Severe acute respiratory syndrome and its impact on professionalism: qualitative study of physicians' behaviour during an emerging healthcar
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《英国医生杂志》
1 Division of General Internal Medicine, University Health Network, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4, 2 Department of Haematology, University of British Columbia, Vancouver, BC, Canada V5Z 4E3
Correspondence to: S Straus sharon.straus@utoronto.ca
Abstract
Recently, medical educators have focused on professionalism with discussion centring on the erosion of competency in this area.1 2 Changes in healthcare systems—such as unionisation of physicians, conflicts of interest precipitated by managed care and for profit healthcare systems, and the role of the pharmaceutical industry in medical education—threaten the values of professionalism. Professional societies have attempted to meet these challenges and recently developed a charter on medical professionalism outlining three fundamental principles including the primacy of welfare of patients, autonomy of patients, and social justice.3 Professionalism was defined as those values that sustain the interests of the patients above the physician's own interests, including a wide range of attitudes and behaviours such as altruism, humility, commitment to excellence in care, honour and respect for others, integrity and compassion, and accountability to patients, colleagues, and society.
The recent outbreak of severe acute respiratory distress syndrome (SARS) allows an opportunity to explore medical professionalism in the context of a new emerging health threat. Stories of personal heroics of physicians who knowingly exposed themselves to contagious and often fatal illnesses with little understanding of the disease abound in history. Similarly history provides stories of physicians who avoided responsibility for treating such patients.4 For example, the emergence of AIDS led to fear about contact with infected patients and to concerns among some clinicians regarding their responsibilities to these patients.5-11 Even though relatively few patients were affected by SARS, the outbreak has been compared with experiences with HIV, smallpox, tuberculosis, and polio. However, it remains unique in the paucity of information about the disease (including its aetiology and mode of transmission) that was available during the outbreak. Moreover, its rapid clinical course, the necessity of providing care for affected colleagues, and the risk of occupational exposure posed unique challenges. All of these concerns affect physicians' response to this disease. We explored the impact of the recent SARS outbreak on healthcare professionalism.
Methods
Attention has focused recently on frustrations among physicians and medical educators because of threats to the values of medical professionalism. The SARS outbreak provided a unique opportunity to explore the impact of an emerging health threat on professionalism. Despite concerns about its erosion, clinicians involved with the SARS outbreak amply demonstrated these values.
Overall the participants thought that physicians exhibited professionalism, though they witnessed several examples of strained professional behaviour. These examples highlight aspects of medical professionalism that medical educators should address. Firstly, attention must be paid to exploring the balance between the clinician's personal safety and the needs of the patients, and these discussions should occur explicitly and early in the training process.13 Cruess and colleagues have suggested that individual physicians should consider the consequences of being seen to put self interests above those of patients.14 A recent survey of 500 house officers asked them to list the attributes of professionalism. Respondents commonly listed competence, respect, integrity, and responsibility, whereas putting patients' needs first was among the least commonly noted attributes.15 Secondly, clinicians should be encouraged to consider the interests of colleagues to enhance professional respect and collaboration. Thirdly, during similar outbreaks, ethical research must be carried out and clinicians who are caring for the patients being studied should be provided with the opportunity to participate fully. Fourthly, while professional values should be incorporated from the onset of the clinical career it should be described as an ideal to be constantly pursued. Finally, it has been suggested that a good way to teach professionalism is through role modelling,16 and those serving as role models need detailed knowledge of professionalism.13
The observation that there were instances of strained professional behaviour is not surprising.17 18 SARS presented the healthcare system with a new potentially catastrophic risk over which physicians believed they had little control and it aroused fear. Further contributing to this fear was the knowledge that healthcare workers had become ill as a result of occupational exposure, and some later died from the infection.
