Part A

Part A: Think of two recent unprofessional experiences (different from each other), which you observed or where you were involved. Explain the professionalism related issues and discuss future behaviour changes in the light of these experiences.
The experiences (narrative) should have the following basic elements:
The abstract (summary and/or point of the story); orientation (to time, place, characters and situation); complicating action (the event sequence, or plot, usually with a crisis and turning point); evaluation (where the narrator steps back from the action to comment on meaning and communicate emotion – the “soul” of the narrative); resolution (the outcome of the plot); and a coda (ending the story and bringing action back to the present).

Experience 1
Abstract; this is the real life incidence of a labouring patient who was lying uncovered on the labour room bed and doctors and nurses were not listening to her. On my interference, they improved their attitude with patients and with the introduction of 360-degree evaluation they start behaving professionally.
Narration; I was working as head of Gynaecology and obstetrics unit 2 at lady Atchison Hospital Lahore. It was my daily routine to do morning round of labour room especially on emergency days between 8.00am to 9,00am. One day as soon as I stepped in Labour room, I saw a young woman of 24-year age, primigravida lying on bed. She was suffering from regular labour pains. She was quite distress and screaming. She was undressed below her belly. 2 to 3 nurses were sitting on table in the middle of the labour room near to her bed and were busy in filling their registers. Beside this, two of my unit doctors were sitting and chatting and other doctors were taking the history of some other patients. No one was attentive towards that patient; she was lying uncovered in front of labour room door. As soon as I entered I saw her lying this. I just turned my face towards senior nurse and my doctors and inquired them why you people are keeping this patient in this condition and why don’t you cover her properly, and why can’t you put screen before examining the patient. Nurse said I do not have screen while doctor said we want to examine her as she is about to deliver. I got upset and angry I asked nurse to arrange screen immediately and I strictly asked my doctor to not to examine patient publically in front of other patients as this is ethically wrong and if I saw doing such thing next time I will penalized that doctor. Moreover, I also realized nurses of their prime duty is to take care of patients and not to do paper work only. Senior sister and doctor apologized for their act and promised not to repeat this thing again. They covered the patient. I talked to the patient and advised to give her some painkiller. Patient was than quiet relaxed. I did the round of other patients and left the labour room.
Actions following this incidence
I came back to ward called the meeting of my senior staff and talked to them regarding this incidence and advised them that they should do daily rounds of ward and labour room and openly discourage any unethical behaviour and politely deal the matter there and then. I also said that they should behave as role model infront of their juniors so that our junior can improve their conduct and attitude towards patients.
Next day when I again went to labour room round the good thing was that sister has kept the screen near labor room entrance and they were using it for examining the patients in privacy. All the patients were properly covered. Doctors and nurses were actively taking care of patients.
But I was thinking why the doctors and nurses have started behaving unprofessionally. Why they started lacking attributes of good doctor I strongly felt that it is the need of the hour that residents should be taught professionalism explicitly and their feedback should be taken on regular basis from their colleagues and patients. In order to improve my unit working I started taking 360 degree evaluation reports of the residents from their pears, patients and paramedics on quarterly basis and giving them feedback upon that. This started to improve their behaviour with each other and with patients. This is how I improved the working of my unit.
This realizes me that we should not let any unprofessional behaviour to prevail and act as role model infornt of our junior and teach those correct things in professional manner.

Experience 2
Abstract: this is an incidence report regarding plagiarism in portfolio, which was carried out by senior neuro surgeon because of which he debarred from exam.
I have done master in medical education more over I have done certificate in CMT (certificate in medical teaching) course from UHS, following that I become facilitator for CMT programme. CMT programme is comprises of two contact session of four days duration that are three month apart. At the end of each contact, session participants have given assignment to complete and make portfolio of their activities. This portfolio is assessed at the end and participant based on portfolio and viva declared pass or fail.
Last time I was internal examiner and I was assessor for portfolio. I had twenty portfolio to check. While I was reading those port folio I felt that two of the portfolio were exactly same even the lecture slides, small group discussion and other assignments’. However, astonishing thing was that both participants were from different speciality one was from neuro surgery and other was from general surgery. Any how I made a note and next day I went for taking viva. I discussed this matter with other examiners as well, and we decided not to take the exam of both candidates and we decided to inform the administration.
When we informed them that they don’t have viva today, both became upset. General surgeon came to me and said that it was actually his portfolio and neurosurgeon asked his portfolio for guidance only and he was not aware of this fact that he has exactly copied his work. But we refused to take exam than he came –in along with neurosurgeon who apologised infront of examiners panel and admitted his unprofessional behaviour and requested that it was solely his fault and not of general surgeon. So he requested to please take his exam. After discussion with other examiners and administration, we took the exam of general surgeon next day. But neuro surgeon was debarred from exam.
