Modeling Skillful and Ethical Be­hav­ior

Modeling professional and ethical behaviors is an important role for physician leaders to play, because credibility depends on how others perceive leaders in both their career roles and private lives. An institution’s supervisors and medical staff always will look to leaders for behavioral guidance. Three important concepts to keep in mind: role modeling, professionalism and ethical behavior. Each concept has important implications for all physician leaders and are essentially interlinked.

First, consider role modeling. It’s based on a set of standards that a person lives and acts by. It includes passing on standards of behavior, values and attitudes to others. These standards might be considered negative or positive. For example, in the workplace, negative standards of behavior can include rumor spreading, sexual harassment and verbal abuse.(1) On the other hand, positive workplace behaviors that others may desire to emulate include innovation, optimism and empathy.(1,2)

As a leader, you should continuously ask yourself, “What behaviors and attitudes am I demonstrating to others, and will these behaviors and attitudes have a positive or negative impact on my constituency?” Most people learn not from experience, but rather from observing the actions of others.(3) People form ideas about how role models should act in certain situations and imitate those behaviors when they are placed in similar situations. This is why it is so important for today’s leaders to recognize how they are perceived by others.

There is limited information on role modeling in physician leadership literature. However, there are resources in the medical education field that evaluate and discuss the characteristics of successful role models.(4) The medical education literature discusses several characteristics that embody an effective role model.(4) The first, and probably most important, of these characteristics are positive personal qualities. These qualities include being supportive, caring and respectful.(4) A successful role model should have a positive outlook, a desire for excellence, and commitment to growth, integrity and leadership. Additionally, a role model should have the ability to inspire others to excel, build and support team functioning, have excellent communication skills, and be nonjudgmental in his/her relationship to other members of the care and administrative team.(4)

The second important concept for leaders to demonstrate is that of professionalism. Professionalism is a set of attitudes and behaviors that are specific to a given profession.(5) Professionalism in medicine is rooted in the social contract that all physicians have with society, which allows physicians to intimately engage with patients like no other profession. Violation of medicine’s professional norms puts at risk the fundamental contract that physicians have with their patients.

There are a number of important responsibilities that form the foundation of professionalism in medicine. These responsibilities(6) include:

• Competency.

• Honesty with patients.

• Confidentiality of patient information.

• Appropriate (i.e., no sexual, financial or private) relationships with patients.

• Improving the quality of care (this should be a lifelong endeavor).

• Improving access to care.

• Distributing resources fairly.

• Maintaining scientific knowledge.

• Managing conflicts of interest.

• Maintaining professional responsibilities.

Many organizations embed certain core values within their mission statement. These core values include behavioral attributes that organizational leaders expect everyone in the organization to follow. These core values should be demonstrated daily by physician leaders. Examples of behavioral traits that organizations might have in the statement of their core values include:

• Altruism (keeping the best interest of a patient in mind).

• Accountability (to patients, society and the profession).

• Excellence (duty to lifelong learning).

• Duty (commitment to service).

• Honor and integrity (fairness, truthfulness).

• Respect for others (patients, families, team members, students, etc.).

• Teamwork.

Professional behavior might also provide fiscal benefits. Patients are more likely to stay with physicians they perceive as behaving professionally. They are also more likely to recommend these physicians to others.(7) Conversely, most patient complaints about physicians involve physicians’ unprofessional behaviors.(8)

Physician leaders should be aware of the risk exposure their medical staff and organization might be under from unprofessional behavior and should understand that lack of professionalism can significantly increase malpractice risk.(8) It is crucial for leaders to remember that these concepts might significantly affect the finances of an organization in the long run.

As you develop your leadership skills, it can be helpful to remember the patient’s perspective. How would a patient perceive and judge you as being professional? One of the most important personal characteristics that you might consider is humility,(9) a mark of maturity and experience that keeps us from becoming arrogant and egotistical.(9) Humility also provides a sense of your limitations, which is important in higher levels of leadership.(9)

Finally, it is crucial to recognize that “the acts of medical professionalism are based on the promises made by physicians to patients and their communities that physicians will use their authority wisely and will not abuse that authority for the sake of money and/or power.”(10)

What About Ethics?

