Domain 4 Professional and ethical role

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

The professionalism of general practitioners (GPs) is a major contributor to general practice being considered one of the most trusted professions by the community at large.1,2 The maintenance of individual professional standards protects the reputation of the profession as a whole and is considered as important as high standards of medical care.3,4 However, one of the significant challenges facing GPs when discussing professional and ethical behaviour is that there is no simple definition of this. Being ‘professional’ is not a technical or simple skill to learn and assess through a series of checklists.5 Professional and ethical behaviour needs to be adapted to the circumstances and embraced as complex and multidimensional. GPs need to consider what the core issues of professionalism are for each context; for example, ensuring that the patient’s health-related interests remain the primary concern,6 and then expand these to logically detail the professional and ethical principles relevant for the situation.7

For centuries, doctors, including GPs, have had a social contract with the community. In return for status and financial rewards, clinicians meet the needs of society through service and altruism.8 Professionalism is about upholding this social contract. It involves building trust between the GP and the patient. This includes intellectual trust, which is the GP’s commitment to scientific and clinical excellence, and moral trust, which is the commitment of GPs and healthcare organisations to protect and promote the health and interests of patients before other interests.6,7 This responsibility also includes treating all people, including patients, their families and carers, colleagues, and other healthcare workers, with dignity, courtesy, respect and compassion.3 GPs are also expected to display attributes such as integrity, truthfulness, commitment to patient safety, confidentiality, respect for cultural differences, self-awareness and reflective practice.9 The maintenance of appropriate patient–doctor boundaries is also required;9 however, this can be challenging for GPs when they are working in rural practice and need to provide healthcare to other GPs or close friends or neighbours. Maintaining boundaries is also a challenge in other areas, such as in the context of mandatory reporting or in the use of social media. Meeting high standards of ethical and professional behaviour increases patient trust and ultimately patient care, and improves workplace harmony, making it a vital element of general practice.1

As is the case with medical knowledge, professional values are not static and continue to evolve over time in response to societal demands and expectations.8,9 GPs are expected to continually develop their professional knowledge, skills and attributes throughout their career.9 This requires GPs to engage in self-reflection and identify and act on areas for development. They are also expected to acknowledge and learn from errors,10 and to engage in honest, open disclosure about adverse events.11,12
GPs can experience stress and isolation due to their career.13 Experiences of isolation are particularly common for those working in rural and remote areas, and those working in after-hours general practices. There are strategies to help mitigate the stress of being a GP, such as attending to physical and mental wellbeing and developing good self-care habits, and these are explored further in the Doctors’ health unit.

A GP’s personal awareness and reflection on their cultural identity impacts on clinical interactions and healthcare service delivery. This might be when interacting with Aboriginal and Torres Strait Islander peoples and people from culturally and linguistically diverse backgrounds, for example. GPs therefore need to actively identify and seek to address their own biases, judgements, assumptions and attitudes. Ongoing cultural competency training14 and partnering with Aboriginal and Torres Strait Islander peoples and healthcare workers from culturally and linguistically diverse communities is vital to meeting professional and societal expectations.

In addition to continuing to grow their own professional knowledge and skills, GPs might also be called upon to educate their peers and other health professionals and provide education for local community groups. Some GPs might be interested in acquiring skills to become GP supervisors or medical educators,15 and all GPs need to engage in patient education in their daily practice.