What is already known on this topic
Little is known about the impact of an emerging healthcare threat on medical professionalism
The SARS outbreak posed several distinct challenges, including the paucity of information about the disease that was available during the outbreak, the necessity of providing care for affected colleagues, and the risk of occupational exposure
What this study adds
The SARS outbreak challenged medical professionalism
Educators and professional organisations must advocate principles of professionalism, including the balance between personal safety and the needs of patients, professional respect and collaboration, the conduct of ethical research, and role modelling of professionalism to trainees
Limitations and strengths of this study
There are limitations to this study. Firstly, this study included only clinicians from university affiliated institutions. The institutions selected for inclusion were those that provided care for almost half of the patients affected with SARS during the initial outbreak in Toronto. Their experiences may not reflect those of physicians working in other settings elsewhere. Secondly, we included only physicians and thus cannot describe the experiences of other healthcare professionals. However, nurses and support staff were the predominant participants in a study evaluating the psychological impact of SARS at a university affiliated hospital in Toronto that found similar results.19
This study is unique in that it provides an in depth exploration of the impact of SARS on medical professionalism. While several studies have explored the experiences of clinicians during the initial experience with HIV,8-10 there is little rigorous qualitative literature on the impact on professionalism of caring for patients with serious infectious diseases. Moreover, this study was completed during a rapidly emerging crisis and therefore we were able to capture physicians' reflections in the immediate setting.
Conclusions
Physicians should be proud of the professionalism displayed during the recent SARS outbreak. However, professional organisations and medical educators must continue to advocate the principles of professionalism, physicians must understand the obligations necessary to sustain professionalism, and we must all strive to role model this behaviour to our students.
We thank W Levinson, W Sibbald, and D Davis for their comments on the study design and earlier drafts of the manuscript and the clinicians who participated in this study.
Contributors: SES developed the idea for the study in collaboration with WLG, MKK, YL, GR, and KW. DR conducted all interviews; SES and GR completed the analysis. SES drafted the initial manuscript and all investigators were involved with revising it. SES is the guarantor for the paper.
Funding: SES is supported by a Career Scientist Award from the Ontario Ministry of Health and by the Knowledge Translation Program at the University of Toronto; KW is supported by a New Investigator Award from the Canadian Institutes of Health Research; MKK is supported by a Research Scholarship from the Canadian Stroke Network and the University Health Network Women's Health Program.
Ethical approval: Ethics approval was obtained from the Ethics Review Boards of the University Health Network and Sunnybrook and Women's College Health Sciences Centre.
References
Misch DA. Evaluating physicians' professionalism and humanism: the case for humanism "connoisseurs." Acad Med 2002;77: 489-95.
Barondess J. Medicine and professionalism. Arch Intern Med 2003;163: 145-9.
Project of the ABIM foundation, ACP-ASIM foundation, and the European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136: 243-6.
Zuger A, Miles SH. Physicians, AIDS and occupational risk. JAMA 1987;258: 1924-8.
Ha KG, Cohen DJ. From plague and tuberculosis to AIDS: a reflection on the medical profession. Tex Med 1991;87: 76-80.
Cohn JA, Warren JW. The HIV epidemic and the primary care physician. MD Med J 1991;40: 185-90.
Emanuel EJ. Do physicians have an obligation to treat patients with AIDS? N Engl J Med 1988;318: 1686-90.
Link RN, Feingold AR, Charap MH, Freeman K, Shelov SP. Concerns of medical and pediatric house officers about acquiring AIDS from their patients. Am J Pub Health 1988;78: 455-9.
Harsh ES, Cromwell G, Ferentz KS, DeForge B. HIV in Maryland. Experiences and attitudes of family physicians. Med Care 1991;29: 1051-6.
Roderick P, Victor R, Beardow R. Developing care in the community: GPs and the HIV epidemic. AIDS Care 1990;2: 126-32.
Loewy EH. Duties, fears and physicians. Soc Sci Med 1986;22: 1363-6.
Mays N, Pope C, eds. Qualitative research in health care. London: BMJ Publishing, 1999.
Cruess SR, Cruess RL. Professionalism must be taught. BMJ 1997;315: 1674-7.
Cruess SR, Johnston S, Cruess RL. Professionalism for medicine: opportunities and obligations. Med J Aust 2002;177: 208-11.
Brownell AK, Cote L. Senior residents' views on the meaning of professionalism and how they learn about it. Acad Med 2001;76: 734-7.
Reynolds PP. Reaffirming professionalism through the education community. Ann Intern Med 1994;120: 609-14.
Slovic P. Perception of risk. Science 1987:236; 280-5.