Actions following incidence
This incidence let us to take steps to avoid such incidence in future. After this incidence, we introduced the rule regarding plagiarism in CMT handbook and explicitly started telling participants during contact sessions to avoid plagiarism. Following that, we never encounter such incidence.

Part B: Decide upon a list of attributes essential to Pakistani medical education context in your context with justification; compare it with those required globally. Discuss how you would incorporate those attributes (professionalism) in the curriculum. Briefly explain the appropriate teaching/learning and assessment strategies (You can add a TOS in the appendix). Support all your argument with references from the literature.

Delivery of quality healthcare is a multi-dimensional and multi-disciplinary function– every discipline and profession is interested and committed to carry out this task with extreme proficiency and dedication1. Helping current and future doctors to meet professional standards should be one of the fundamental missions of any medical education endeavour. Therefore, from the first day the student enters into medical school, he or she begins the process of becoming the professional.
PROFFESSIONALISM
Professionalism may be defined as adopting and adhering to a set of values, acting according to standards that define standard medical practice and being eventually accountable to the patient, he/she serves. Medical profession has public and social purpose, without which it loses its ‘distinctive aspect’ that inspires the society to trust in the profession 2
Behaviors that hold high personal standards include empathy, altruism, accountability, excellence and commitment to quality, good communication, team work, lifelong learning, ability to deal with ambiguity and complexity, responsiveness to societal needs and reflection. 3
Attributes of Physician in Pakistani Context
The medical profession is challenging as well as rewarding. No code or guiding principle can ever comprehend every circumstances or replace the vision and professional verdict of good doctors. Good medical practice involve practicing according to the standards set by the regulatory bodies according to societal and community needs. Although doctors have their own individual beliefs, values and ethics, but there are certain professional values according to which all doctors expected to work.4
Similarly, Pakistan Medical and Dental Council has declared certain ethical standards of professional competence, care and conduct, which Pakistan physician must own in order to practice. And should be the part of medical education and be taught explicitly throughout their undergraduate and postgraduate level.
Attributes of Medical Doctor 5
• Patient care: while dealing with patients, patient care is of paramount importance. Doctor should keep patient interest and his health at first priority. His behavior and conduct should be that it develop the relation of trust between them. They should give patients their full attention, allowing the patients enough time to let them know what is wrong with them and being non-judgmental and open to what patients are saying. Involve patients in the discussion and treatment decisions. Physician should counsel the patients and relative by themselves and not by any assistant or associate. Medical specialist must be able to provide effective treatment for the health problem. He should be compassionate, altruistic, and empathetic towards patient.
• Honest and justice: A professional doctor should maintain and demonstrate a high standard of honesty and justice towards their patients. This is the primary responsibility of the doctor to explain fairly everything to patient in clear words and fulfil the patients’ needs. Their professional decision must not be influenced by motives of fee or profit. Similarly, doctor should be honest for dealing with other health issues. Not receiving or giving any fee or any other concern merely to get the referral of a patient or referring a patient to any source.
• Unbiased and fair: physician should be fair, objective, factual, unbiased as a assessor far any scientific publication; for funding of any project; and when providing reference, ensuring that comments are unbiased, honest, justifiable, and evidence based . Doctor must be honest in financial and commercial dealings with patients, employers, insurers and other organizations’ or individuals
• Collaborator: They should be able to work in collaboration with any health care team and be able to maintain timely and legible medical records to serve patient’s best interests
• Polite and friendly: physician should be considered as a friend ta all individuals of any caste, class , religion; sex, ethnicity and occupation. And deal their patient in friendly atmosphere.
• Gender ethics: physician should take care of gender ethics, while giving consultation, examining, or doing any procedures on a female patient by male doctor a presence of a female attendant should be there. In gynecological examination, female patient privacy should be ensured .
• Leadership: The doctor should act as leader of the medical team as all responsibility of the patient care rests upon him and he is the one responsible for directing and delegating work to his colleagues/ Paramedical staff within his team.
• Dealing with conflict of interest.- A medical or dental practitioner must act in patient’s best interests when making referrals and providing or arranging treatment or care and no inducement, gift or hospitality which may affect or be seen to affect judgment may be accepted and nor shall such inducements offered to colleagues. Financial or commercial interests in organizations providing health care or in pharmaceutical or other biomedical companies must not affect the way that patients are prescribed, treated or referred.