References
  1. Ahpra Medical Board. Doctors the most trusted profession: Board research. Melbourne: Ahpra, 2016 [Accessed 24 November 2021].
  2. Michael C. Doctors become the world’s most trusted profession. London: Ipsos MORI, 2021 [Accessed 25 November 2021].
  3. Longman C, Temple-Smith M. Promoting professional behaviour in general practitioner training practices: The views of practice managers. Aust J Gen Pract 2019;48(6). doi: 10.31128/AJGP-11-18-4765.
  4. Ahpra & National Boards. Regulatory Guide: June 2020. Melbourne: Ahpra, 2020 [Accessed 24 November 2021].
  5. Lucey C, Souba W. Perspective: The problem with the problem of professionalism. Acad Med, 2010. 85(6):1018–24. doi: 10.1097/ACM.0b013e3181dbe51f.
  6. McCullough LB, Coverdale JH, Chervenak FA. Trustworthiness and Professionalism in Academic Medicine. Acad Med 2020;95(6):828–32. [Accessed 25 November 2021].
  7. Brody H, Doukas D. Professionalism: A framework to guide medical education. Med Edu 2014;48(10):980–87. [Accessed 24 November 2021].
  8. Bhugra D. Medicine’s contract with society. J R Soc Med 2014;107(4):144–47. doi: 10.1177%2F0141076814525068.
  9. Medical Board of Australia. Good medical practice: A code of conduct for doctors in Australia. Melbourne: MBA, 2014 [Accessed 10 November 2021].
  10. Hodges BD, Robert P, Ginsbury S, The Ottawa Consensus Group Members. Assessment of professionalism: From where we have come – to where are we going? An update from the Ottawa Consensus Group on the assessment of professionalism. Med Teach 2019;41(3):249–55 [Accessed 25 November 2021].
  11. Sturman NJ, Saiepour N. Ethics and professionalism in general practice placements: What should students learn? Aust Fam Physician 2014;43(7):468–72 [Accessed 10 November 2021].
  12. Australian Commission on Safety and Quality in Health Care. Australian Open Disclosure Framework – Better communication, a better way to care. Sydney: ACSQHC, 2013 [Accessed 10 November 2021].
  13. Beyond Blue. National Mental Health Survey of Doctors and Medical Students. Hawthorn, Vic: Beyond Blue, 2013 [Accessed 10 November 2021].
  14. Brown J, Kirby C, Wearne S, Snadden D. Remodelling general practice training: Tension and innovation. Aust J Gen Pract 2019;48(11):773–778. doi: 10.31128/AJGP-05-19-4929.
  15. Farrell E, Cooke G. Registrar medical educators--experiences in the Australian General Practice Training Program 2005-11. Aust Fam Physician 2012;41(6):430–32 [Accessed 10 November 2021].

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP. These are expressed as core competencies that are required of a GP across all clinical consultations, interactions and contexts. These core competencies are further detailed as measurable core competency outcomes.

Professional and ethical role
Core competencies Core competency outcomes
  The GP is able to: 
  1. GPs are ethical and professional
  1. adhere to relevant codes and standards of ethical and professional behaviour
  2. maintain duty of care
  3. identify and manage critical incidents and potential critical incidents including appropriate use of open disclosure practices
  4. display a positive and professional demeanour
  5. recognise and preserve therapeutic boundaries in an ethical and professional manner
  1. GPs are self-aware
  1. identify and act on areas for professional development
  2. undertake regular self-reflective practice and appraisal
  3. demonstrate a positive personal health and wellbeing outlook
  4. show awareness of the influence that their values and behaviour have on others
  5. implement an ongoing plan to overcome professional isolation

Aboriginal and Torres Strait Islander health
  1. demonstrate awareness of their own cultural identity and the impact of this on clinical interactions and healthcare service delivery
  2. identify and actively seek to redress their own biases, judgements, assumptions and attitudes
  3. identify and promote strategies for responding to systemic racism in healthcare services
Rural health
  1. implement an ongoing plan to overcome professional geographical isolation
  2. be prepared, resourceful and adaptive to challenges that arise in geographic and professional isolation
  3. identify and acquire extended, or specific local knowledge to meet the healthcare needs of their community
  1. GPs mentor and teach
  1. share professional knowledge and experience with others
  2. utilise formal and opportunistic activities to engage in GP teaching and mentoring
  3. identify and ethically support colleagues and co-workers in difficulty

Aboriginal and Torres Strait Islander health 
  1. engage with and support Aboriginal and Torres Strait Islander cultural education
  2. promote the professional development and support of the Aboriginal and Torres Strait islander health workforce
  1. GPs participate in evaluation and research
  1. apply critical analysis skills to medical and grey literature
  2. participate in regular evaluations of clinical care, including appropriate clinical governance, incident review and clinical audits

Aboriginal and Torres Strait Islander health
  1. engage and support Aboriginal and Torres Strait Islander health research
  2. promote the use of Indigenous research methods and support for the AIATSIS Code of Ethics for Aboriginal and Torres Strait Islander Research

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Domain 4 Professional and ethical role

Maria, a regular patient of your colleague, comes to see you with a persistent cough. She asks about the results of a mammogram and ultrasound that were organised three weeks ago, as she had a breast lump. She thinks the lump is smaller, although still present, and has assumed that the results were alright, as she has not heard from your colleague. You cannot find any results in her notes. You contact the radiology provider, and the results indicate potential malignancy.

Questions for you to consider Clinical exam assessment area Domains

What will you say to Maria about the lack of follow up? How will you explore Maria’s understanding of the incident?

How will you discuss this incident with your colleague? What if your colleague is your supervisor?

If your colleague becomes defensive or angry, how will you manage that?