Gray GM, Ropeik DP. Dealing with the dangers of fear: the role of risk communication. Health Aff (Millwood) 2002;21: 106-16.
Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ 2003;168: 1245-51.(Sharon E Straus, assistan)
Correspondence to: S Straus sharon.straus@utoronto.ca
Abstract
Recently, medical educators have focused on professionalism with discussion centring on the erosion of competency in this area.1 2 Changes in healthcare systems—such as unionisation of physicians, conflicts of interest precipitated by managed care and for profit healthcare systems, and the role of the pharmaceutical industry in medical education—threaten the values of professionalism. Professional societies have attempted to meet these challenges and recently developed a charter on medical professionalism outlining three fundamental principles including the primacy of welfare of patients, autonomy of patients, and social justice.3 Professionalism was defined as those values that sustain the interests of the patients above the physician's own interests, including a wide range of attitudes and behaviours such as altruism, humility, commitment to excellence in care, honour and respect for others, integrity and compassion, and accountability to patients, colleagues, and society.
The recent outbreak of severe acute respiratory distress syndrome (SARS) allows an opportunity to explore medical professionalism in the context of a new emerging health threat. Stories of personal heroics of physicians who knowingly exposed themselves to contagious and often fatal illnesses with little understanding of the disease abound in history. Similarly history provides stories of physicians who avoided responsibility for treating such patients.4 For example, the emergence of AIDS led to fear about contact with infected patients and to concerns among some clinicians regarding their responsibilities to these patients.5-11 Even though relatively few patients were affected by SARS, the outbreak has been compared with experiences with HIV, smallpox, tuberculosis, and polio. However, it remains unique in the paucity of information about the disease (including its aetiology and mode of transmission) that was available during the outbreak. Moreover, its rapid clinical course, the necessity of providing care for affected colleagues, and the risk of occupational exposure posed unique challenges. All of these concerns affect physicians' response to this disease. We explored the impact of the recent SARS outbreak on healthcare professionalism.
Methods
Attention has focused recently on frustrations among physicians and medical educators because of threats to the values of medical professionalism. The SARS outbreak provided a unique opportunity to explore the impact of an emerging health threat on professionalism. Despite concerns about its erosion, clinicians involved with the SARS outbreak amply demonstrated these values.
Overall the participants thought that physicians exhibited professionalism, though they witnessed several examples of strained professional behaviour. These examples highlight aspects of medical professionalism that medical educators should address. Firstly, attention must be paid to exploring the balance between the clinician's personal safety and the needs of the patients, and these discussions should occur explicitly and early in the training process.13 Cruess and colleagues have suggested that individual physicians should consider the consequences of being seen to put self interests above those of patients.14 A recent survey of 500 house officers asked them to list the attributes of professionalism. Respondents commonly listed competence, respect, integrity, and responsibility, whereas putting patients' needs first was among the least commonly noted attributes.15 Secondly, clinicians should be encouraged to consider the interests of colleagues to enhance professional respect and collaboration. Thirdly, during similar outbreaks, ethical research must be carried out and clinicians who are caring for the patients being studied should be provided with the opportunity to participate fully. Fourthly, while professional values should be incorporated from the onset of the clinical career it should be described as an ideal to be constantly pursued. Finally, it has been suggested that a good way to teach professionalism is through role modelling,16 and those serving as role models need detailed knowledge of professionalism.13
The observation that there were instances of strained professional behaviour is not surprising.17 18 SARS presented the healthcare system with a new potentially catastrophic risk over which physicians believed they had little control and it aroused fear. Further contributing to this fear was the knowledge that healthcare workers had become ill as a result of occupational exposure, and some later died from the infection.