• Advertising: When reproducing or broadcasting any information the doctor must not make claims about the excellence of facilities provided nor they equate services with those delivered by colleagues:” Broadcasts should not, in any means, offer assurances of cures, nor exploit patients’ vulnerability or lack of medical knowledge. They should not pressurize patients to use those services for example by arousing false anxiety for their future health. They should not highlight fake information or their degrees in order to attract patients. They should give honest opinion to patients in all areas
• Medical Knowledge: The specialist should be abreast with latest medical literature and research in order to upgrade his knowledge and to deal with challenging health care day-to-day problems.
• Interpersonal and Communication Skills: The doctor should exhibit good and effective communication skills to communicate with patients, their families, and other health care professionals. They should be able to deal with patients of different socioeconomic and cultural backgrounds. As professionals, physicians are expected to act in a courteous, dignified and civil manner towards their patients, their colleagues (i.e., all those who work with the physician, whether members of a health regulatory college or not) and others involved in the provision of health care. Therefore, this is the physician’s responsibility to act in the best interests of the individual patient. This includes acting respectfully toward patients and their families, friends and visitors, even under stressful situations. For example breaking a bad news to the patient or family is very sensitive and one of the most difficult responsibilities in the practice of medicine. Yet medical education typically offers little formal preparation for this daunting task. Without proper training, the discomfort and uncertainty associated with breaking bad news may lead physicians to emotionally disengage from patients 6. Therefore, doctor should be very polite, sympathetic towards patient and be careful regarding emotion and reaction of patient. They should be able to deal with patients of different socioeconomic and cultural backgrounds.
• Moreover, to promote the safe and efficient delivery of health care to all, physicians are expected to work respectfully and collaboratively with other members of the health care team. This includes other physicians, hospital staff, volunteers, students, and all other individuals who contribute to health care delivery. As pleasant personality of doctor, help patients to reduce their anxiety and courage to fight against their disease.
• Competent: they should be competent enough to deal with patients problem and when they feel that they are not competent enough or the patient problem is beyond their skill, they should have courage to refer the patient to concerned competent doctor rather than to mistreat the patient just for sake of money and of fear, not to lose the patient. .
• Professionalism: One of the core competencies is professionalism. Specialist must be committed to their professional responsibilities and ethical principles. They should demonstrate compassion, integrity, altruism and respect for patient privacy and autonomy. They should be responsive to diverse patient population and be accountable to patients, society and the profession. Doctor should be honest and open and act with integrity, never discriminate unfairly against patients or colleagues and never abuse your patients’ trust in you or the public’s trust in the profession
• Confidentiality: they should maintain the confidentiality of patients and should not disclose patient information in any case even to their relatives if patient want to hide that information. When doctors are requested to provide any certificates regarding birth or death or any medical reports etc., such documents shall be truthful, factual and honest to the best of their knowledge..
• Conflicts of interest: Doctor should prescribe the medicine only if needed to the patient and not under the pressure of the pharmaceutical companies to get their own benefits. Therefor keeping in mind the dignity of profession and commitment to medical profession, doctor should be compassionate, altruistic, and empathetic towards patient 7.
• Practice-Based Learning and Improvement (PBLI): Doctor should seek latest professional knowledge and trends to provide best possible patient care, through continuous medical education and with evidence based medicine. He should be able to reflect on his practice and be able to bridge the gap between his knowledge and skills. He should incorporate formative evaluation feedback into daily practice and use information technology to optimize learning; and, participate in the education of patients, families, students, residents and other health professionals. Doctor should be prepared to contribute to teaching and training doctors and students. He must make sure that all staff he manages has appropriate supervision.
• Systems-Based Practice (SBP): Doctors must be able to work effectively in various health care delivery settings and systems relevant to their clinical specialty. They should be able to provide effective health care in a cost effective manner and participate in identifying system errors and implementing potential systems solutions. They should continuously improve patient care based on constant self-evaluation and life-long learning. Doctor should protect patients and colleagues from any risk posed by his/her health. If they know or suspect that have a serious condition that they could pass on to patients, or if their judgment or performance could be affected by a condition or its treatment, then they must consult a suitably qualified colleague and follow his advice regarding any change in their practice, to avoid risk to the patients.
• Business and contractual obligations: doctors must not engage in any activities that adversely influences directly or indirectly on patient care. Business or contractual obligations should never interfere with clinical judgement and decisions or negatively affect patient care in anyway. Doctors should be discouraged for such activities that include’ financial inducements; sharing of fees including payments for patients referral for any lab investigations or other procedures except when an enterprise is publicly known.