  1. Communication and consultation skills
1,2,5
 

What other information would you like in relation to this incident? Are there any other sources you could collect information from?

How will you ensure you explore your colleague’s perspectives?

  1. Clinical information gathering and interpretation
2   

On further questioning, your colleague admits to feeling stressed recently and having difficulty sleeping. What health and wellbeing issues for your colleague might you consider at this stage?

  1. Making a diagnosis, decision making and reasoning
2   

What needs to be considered in managing the incident from the perspective of Maria, your colleague and the practice?

  1. Clinical management and therapeutic reasoning
2   

If after talking to your colleague, you have concerns about their clinical practice, would you discuss this with anyone else in the practice? If so, who?

What other resources/groups might you suggest your colleague contact for further support or advice?

  1. Preventive and population health
1,2,3      

 

Your colleague asks you for a script to help with sleeping, which is worse since this incident. How might you manage this request?

What is your approach to requests for medication from colleagues or practice staff?

What if you were working in a remote rural area and your colleague was unable to access another GP for support?  

  1. Professionalism
4   

What documentation would you complete in relation to this incident?

What practice systems are there for managing near misses or critical incidents?

What are the requirements for mandatory notification of health professionals? Would you need to notify in this situation? What if you were concerned your colleague was misusing medication? 

  1. General practice systems and regulatory requirement
5   

N/A

  1. Procedural skills
2   

How would you manage the consultation if Sam told you she isn’t sure that she wants to participate in health screening?

  1. Managing uncertainty
2   

N/A

  1. Identifying and managing the significantly ill patient
2

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Professional and ethical issues are never resolved with a one-size-fits-all approach. You need to tailor your approach and consider the unique circumstances of each situation. Similarly, there is rarely a ‘gold standard’ way of dealing with a situation, but rather several reasonable courses of action, some of which can be done simultaneously. Be prepared to be responsive. As circumstances change, you also need to change your approach.
  2. Professionalism is often learnt through reflective observation. You will see clinicians behaving with professionalism, and sometimes you will see unprofessional behaviour. Identify and reflect on both ‘good’ and ‘bad’ behaviour, and consider your own behaviour in light of these reflections. Talk with trusted colleagues or mentors about your reflections. Often the act of verbalising what you’ve observed can help clarify the issues and identify the best path forward.
  3. Listen to your inner monologue about professionalism issues. If you feel uncomfortable about a situation, or if you are about to do something that you wouldn't be comfortable to record in your notes or tell a peer about, then it is probably bordering on unprofessional behaviour. Equally, if what you are about to do is significantly different to the approach of your colleagues and peers, then stop and consider why that is. Remember that although ethical behaviour and medico-legal concerns are often considered together, just because something is legal (ie self-prescribing in certain states) doesn’t make it ethical professional practice.
  4. Reflect on some of the overarching causes of unprofessional behaviour. These include not understanding the role of a GP, having role conflict (eg being a parent and a doctor and struggling to manage the boundaries between the two), breaching boundaries with patients or being unmotivated to fulfil the role properly. Understand that unprofessional behaviour will impact on your practice. Many contacts with AHPRA are related to these issues. It is important to devote the time and energy to gain a deep understanding of professional practice, not just for your exam, but for your entire career.
  5. Receiving feedback is hard. Most GPs want to do the best by their patients and colleagues, and no one likes to hear that they could have done better. But we are all susceptible to making mistakes and could improve in some areas, so it’s important to have an open mind and be willing to change. Although it’s hard, this will definitely help you become a better doctor. Again, having someone (medical or non-medical) to talk to is helpful.
  6. General practice requires lifelong learning to keep up to date with changes and to maintain excellence in clinical care. Identify your learning needs and focus your professional development in those areas. Engaging in learning is a sign of professional behaviour.
  7. As doctors, we have an ethical and professional responsibility to look after ourselves so we can provide care for our patients. Review the doctors’ health unit for tips and strategies.

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Identify your ethical duty of care obligations; for example, notification of disease, detaining a patient under a mental health act, mandatory reporting for child protection, fitness to practice for medical professionals, and fitness to drive.

  • What are your obligations? How and where would you report in each of these areas?
  • What are the barriers to you reporting? How do you overcome these?

Reflect on a near miss or critical incident that you were involved in. If you feel comfortable, tell a supervisor, friend or mentor about the situation and what you learnt.

  • How did you feel after the incident? What did you learn from this situation? How have you changed your practice as a result?

