- Email: [email protected]
Radiology in Mexico: Professionalism and High-Quality Radiology Practice
A VIEW FROM ABROAD
BIRGIT ERTL-WAGNER, MD
Radiology in Mexico: Professionalism and High-Quality Radiology Practice José Luis Ramírez-Arias, MD, José Luis Ríos-Reina, MD, Germán Fajardo-Dolci, MD The World Health Organization organized a meeting [1] in 1999 in Geneva, Switzerland, to address education and training for medical imaging worldwide. One of the conclusions that emerged was that because of the low percentage of gross national product invested in medical care in most Latin American countries, including Mexico, the medical infrastructure is weak in many cities. This is especially true in small cities. Capitals and larger cities usually have better equipped public and private hospitals and are more likely to be involved in academic medicine, including radiology. This form of centralism is related to the number of inhabitants. The size of the population is closely related to the budget for postgraduate education for all specialties, and radiology is no exception. Well-equipped hospitals and radiology departments generally have well-trained radiologists, and many are interested in scholarly activities, as these departments are frequently linked to university programs in which radiology residents are trained. Mexico is a Latin American country with 107 million inhabitants, 50% of whom live in the 10 largest cities, including Mexico City, Monterrey, and Guadalajara. The Human Development Index report for 2009 [2] lists the following demographics for Mexico: ● ● ●
814
a life expectancy at birth of 71 years; 5.8% of gross national product invested in medical care; a Human Development Index ranking of 53;
●
●
14.9% of adults (aged ⱖ 25 years) with higher education attainment; and total population in 1990, 2007, and 2020 (projected) of 83.4 million, 107.5 million, and 119.7 million.
The Mexican health system has two social security institutions, one for nongovernment workers, which covers about 50% of the population, and one for government workers and their families, which has a coverage of about 5 million. There are also the military and marine health services and some other state-owned institutions for people without any other source of medical coverage. Private practice is a crucial component of the Mexican health system. Nationwide, small offices with general practitioners and specialists take care of an important number of non–government-insured patients, some of them with private medical insurance. High-technology medical equipment, including medical imaging equipment, is situated in both public and private offices in most states’ capital cities, including the largest cities, Mexico City, Monterrey, Guadalajara, Mérida, Toluca, and Chihuahua. In all of Mexico, there are nearly 250 MRI scanners and about 1,000 CT scanners. RADIOLOGY IN MEXICO The first radiology organization in the country was the Mexican Electro-Radiology Society, founded in 1926 in Mexico City. The name of the society was later changed to the Mexican Society of Radiology and Imaging. In 1972, this society and
the 30 state societies were united as the Mexican Federation of Radiology and Imaging. In the same year, the Mexican Council of Radiology and Imaging was established and began to certify radiologists by oral, written, and film-reading examinations. This certification is valid for 5 years. After this period, recertification can be obtained, once again by examination or by academic points accumulated through participation in continuing medical education programs, publications, and other academic activities. In parallel, government offices also can give general practitioners and specialists official documents that authorize them to practice. The Mexican Federation of Radiology and Imaging has 3,500 certified radiologists registered in Mexico. As noted above, most practice in the larger cities. For the most part, certification is specialty specific. However, general practitioners are allowed to practice diagnostic ultrasound after taking a non– university-based course organized by any group, although they are not necessarily registered by a radiology ultrasound society. There is no mechanism to determine if this practice poses a problem. There are likely about 1,000 ultrasonographers in the country. The postgraduate division of the School of Medicine of the National Autonomous University of Mexico unified the radiology programs in 1991 [3]. We now have a 4-year program that comprehensively prepares trainees for contemporary practice and also includes the fundamentals of molecular imaging.