• Reflect learn and teach others: Acquire, assess, apply and integrate new knowledge. Establish the foundations for lifelong learning and continuing professional development. Continually and systematically reflect on practice , Manage time and prioritize tasks, and work autonomously, Recognize own personal and professional limits, Function effectively as a mentor and teacher including contributing to the appraisal, assessment and review

How these attributes different from other countries
There is no single agreed definition of professionalism. It is dynamic process and vary according to
1. Cultural context, which include knowledge, beliefs, law, morals, habits and customs
2. Socio-economic Factors (Public expectations, Politics, Resources)
3. Traditional versus Contemporary (New Professionalism) Literature
Different regulatory bodies of different countries like Can MEDS 2015 of Canada 8, GMC of UK 9, Pakistan PMDC 5, Australia 10, and AGCME of USA have given certain standard attributes which there doctors must possess in order to practice. Worldwide most of the attributes are common to medical doctor and they act universally according to those standards in order to provide best possible care to their patients. But depending upon the above factors there are certain difference seen in these attributes of doctors across the globe.
According to cultural dimension theory 11 western culture countries like UK, Europe and North America where unequal power distribution is unacceptable patients consider doctors as equivalents, take active part in their treatment decision, and actively supply required information. Moreover, superior consultants and subordinates consider each other colleagues, teams members are open to give their opinion and expect to be consulted before decisions are made 11. While in eastern culture like in Pakistan patients treat doctors as superiors, and depend upon doctor for their treatment options. More over there is strong hierarchical culture exist in Pakistan and other eastern countries where consultant are taken as superior and other juniors have to follow them in patient care and other ward working. Moreover, in eastern countries like Pakistan, there is strong family bonding from birth onward (collectivist). Families play an important role in patient care, doctors are less assertive as compare to western well-developed countries which work as individualistic, where patient want to have one on one interaction with the doctor and share the responsibility of treatment along with his doctor13.
Another cultural difference is uncertainty-avoidance (strong vs. weak) which refers to how culture deals with flexibility, change and uncertainty. Eastern countries (Arabic Gulf region and Asian Subcontinent like Pakistan) avoid uncertainty. Due to this cultural difference doctors pay less attention on rapport building (e.g., less eye contact) with patients13, doctors may avoid ambiguity in diagnosis 14, and more money tends to be spent on doctors than nurses, thus more tasks are performed by doctors themselves 11. It indicates the extent to which the members of a culture feel threatened by uncertain, unknown or unstructured situations. As compare to this western countries deal with uncertainty, standards and guidelines followed strictly, people are more expressive 11 and patients are partner to doctors in their treatment plans.
Gender ethics have given importance in Pakistan because of cultural and religion difference while in western countries it is norm.
Showing altruism towards patients, considered important attribute in Asian countries including Pakistan and North America while in UK and Europe this attribute of doctors is not much important because of cultural and socioeconomic differences.
In Pakistan and North America doctor are accessible to their patients. In Pakistan, patients got appointments easily and even patients can consult their doctors on telephones. While in UK and Europe this attribute is not considered essential because of their cultural differences
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Teaching Professionalism
Professionalism, is important aspect of medical practice, It is the foundation of ”social contract” 15 between medical practice and society. The social contract expresses the society’s expectations of medicine and that of medicine’s to society. Hence, nature of medical professionalism directly influenced by social contract. Which in turn dependent upon cultural context of any country/.Although the basic role of healer is universal but how professionalism is expressed will differ among countries according to their social contract,. Therefore when professionalism is taught, it should be related to the national social contract and must be taught explicitly 15,16 is not as easy to teach as knowledge of medicine. Principles of professionalism should be clearly articulated at a programmatic or institutional level. Teaching of professionalism occurs best in as close to real life context as possible. Such strategy allows teachers to address real life scenarios and the informal or hidden elements of the curricula that emerge only in the course of daily practice.
Teaching the theoretical part of professionalism and providing opportunities for the internalization of its values and behaviors are the cornerstones for teaching of professionalism at all levels. Situated learning theory provide practical guidance for its implementation. Although the application of situated learning theory may vary with the nature of curriculum, the institutional culture, the principles outlined and the resources available, should remain constant.
Professionalism is essential to the social contract during which individuals gain the knowledge, skill, attitudes and values, and become the member of that culture 17,18. Situated learning theory suggests that teaching and learning must be entrenched in such authentic activities, which assist to transform knowledge from the intellectual and theoretical to the useful and usable. There must be a balance between explicit teaching of a subject and activities in which the knowledge learned is used in an authentic context 19.