Reflect on hypothetical patient scenarios that might make you feel uncomfortable because they raise conflicts with your personal or ethical principles. For example, a patient presenting for voluntary assisted dying, a patient with seven children refusing contraception, a parent refusing vaccination for their child, a perpetrator of domestic violence or sexual abuse, or a request for termination of pregnancy. You could also reflect on other patients that could challenge you such as a patient misusing drugs or a patient who is unemployed.

  • How do these situations make you feel?
  • How do you manage the tension or conflict between these issues and your ethical principles? What strategies could you use to help manage these situations?

Think about a role model you admire. Describe the characteristics of that role model.

  • What are the attributes (ie knowledge, skills and behaviours) of the role model you admire?
  • What could you do to become more like that person? What changes do you need to make?
With a supervisor
Ask for feedback from your supervisor. This might be on consulting skills, teamwork within the practice, development of management plans, etc. Practise actively listening to what they say. Ask further probing questions or ask for examples if you don’t understand. Identify what you can do to improve. Take some time to think about this.
  • How did you feel during the feedback session? What made the feedback easier or harder to listen to?
  • Are you clear on where you could improve? What changes can you make next time? How can you go about seeking regular feedback during the term? Can you identify any other sources of feedback? Could you undertake multisource feedback from other colleagues?
Read the Medical Board of Australia’s Good medical practice – code of conduct (see learning resources section). Make a list of five things that you learnt from this code. Discuss these with your supervisor.
  • What did you learn? Was there anything in the code that surprised you? How will you incorporate this into your practice?
  • If you were a supervisor orientating a new doctor to Australian general practice, what key things would you highlight?
Observe your supervisor consulting. Focus on the aspects of professionalism in the consultation.
  • What were the aspects of professionalism you observed in the consultation? Discuss these with your supervisor. Did they think you missed any? What did they do well?
  • What can you learn from this observation? How can you incorporate that into your practice?
Discuss with your supervisor the issues of maintaining boundaries with patients. This is especially challenging in rural areas. Look through the learning resources section. What information did you find to help you manage these boundaries?
  • How does your supervisor manage professional boundaries?
  • Are there ‘hard boundaries’ and ‘soft boundaries’?
  • How can you be self-aware of your boundaries?
What can you do if you are concerned there is a crossing of boundaries?
In a small group

Role-play a patient asking for a medical certificate and then discuss as a group. Consider the following scenarios:

  1. A patient who is resisting having a mandatory vaccination for their work and would like to go on sick leave while they think about this.
  2. A new patient who has long-standing back pain requesting three weeks’ leave because that is usually how long it takes for them to recover.
  3. A person who is retiring next year and has 100 days of sick leave. They want to use some of their sick leave to go on a holiday for three weeks; and their boss has said it was fine to use sick leave and to just to get a medical certificate from their doctor.
  • When were your views different from your peers? Why might your peers think the way they do?
  • In what situations is it appropriate to give a medical certificate? In what situations is it not appropriate?
  • What if the scenarios changed slightly? For example, the patient resisting vaccination only wanted three days’ sick leave, or they had significant mental health issues.
  • What are your legal obligations around giving medical certificates?
  • How did you manage these consultations?

Consider the following scenarios and identify the issues related to professional and ethical behaviour:

  1. A reception staff member books an appointment with you to obtain a pathology form for a blood test that their naturopath has requested.
  2. A doctor approaches you in the corridor asking for a script for the contraceptive pill.
  • What issues do these situations raise? How do you manage these situations? How do your peers manage these situations? Do these scenarios breach professional boundaries?
  • What strategies might help if you are faced with these situations in the future?

Discuss the following cases about social media use:

  1. A medical student who wrote on a medical students’ private WhatsApp group a funny story about a patient he had seen in the emergency department, and then shared the story on his Facebook page. The patient’s name wasn’t used, but their symptoms and circumstances were.
  2. Accepting a friend request from a patient.
  3. Tweeting a photo at work on Monday morning with the caption: ‘This is why you should never drink on a Sunday night #hatemondays'.
  4. Talking about patients (in a de-identified manner) on a private Facebook group.

Once you’ve discussed these, go to the following two websites to see the perspective of the UK General Medical Council (GMC), which discusses these cases in detail:
Social media use - case study
Dr Walter scenario 2 case study

  • What did you think about these situations? What was acceptable or unacceptable behaviour? Was there disagreement in the group? How did this compare to the UK GMC advice?
  • How will you approach these situations in the future?
With a friend or family member

Read a Cochrane Review on a management topic in your learning plan; for example, management of basal cell carcinomas in elderly patients or evidence-based weight loss treatment. Explain the research findings to a friend or family member in a language they understand. Then read the plain language summary together and compare this to your explanation. Get feedback from your family member/friend.