© 2010 American College of Radiology 0091-2182/10/$36.00 ● DOI 10.1016/j.jacr.2010.05.004
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Because of different hospital and radiology departments’ infrastructures, radiology education can be dissimilar. Therefore, radiologists, after finishing their training, may have variable levels of knowledge even after passing the Mexican Council of Radiology and Imaging examination. Trained and council-certified radiologists, as well as radiology residents, must understand that continuing radiology education is essential. We have considered that professionalism can be an important way to make radiologists aware of this condition and incorporate the work of others that may improve quality in radiology practice. PROFESSIONALISM IN RADIOLOGY Medicine worldwide has witnessed tremendous advances in technology, which have been considered essential for a better approach to diagnosis and for the treatment of many diseases. However, the real challenge is ensuring that the humanistic practice of medicine does not fade away. The dehumanization of medical practice is approaching rapidly, but it must be avoided at all cost [4]. We address this concern through the adoption of professionalism. The term professionalism is used frequently in Mexico by people in relation to good performance or good service, for example, “The waiter was very professional; he served us very well”; “In that office, the secretaries are very professional and efficient”; or “The people working in that bank are highly professional, and you never have to wait long in lines.” The term medical professionalism is known only by few, though much is known and commented on regarding medical ethics, humanism, high quality and excellence in
medical practice, good background medical education, patients’ rights, informed consent, medical conflict, malpractice, confidentiality, altruism, and similar concepts. Distinguished Mexican physicians have written papers and book chapters on these issues. Ignacio Chávez, MD, (18971979) was a prominent cardiologist known worldwide, founder of Instituto Nacional de Cardiologia (the National Cardiology Institute), dean of the National Autonomous University of Mexico, and doctor honoris causa of the University of Oxford and of the University of Paris. He was also one of the most illustrious humanists in Mexico. His concepts and thoughts [5,6] were frequently directed toward ethics, humanism, patients’ rights, and the responsibility and duty of studying and applying the best of knowledge on behalf of patients. All these points are part of the modern concept of professionalism. The pneumologist Octavio Rivero Serrano, MD, (born 1929) is also a past dean of the National Autonomous University of Mexico. He was president of the National Academy of Medicine in 1977 and served the government as Mexico’s ambassador to Italy for 5 years. Dr Serrano has focused his humanistic interests on ethics and has published several books on this topic [7,8]. He has also promoted ethics at meetings, conferences, and medical seminars, most at the School of Medicine of the National Autonomous University of Mexico. Dirección General de Profesiones (the Professions’ General Direction), an office of the public education secretary, regulates all professions in Mexico. After finishing correspondent studies, a professional must obtain a license from this office called cédula de profesiones (a profes-
sional license) that allows professional practice. The Professions’ General Direction also recognizes and regulates professional colleges, understanding that they are civil associations that have the mandate of supervising professional practices according to article 5 of the Mexican constitution. Colleges can also promote the expedition or modification of laws to improve and adapt professions to modern times. In medicine, for example, the Professions’ General Direction recognizes specialties’ certification councils (boards). The Professions’ General Direction published in 1995 the code of professional ethics [9] that lists the following obligations: ● ● ● ● ●
professional obligations, obligations to colleagues, obligations to clients, obligations to the profession, and obligations to society.
In relation to professional obligations, the code of ethics aims to encourage professionals to perform their trades with honesty, legitimacy, and morality on behalf of society, and it also mentions that professionals must apply the best of scientific knowledge and technical resources to the exercise of their professions and that their practices should be honest, just, diligent, loyal, responsible, formal, discrete, honorable, sincere, and, in addition, performed with dignity, good faith, and strict observation of legal and ethical standards. It also enumerates the human rights of clients, colleagues, and society in general. In the section on obligations to colleagues, the code appeals to the respect that must exist toward opposing ideas and the support that should be given when injustices are committed against a peer. With regard to obligations to clients, the code of ethics points out
816 A View From Abroad
the importance of professional relationships, which must be conducted with honesty and respect. It also states that in case of activity that is any less than diligent, mistakes, damages, or injuries thus arising should be recognized. The section on obligations to the profession mentions that professionals must always be up-to-date on scientific and technical advances so that they may provide the highest quality service possible. It also states the moral obligation of transmitting experience, knowledge, and skills to students and colleagues. The contribution of research to dignifying the profession is also part of this section. The fundamental obligations to society mentioned in the code are the moral necessity to support government authorities and educational institutions in whatever needs they have. Also mentioned are the importance of professionals as promoters and transmitters of cultural and national values and the responsibility to contribute to national development. In medicine, there are codes of ethics or charters of integrity in many medical colleges. Radiology, for example, has Colegio Mexicano de Médicos Especialistas en Radiología e Imagen (the Mexican College of Physicians Specializing in Radiology and Imaging). In the statutes of this body, a code of ethics is included that is similar to that of the Professions’ General Direction with some adaptations to radiologists. Two universities have began to work in medical professionalism— the School of Medicine of Instituto Tecnológico de Estudios Superiores de Monterrey and the School of Medicine of the National Autonomous University of Mexico. The first has analyzed in different forums how the practice of medicine has changed in the past 30 or 40