Teaching the cognitive base of professionalism is not that difficult but to provide opportunities to learn through experience in an authentic context 19,20,21. is difficult to arrange. The institutional culture in this respect plays an important role. Number of forces within institution and health care system 19,22 influences the teaching of professionalism. Formal curriculum is an important factor which is reflected in institutional objective and mission statement and which teachers are supposed to teach formally 23,24. Another important factor is ‘informal curriculum’ that is unplanned, unscripted, and highly interpersonal forms of teaching and learning among and between students and faculty. Role modeling is an example of that which has profound effect either good or bad on attitudes of students and colleagues. . In addition, there is a set of influences which is largely hidden that function at the level of the organizational structure and culture. The informal and hidden curricula are partially responsible for the difference between what students are taught and what they actually learn 18. In order to bring a positive change in professional attitudes of students, a broad based faculty development programme with due attention to informal and hidden curricula is important 18,22.
The curriculum committee of the institution should ensure that adequate information on professionalism has been included in the undergraduate as well postgraduate courses. There should be allocation of resources like space, placing in timetable and faculty training. Institution should give due importance to professionalism. There is international consensus that it should be an important part of any medical curriculum 25.
Professionalism should be taught in a way that provide opportunities for gaining experience and reflecting on it 26,27 Students and residents should be taught through structured activities which help students and residents to learn and discuss professional issue and reflect upon them in safe environment. This help them to internalize values and ethics which help them to develop their professional identity and making them skillful professional. 28,22,29
Professionalism should be taught rigorously and explicitly throughout the academic years, from first year to final year, from dead bodies to real patient concerns. All the ethical issues that they come across during their educational years should be discussed and explained there and then to produce competent, ethical and professional doctors of tomorrow. So that they can deal effectively with growing biomedical and pharmaceutical companies’ pressure on doctors’ professionalism 31 Moreover they should be clear about their ethical values, so as to deal with conflicting situation of medical practitioner who is caught between their responsibilities to patient on one hand and the notion of entrepreneurship on other hand. Therefore teaching the teacher must be an integral part of medical education. To make sure that faculty have attain the required knowledge and skills to teach and role model professionalism, faculty development is necessary 11 The role must be made explicit to the role model as well as the student.
As a role model faculty should be aware of their role they should have effective knowledge and skill, good communication skills, sound clinical reasoning, respond actively to student’s needs, encourage self-learning and reflection in students and provide timely feed back to the students. In addition to these they should possess some important personal attributes like compassion and care, honesty and integrity, commitment to excellence, effective interpersonal skills and enthusiasm for the medical practice. They should be aware of a fact that they have to act as role model for students in every aspect of their life from classroom lectures to wards and clinic. Virtually any situation in which a student can observe a clinical teacher.32, The objective of this will be to create an environment within the institution form where students can learn positive attributes and can act as role models to their juniors.
Professionalism can be taught by, lectures, problem based learning, Hospital based clinical sessions, clinical skill laboratory, primary health care training sessions, field research projrcts, independent learning sessions, arranging courses on professionalism that include ethics, doctor patient relationship and moral reasoning. Literature, art and film can be used to teach elements of professionalism. Role modelling, case studies .and mentoring is another way to teach professionalism, negative role models inspire students more to improve their behaviors.
All medical and dental colleges running MBBS and BDS courses, College of Physician and Surgeons of Pakistan and universities running the postgraduate medical courses in Pakistan may incorporate medical ethics into their curriculum 33
Relevant books and journals shall be made available in the central and departmental libraries of the medical institutions, and publication of papers on issue related to medical ethics.
Once professionalism taught, its evaluation and assessment to ensure that its cognitive base has been learned and its values and standards are internalized and reflected by activities and performances must be recorded; The society must be confident of the competency and characteristics of graduates of both undergraduate and postgraduate programs. Medical profession has granted the honor of selfregulation, which necessitates that it established and maintain standards 34 As assessment drives learning. Therefore, regular, consistent and rigorous evaluation is crucial to meet this commitment, both as formative and summative assessment to provide evidence of the profession’s accountability.

The professionalism cognitive base can be assessed written assessment in form of MCQ/EMQ and modified essay questions. In addition, PBL learning sessions and individual assessment sessions, patients, survey, peer evaluation can also be used to asses students professionalism. Encouraging students to maintain portfolio of their daily practices and by reflecting upon it is another method used successfully to assess professionalism. Clinical part of their professionalism can be assessed in simulated environment by OSCE (Objective structured clinical examination) and in real life through workplace based assessments, DOPS, mini CEX, and 360 degree evaluation.
Therefore, teaching the professionalism should emphasize the recognition of its cognitive base that must be taught and evaluated explicitly and which in turn must be reinforced and internalized by the graduates through experiential learning. This necessitates a strong institutional and organizational commitment to support the educational program throughout the learning process. The medical professionalism is of paramount importance to both doctors and society as ”medical