A final concept is ethical behavior. Others will have trust and confidence in you as a leader when you demonstrate ethical behavior. Intertwined into the concept of professionalism, ethical leadership specifically identifies behaviors of integrity, honesty and trustworthiness as core behaviors for moral people. More specifically for physicians, the relationship physicians have with their patients is bound by the principles of biomedical ethics. Biomedical ethics describe the duties of beneficence (serving the best interests of their patients), nonmaleficence (not doing harm to their patients), respect for autonomy (respecting patients’ rights to make their own decisions about their health care), and justice (acting with impartiality and fairness).(11) In addition, there are other ethical considerations that physician leaders need to be concerned about, including, but not limited to, informed consent, confidentiality, conflicts of interest, sexual relationships and medical research.(12)

Not only must leaders be ethical at all times, but they must also ensure their organizations have systems that teach, maintain and monitor ethical conduct by all employees.(13) It has been suggested that unethical behavior in an organization can result in undesirable outcomes for not only the organization but its employees and its consumers, too. Unethical behavior might also damage the reputation of the organization and lead to costly litigation. A classic example of this is the Enron scandal of 2001, where executives lied and misled the board of directors for financial gain.(13)

The benefit of having systems of ethical training and oversight in an organization is higher quality of care and greater consumer protection, which is difficult to argue against.(13) Finally, physician leaders always should remember that in difficult times when failure has occurred, they should admit to the failure when their decisions were the cause of the failure.(3)

Much of the recent legal efforts to encourage ethical business behavior has been focused on keeping top executives of organizations accountable. One example of this is the federal Sarbanes-Oxley Act.(14) Enacted by the U.S. Congress in 2002, this act was passed to “protect investors by improving the accuracy and reliability of corporate disclosures made pursuant to the securities laws, and for other purposes.”(14) Indeed, it is important for top managers to engage in fostering ethical business practices in their organizations.

Interestingly, however, employees are actually more influenced by those individuals they work with most often.(3) Thus, it is also important to ensure that there is a systematic and systemwide effort to teach and monitor individuals’ ethical behaviors in an organization. In addition, one should remember that microcultures (at the individual work units in the organization) play significant roles in shaping the ethical behavior of employees.(3)

Dual Role as a Leader

It is easy to appreciate the importance you play in being a role model for professional and ethical behavior. However, you should also be aware your job entails a dual role of being an administrator (generally reporting directly to the chief executive officer of the organization) and leader (of the clinical enterprise). Thus, you are not only expected to report directly to the CEO of the entire organization, but you are also expected to make decisions that further the best interest of patients and the clinical care teams.

Because of this fact, you might face certain moral or ethical dilemmas. What if you are asked by your CEO to eliminate a clinical program, considered by you and your medical staff as important for overall patient care, because of cost concerns? How would you respond? Disagreeing with your CEO would likely put you in jeopardy of losing your job. However, eliminating the program might put you in violation of one or more of the four principles of biomedical ethics. Situations like this are faced daily by leaders. While discussing how to approach these situations is beyond the scope of this article, physician leaders should remember that it is critical to have a plan in place to handle these individual situations.

References

1. Appelbaum SH, Iaconi GD, Matousek A. Positive and negative deviant workplace behaviors: causes, impacts, and solutions. Corporate Governance: 2007. The International Journal of Business in Society 7(5):586-98, Oct. 23, 2007.

2. Nelson D, Cooper CL, editors. Positive Organizational Behavior. Thousand Oaks, CA: Sage Publications, 2007.

3. Weaver GR, Trevino LK, Agle B. Ethical role models in organizations. Organizational Dynamics 34(4):313-30, 2005.

4. Wright SM, Carrese JA. Excellence in role modeling: insight and perspectives from the pros. CMAJ 167(6):638-43, Sept. 17, 2002.

5. Hammer DP. Professional attitudes and behaviors: the “a’s” and “b’s” of professionalism. American Journal of Pharmaceutical Education. 64(4):455-64, Winter 2000.

6. Issued jointly by the American Board of Internal Medicine, the American College of Physicians and the EuropeanFederation of Internal Medicine, ProjectMP. Medical professionalism in the new millennium: a physicians’ charter. The Lancet 359(9305):520-2, Feb. 9, 2002.

7. Hall MA, Zheng B, Dugan E, et. al. Measuring patients’ trust in their primary care providers. Med Care Res Review 59(3):293-313, Sept. 2002.

8. Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and malpractice risk. JAMA 287(22):2951-7, June 12, 2002.

9. Collins J. Good to Great. 1st ed. New York, NY: HarperCollins. 2001.

10. Pellegrino E, Thomasma DC. A Philosophical Basis of Medical Practice. New York, NY: Oxford University Press, 1981.

11. ACEP Board of Directors. Code of Ethics for Emergency Physicians. 2008. https://www.acep.org/ClinicalPractice-Management/Code-of-Ethics-for-Emergency-Physicians/

12. http://www.art-of-patient-care.com/medical-ethics.html .

13. Brodhead MT, Higbee TS. Teaching and maintaining ethical behavior in a professional organization. Behav Anal Pract. 5(2):82-8, Winter 2012.

14. Act SO. Sarbanes-Oxley Act of 2002. Public Law. 2002(107-204).