A personal reflection on professional Integrity through the lens of a program director

By:  Jamiu Busari

As a Clinician Educator and residency program director, one of my duties is to conduct periodic assessment meetings with our residents.  The purpose of these meetings is twofold, namely to monitor the progress of our residents’ performance and provide feedback and to provide periodic judgment of professional growth of residents during their training. These encounters usually last between 30- 60 minutes, depending on the specific needs of the residents. The frequency of these meetings is four times a year.

The content of what we discuss and the parties involved also vary depending on whether it is an informal (formative) meeting (one-on-one sessions) or the formal (summative) session and for which the resident’s mentor or deputy program director is also invited to be part of the meeting.

These periodic progress meetings constitute part of the competency-based curriculum of the Dutch postgraduate training and are crucial for the professional development of our residents (16 in total in various stages of training).  As a program director, I usually look forward to these meetings and make sure that I am well prepared whether the encounter is formative or summative.  The meetings I enjoy most are the informal ones that involve just the resident and me.  These sessions are usually loosely structured, organic in nature with the outcomes or learning points evolving spontaneously from the discourse.  What I particularly like about these sessions is that it not only provides the residents the opportunity to explore those areas where they need additional support, but it also provides me with the opportunity to reflect and gain new insights into my own professional competencies.

The topics we discuss during these conversations are diverse, ranging from disease-specific, clinically related issues to dilemmas in interprofessional collaboration, resident leadership responsibilities, and patient-related health advocacy issues. A topic I recently discussed with one of our residents was professional integrity, and it struck me as an interesting one, as it coincided with the then volatile political campaigns in the run-up to the US presidential elections. Coincidence or not, the current debate at the time created the ideal context for us to reflect on our professional roles and responsibilities as physicians, especially about the patients we serve.

What followed between my resident and I was an exploration our understanding of integrity in health care and what it meant for us as professionals in the process of teaching, learning and practice.  Not too long before this encounter, I had written a reflection on professional integrity within health care, and I was particularly interested in the views of the resident about his current training.

Integrity as a concept can be described as a quality (or state) of being complete or faultless.  Evolving from the Latin adjective “integer”, integrity refers to the state of being “whole.” When translated to our behaviors as physicians, it is best described as the state of being correct, exhibiting high moral principles and being consistent all the time (i.e. moral uprightness).  We took a closer look at this definition through the lens of how health care is currently organized in our (and many other) institution(s), the conflicting interests of the different stakeholders and the impact these had on the delivery of care. The feeling we were left with was unsettling.  With the uncertainties and complexities in healthcare suggested above, it was clear that we could not claim to have integrity if we had maintain such a significant consistency in character. Taking it a step further, it was obvious that there was barely any professional who could argue to have integrity based on the definition described above.

So we set out to reframe our thought process and asked ourselves the question: Is this a case of physicians lacking integrity or are we applying a wrong interpretation of integrity to our role as doctors?

Getting it right, Integrity that works

Presently, the “moral” approach to integrity that we are all too familiar with is difficult to sustain in the “fast-paced” world of healthcare delivery. This challenge means that based on the definition described above, it would cost us little or no effort at all to identify situations where integrity is lacking either in the performance of our duties or our interactions with others.  Furthermore, integrity in the context of our clinical practice and relation to competency-based training derives from qualities such as honesty and consistency of character. For Clinician Educators and for the residents we train, this quality represents an essential element of our responsibilities. We must acknowledge that it remains the personal choice of an individual to adhere to the moral and ethical standards of the profession (or not) and at the same time not shy away from the (in)direct consequences of unethical professional behavior during the performance of our duties. For this reason, we should be able to judge an individual’s “level of integrity” by the extent to which he/she acts in agreement with the values, beliefs, and principles he/she claims to hold.

Going back to the definition of integrity stated above, I argued that within the current context of health care, it is very easy to catch ourselves in situations where our behaviors or actions can be considered dishonest, untruthful or inaccurate. This means that a bold step needs to be taken to challenge the conventional definition of professional integrity and argue for an alternative approach that would work better. This alternative should be one that is achievable for every care provider without jeopardizing the safe and efficient delivery of health care. This alternative approach in my view should also allow the acceptance of situations where integrity is lacking or has been broken and do away with the blame and shame culture witnessed in many health care settings. A new and neutral context i.e. “space for acknowledgment” should be introduced that embraces every single professional activity (i.e. behavior or actions) irrespective of the outcome.  It is crucial that this context is evident and palpable to all members of the healthcare team at the outset of any collaborative medical encounter and can establish the safe environment required to restore “integrity.” For example, this can be achieved by reenacting new agreements or planning alternative arrangement to meet a previous deadline where this has failed.  In this context, individuals not only get the chance to “make whole what was incomplete” but also get the opportunity to perform the initial task better than was expected, in time.  This alternative approach to integrity creates the space for open communication among members of the medical team without fear of unnecessary and unconstructive reprisals.  Simply stated, psychological safety and compassion within the health care process is a major prerequisite for professional integrity (Edmonson et al. 2016).

Conclusion

So, what was the implication of this discourse on integrity for me as a program director? What new insights relevant to the content/process of residency training program were generated?  First, the exercise was very refreshing and triggered me to reflect seriously on the definition of integrity and how it influenced different stakeholders’ expectations of physicians. Secondly, it highlighted the importance of looking at integrity through a different lens and mapping it out in a way that trainees could get a more solid understanding of how to apply it in practice. Finally, a new responsibility emerged in having to translate this alternative approach of integrity for use in practice. What evolved was a new construct of integrity that we coined as the acronym “HEAR.” As in “don’t just honor your word, but hear your word.”

  1. Honor your word
  2. Exceed your word
  3. Acknowledge setbacks (where applicable)
  4. Restore your word

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Image 1 Chris Evans via Flickr under Creative Commons License CC2.0

Image 2 Talk Nerdy 2 Me


Reference: 

Amy C. Edmondson, Monica Higgins, Sara Singer & Jennie Weiner. Understanding Psychological Safety in Health Care and Education Organizations: A Comparative Perspective. Research in Human Development. 2016. 13 (1): 65-83.