years, how technology has influenced medical practice, and, also, how physicians have begun to shed the social commitments of their profession, affecting patients’ interests. They have suggested that commitment to standards of medical professionalism can help avoid or diminish this serious problem. They have emphasized in addition the importance of teaching medical professionalism to medical students. Because of this necessity, the university created in 2001 a professionalism committee [10]. The program of this committee is founded on setting standards of professionalism as competencies directed toward medical students. They must acquire, among the most important, altruism, knowledge, skill, and the moral obligation to honor commitments. Some competencies also mention the importance of subordination of physicians on behalf of patients, the adherence to morals and ethics, the response to social necessities, and the obligation to perform their duties with honesty, integrity, values, warmth, compassion, empathy, and respect to others and that they must also be inspirers of confidence. They promote as well that students should always be committed to excellence, and they do not omit the obligation to transmit knowledge to others. All these professionalism concepts are evaluated periodically in conjunction with the medical topics of the career. The National Autonomous University of Mexico’s School of Medicine has also been very interested in promoting professionalism and has published medical professionalism seminars [11,12]. The authors mention that society has expressed a preoccupation with physicians’ conduct, seeing them as less committed than they should be to patients’ interests, blam-
ing in part patients’ legitimate medical requirements and the availability of resources. They analyzed the important increases in health care costs and the impact on government and private medical institutions. They also stated that physicians are confused and afraid of losing the social and economic privileges they were used to, and frequently they do not understand thoroughly the difference between traditional and administrative medicine. In these seminars, it was also noted that medical students must have in addition to their medical vocation attributes of professionalism, among the most important the capacity to acquire and apply the necessary knowledge and skills in good medical practice. They must also have open minds and good judgment, with a capacity to establish adequate communication with patients, family, and peers. The seminars promote the important concept that all medical activities be performed with honesty, ethics, integrity, compassion, justice, and confidentiality. Because all these concepts are known to be related to excellence in medicine, professionalism seminars have been incorporated in all university specialty programs. One problem for the incorporation and follow-up of the recommendations of these seminars, for example, in radiology postgraduate programs, is the lack of knowledge of academic radiologists of concepts of medical professionalism. Frequently, few will be interested in reading about this subject, constituting a real challenge for the advancement of a more humane radiology practice. Only one paper has been written referring to professionalism in our specialty [13], in which the authors emphasize the importance of adequate communication between clini-
A View From Abroad 817
cians, referring physicians, and radiologists. Some other subjects of professionalism are also mentioned. Also in 2009, a symposium devoted to medical professionalism in radiology was organized by the National Academy of Medicine and the National Commission for Medical Arbitration [14]. The program included topics on communication, with Leonard Berlin, MD, as a speaker, as well as high quality in radiology, with the participation of distinguished radiologists from the Mexican Federation of Radiology and Imaging. Legal issues in radiology, including malpractice, were also part of the program in which government medical officers participated. The National Commission for Medical Arbitration has also published several guidelines related to the quality of care in different medical areas. Such is the case of the “General Recommendations to Improve the Quality of Care in Radiology and Imaging” [15], which are based on medical complaints received at the commission regarding problems in radiologic and imaging procedures. Five main points are raised in this document—the need to always perform within the legal framework of medical practice; collaborate with treating physicians in the study and integral diagnosis of patients; avoid unnecessary risks during invasive radiologic and imaging procedures; guarantee patients professional medical attention before, during, and after studies; and obtain informed consent in writing before doing any procedure that may involve risk to a patient. A more recent activity was a medical professionalism workshop organized by Hospital Angeles del Pedregal in September 2009 [16], with the participation of 35 specialists, including radiologists. Other participants were educational authorities and
medical division chairs. The main objective of this workshop was to analyze how to improve quality and security standards in hospital medical practice. After an introduction, the coordinator made reference to the new concepts of professionalism published in 2002 [17], emphasizing the principles of professional competence, ethics, good medical practice, and patients’ rights. The welfare and autonomy of patients were also noted, and finally, moral commitments were mentioned, including professional competency, honesty, confidentiality, maintaining good relationships with patients, improving quality in medical practice, improving access to health services, a just distribution of medical resources, medical knowledge, maintaining confidence in conflicts, and professional responsibility. The coordinator also stated the importance of having a code of ethics in every specialty college or society. He presented as an example the code of the Radiological Society of North America [18], which incorporates many of these concepts, among the most important setting and maintaining standards of competency and integrity, providing expert advice to the society on matters of health, and good medical practice, ethics, knowledge, values, and communication. When discussion was opened to the participants at the workshop, the following points were considered as capable of compromising medical professionalism standards: incompetence, abuses of power, rancor among colleagues, fraud and lying, inadequate communication, conflicts, and arrogance. It was also stated that medical professionalism involves not only physicians but also residents, medical students, nurses, paramedical personnel, and administrative health personnel.
The workshop participants were divided into groups for analysis and discussion of topics regarding professionalism. ●
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Commitment to improving quality in health care: Among the important conclusions reached was the necessity of maintaining competence. Commitment to confidence and trust: Ethics and integrity were mentioned in the discussion, as well as the importance of good communication to avoid medical conflicts. Commitment to scientific knowledge: This topic, although related to medical competence, also involves the importance of maintaining certification and the responsibility of hospital accreditation committees for strict and rigid medical registration. Participants also discussed the necessity and moral obligation of transmitting knowledge and skills to students and colleges. Commitment to confidentiality: Participants felt that this concept must be strictly adhered to, particularly today, when frequently medical records can be electronically acquired or transmitted.