  • Did you understand the research findings?
  • How did you go explaining these? Did you family member/friend understand them?
  • How could you use this information in your clinical practice?
  • How could you improve your explanations of the rationale for management in the future?

Talk about signs of burnout and when you might need help.

  • What are the signs that you might need help? Are these different to signs other people might exhibit?
  • How can you recognise that you might not be functioning at optimal capacity? How could you be more self-aware of your need for help?

Discuss the idea of professionalism and ethical behaviour with a friend or family member.

  • What sorts of behaviours do they consider to be professional? What sorts of behaviours to be unprofessional?
  • What do they think is the role of the GP in terms of advocacy for health system change?
  • What changes could you make to your practice as a result of your discussion?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Know and adhere to relevant standards of practice, such as:
    • Good medical practice (AHPRA guidelines)
    • Medical Board of Australia registration
    • Code of Ethics (AMA):
    • duty of care in mandatory notifications:
      • disease notification
      • child protection
      • medical practitioner fitness to practice
      • fitness to drive
      • assessment of patients under a mental health act
      • substitute decision-making.
  • Understand the principles of ethical practice, with particular reference to:
    • behaving professionally with patients, colleagues and staff in the practice
    • maintaining professional boundaries and being aware of transference and countertransference
    • setting boundaries when treating family and colleagues
    • supporting colleagues in difficulty
    • mandatory reporting of colleagues, including when it is and is not indicated
    • understanding the right of patients to be fully informed and their right to self-determination
    • respecting a patient’s culture and values, and being aware of how these have an impact on the therapeutic relationship
    • recognising various conflict of interest scenarios, including attending funded events, meeting with pharmaceutical representatives, or promoting goods and services in which the GP has a financial interest
    • understanding and working within the Australian healthcare system.
  • Demonstrate reflective skills, be self-aware and embrace learning, including:
    • regular reflection and evaluation of one’s own strengths, limitations, and knowledge gaps
    • understanding the need for lifelong learning and to maintain professional standards
    • planning meaningful learning to address learning needs
    • identifying critical incidents
    • demonstrating a willingness to learn from mistakes
    • managing patient feedback and complaints to improve care.
  • Fulfil the role of teacher, leader and change agent to contribute to the development of general practice.
  • Maintain personal health and wellbeing by:
    • managing personal and professional isolation
    • understanding psychological issues affecting doctors, such as stress, depression, burnout, addiction and dysfunctional interpersonal relationships
    • maintaining one’s own health through self-awareness and self-care
    • dealing with one’s own reactions to patients and daily problems
    • developing personal and professional support mechanisms.
  • Be engaged in research and evaluation, including:
    • demonstrating research, evaluation and audit skills
    • understanding and participating in research, as appropriate.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
Ethical issues in the case of a doctor who is alleged to be performing poorly. Three articles on maintaining boundaries with patients. The second is written for psychologists but is still relevant to GPs. Ethical issues in liaising with the pharmaceutical industry and conflicts of interest. Disclosing errors to the patient. Issues in refusal of treatment. Ten tips to help you receive and act on feedback. Insights into why patients complain and how to manage these complaints (from the UK).
Textbooks
How to thrive in medicine during advances and changes in global health systems and medical services.
  • Rowe L, Kidd M. Every Doctor: Healthier doctors = healthier patients. Boca Raton, FL: CRC Press, 2018. (Available from the RACGP library.)
Online resources
AMA guide to social media, including case studies and tips about managing social media as a doctor. A clear description of the standards of ethical and professional conduct expected of all doctors in Australia. Resources to support doctors in difficulty, including articles, guidelines and podcasts.
Learning activities
How to navigate situations in which a GP needs to exercise their ethical and legal obligations.
  • The Royal Australian College of General Practitioners. gplearning:
    • Ethical and legal considerations in general practice MCQs
A series of ethical dilemmas written by GP supervisors with notes from MDA National (a medical indemnity insurance provider). Sections 2, 6 and 7 of this UK guide are helpful in understanding what a reflective practitioner is and why they are important.
Other
A 20-minute podcast on how to receive feedback.
  • MacEmerg Podcast. Episode 18 – start at 1:00:00.
Case studies that outline when and when not to make a mandatory notification of a medical practitioner. More resources related to doctors’ health are available in the Doctors’ health unit.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/domain-4 28/06/2022