What is already known on this topic
Little is known about the impact of an emerging healthcare threat on medical professionalism
The SARS outbreak posed several distinct challenges, including the paucity of information about the disease that was available during the outbreak, the necessity of providing care for affected colleagues, and the risk of occupational exposure
What this study adds
The SARS outbreak challenged medical professionalism
Educators and professional organisations must advocate principles of professionalism, including the balance between personal safety and the needs of patients, professional respect and collaboration, the conduct of ethical research, and role modelling of professionalism to trainees
Limitations and strengths of this study
There are limitations to this study. Firstly, this study included only clinicians from university affiliated institutions. The institutions selected for inclusion were those that provided care for almost half of the patients affected with SARS during the initial outbreak in Toronto. Their experiences may not reflect those of physicians working in other settings elsewhere. Secondly, we included only physicians and thus cannot describe the experiences of other healthcare professionals. However, nurses and support staff were the predominant participants in a study evaluating the psychological impact of SARS at a university affiliated hospital in Toronto that found similar results.19
This study is unique in that it provides an in depth exploration of the impact of SARS on medical professionalism. While several studies have explored the experiences of clinicians during the initial experience with HIV,8-10 there is little rigorous qualitative literature on the impact on professionalism of caring for patients with serious infectious diseases. Moreover, this study was completed during a rapidly emerging crisis and therefore we were able to capture physicians' reflections in the immediate setting.
Conclusions
Physicians should be proud of the professionalism displayed during the recent SARS outbreak. However, professional organisations and medical educators must continue to advocate the principles of professionalism, physicians must understand the obligations necessary to sustain professionalism, and we must all strive to role model this behaviour to our students.
We thank W Levinson, W Sibbald, and D Davis for their comments on the study design and earlier drafts of the manuscript and the clinicians who participated in this study.
Contributors: SES developed the idea for the study in collaboration with WLG, MKK, YL, GR, and KW. DR conducted all interviews; SES and GR completed the analysis. SES drafted the initial manuscript and all investigators were involved with revising it. SES is the guarantor for the paper.
Funding: SES is supported by a Career Scientist Award from the Ontario Ministry of Health and by the Knowledge Translation Program at the University of Toronto; KW is supported by a New Investigator Award from the Canadian Institutes of Health Research; MKK is supported by a Research Scholarship from the Canadian Stroke Network and the University Health Network Women's Health Program.
Ethical approval: Ethics approval was obtained from the Ethics Review Boards of the University Health Network and Sunnybrook and Women's College Health Sciences Centre.
References
Misch DA. Evaluating physicians' professionalism and humanism: the case for humanism "connoisseurs." Acad Med 2002;77: 489-95.
Barondess J. Medicine and professionalism. Arch Intern Med 2003;163: 145-9.
Project of the ABIM foundation, ACP-ASIM foundation, and the European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136: 243-6.
Zuger A, Miles SH. Physicians, AIDS and occupational risk. JAMA 1987;258: 1924-8.
Ha KG, Cohen DJ. From plague and tuberculosis to AIDS: a reflection on the medical profession. Tex Med 1991;87: 76-80.
Cohn JA, Warren JW. The HIV epidemic and the primary care physician. MD Med J 1991;40: 185-90.
Emanuel EJ. Do physicians have an obligation to treat patients with AIDS? N Engl J Med 1988;318: 1686-90.
Link RN, Feingold AR, Charap MH, Freeman K, Shelov SP. Concerns of medical and pediatric house officers about acquiring AIDS from their patients. Am J Pub Health 1988;78: 455-9.
Harsh ES, Cromwell G, Ferentz KS, DeForge B. HIV in Maryland. Experiences and attitudes of family physicians. Med Care 1991;29: 1051-6.
Roderick P, Victor R, Beardow R. Developing care in the community: GPs and the HIV epidemic. AIDS Care 1990;2: 126-32.
Loewy EH. Duties, fears and physicians. Soc Sci Med 1986;22: 1363-6.
Mays N, Pope C, eds. Qualitative research in health care. London: BMJ Publishing, 1999.
Cruess SR, Cruess RL. Professionalism must be taught. BMJ 1997;315: 1674-7.
Cruess SR, Johnston S, Cruess RL. Professionalism for medicine: opportunities and obligations. Med J Aust 2002;177: 208-11.
Brownell AK, Cote L. Senior residents' views on the meaning of professionalism and how they learn about it. Acad Med 2001;76: 734-7.
Reynolds PP. Reaffirming professionalism through the education community. Ann Intern Med 1994;120: 609-14.
Slovic P. Perception of risk. Science 1987:236; 280-5.
Gray GM, Ropeik DP. Dealing with the dangers of fear: the role of risk communication. Health Aff (Millwood) 2002;21: 106-16.
Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ 2003;168: 1245-51.(Sharon E Straus, assistan)