are hard-wired into those of us who become clinicians, and are not the sort of thing that can be learnt.

Professional skills
Sean Hilton, professor of primary care at St George's, University of London, argues that we gain professional skills through training by a process of attainment - informed by good role models, experiences that promote reflective learning and social involvement.

That attainment may be partially undone by influences that work against the development of professionalism: exposure to poor role models or overwork, for example.3

These kinds of experiences continue throughout a doctor's life in clinical practice, but in early years as an undergraduate or postgraduate they are, arguably, more formative.

Even this analysis does not answer the part of the question above to do with what we are as individuals, or what our intrinsic attributes might contribute to our professional role. These kinds of attributes have been called virtues in the historical literature.

To be honest, for example, is to be honest in clinical practice as well as in personal life. To act with integrity is to hold to one's own moral values similarly in both spheres. This way of looking at the moral world is a specific ethical framework that deserves more mention or thought than it usually gets.4

Consider this case
Bill Fellows is an ST3 in his last month of training. He has a post arranged at a nearby practice after getting his CCT, for which all the necessary exams have been passed.

Bill sees a temporary patient, previously unknown to him. This patient explains that he is in town for a few days and has run out of his usual medicines that his GP 50 miles away prescribes. These consist of diazepam, dihydrocodeine and nitrazepam in standard doses. Bill takes a full history and then asks the patient to wait while he phones the GP to check. At this point the patient rises from his seat, gets agitated and starts threatening Bill - should he not prescribe his medicines?

This sort of nightmare consultation will be familiar to most GPs. Thankfully rare, it can illustrate the personal qualities, or virtues, we might wish for in Bill to help him get through it and deal professionally with the patient.

In a brief review of this scenario, we could cite courage, calmness or even wisdom as being the sort of attributes Bill could use in this challenging interaction.

Clearly declaring those virtues is not the complete picture in thinking how to deal professionally with such a case, but it is an approach of value.

References
1. King's Fund, Royal College of Physicians. Understanding doctors: harnessing professionalism. London, Kings Fund, 2008. http://old.rcplondon.ac.uk/professional-Issues/Documents/ Understanding-doctors(Kings-fund)-FINAL.pdf

2. Paul C. Internal and external morality of medicine: lessons from New Zealand. BMJ 2000; 320: 499-503.

3. Hilton S. Medical professionalism: how can we encourage it in our students? Clin Teach 2004; 1(2): 69-73.

4. Toon PD. Towards a philosophy of general practice: a study of the virtuous practitioner. Occas Pap R Coll Gen Pract 1999; 78: iii-vii, 1-69.

CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Read one or more of the references (above) and write a short reflective piece on how they might apply to you.
  • Read a work of fiction about the work of a GP (for example, The Plague by Albert Camus) and write some notes on what you have learnt about professionalism from it, and how it applies to your clinical practice.
  • Think about the last challenging case you dealt with. Analyse it from the perspective of issues of professional qualities, and present the case to a practice meeting.

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