The final remarks made at this workshop addressed the importance of following recommendations of hospital medical committees, among the most important are those of infection, ethics, and morbidity and mortality committees. The participants considered that the fulfillment of medical professionalism standards is to the benefit of quality and secure health care and therefore all physicians registered in a hospital must adhere to the Decalogue Hospital Code of Ethics, which among its most important concepts states that the aim of medicine will always be to provide services to individuals and society with principles of benevolence
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and beneficence toward patients and colleges. Also, part of this code is the patients’ rights, including the rights to receive information about their diagnoses and prognoses so that they can decide and accept through informed consent the procedures to be performed. The professional secret, patient autonomy, and human medical practice are also parts of this code. In radiology, the principles of professionalism mentioned must be applied, and in this paper, some considerations are made. Frequently, while undergoing imaging studies, patients are not in contact with radiologists because radiologic technicians are the ones who, most of the time, perform the broad range of imaging procedures. Unfortunately, radiologists may seem more interested in their workstations and films than in the sick patients under their care. In this event, patients are often denied the benefit of clinical radiology consultation. This is wrong. Most patients are sick and frightened. Physicians should be sensitive to their feelings, providing them the best of their knowledge and kindness, always bearing in mind patients’ rights and having their best interests at heart [19]. As mentioned earlier, ethics and integrity are essential components of medical professionalism and key to radiologists’ understanding of how our knowledge and skills in radiology benefit our patients, as well as how our lack of them could be harmful to our patients’ interests. Radiologic competence is essential to good patient care, making it vital to remain up-to-date in our specialties or subspecialties. This underlines the importance of holding and maintaining certification, which is supported by enrolling in continuing medical education programs based on the concepts of life-
long learning and adult learning [20]. Access to large image and associated other databases, along with participation in workshops to improve their skills, can help radiologists stay current in their knowledge and skills. Research is also a very important part of education, and its promotion and improvement must be encouraged. Good communication among radiologists, technicians, and patients is imperative in a professional radiology practice [21,22]. Patients benefit when radiologists have the essential clinical information that supports and enhances the radiology report. Clinical information must come from referring physicians as part of their imaging requests. When this is not enough, it is necessary for radiologists to obtain the information directly from patients’ records or from patients themselves. High-quality radiology practice also requires improved administrative activities within radiology departments. Reception personnel, in charge of appointments and providing patients with instructions for studies, as well as radiology technicians, must be well trained and sensitive to providing careful and courteous attention. They must always report if patients are not feeling well or seem to need special or urgent care. Informed consent is an essential part of professionalism. As radiologists, we should evaluate and discuss with referring physicians and sometimes with patients themselves the best imaging procedures, taking into consideration associated risks and costs. Given that we are in troubling financial times, many patients, especially those who are retired or unemployed, can be seriously affected. Departments must make sure patients are always fully and clearly informed about the di-
agnostic procedures to be performed, especially when risk is involved (eg, when there is a need to use iodinated contrast medium or with interventional procedures). Patients must make important decisions to preserve or recover their health. It is important to have very good patient-physician relationships. Openness, honesty, and integrity are essential. Patients will appreciate them and will be thankful for warm, respectful, and courteous attention. The quality of care should be determined by the suitability of such care, professional competence, safety, and ethics toward the fulfillment of patients’ health needs and expectations. High-quality radiology practice performed by committed radiologists gives them the satisfaction of providing professional medical attention. It is important for radiologists to promote among radiology residents the practice of our specialty with honesty, integrity, and all other principles of medical professionalism [23]. REFERENCES 1. WHO (World Health Organization) Meeting on Training and Education in Diagnostic Imaging, Geneva, May 31 - June 3 1999. WHO/HQ (Headquarters). 2. United Nations Development Programme. Human development report 2009: Mexico: the Human Development Index— going beyond income. Available at: http://hdrstats. undp.org/en/countries/country_fact_sheets/ cty_fs_MEX.html. Accessed August 9, 2010. 3. Plan único de especializaciones médicas, radiología e imagen. Mexico City, Mexico: Facultad de Medicina, Universidad Nacional Autónoma de México; 2003. 4. Sox CH. Professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243-6. 5. Chávez I. Grandeur and poverty of medical specialization. Aspiration toward a new humanism. Circulation 1959;20:481-9. 6. Chávez I. Professional ethics in medicine in our time. JAMA 1964;190;226-31.
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7. Serrano OR, Durante MI. Tratado de etica médica. Mexico City: México Editorial Trillas; 2009. 8. Serrano OR, Paredes SR. Etica en el ejercicio de la medicina. Mexico City, Mexico: Editorial Médica Panamericana; 2006. 9. Dirección General de Profesiones. Secretaría de Educación Pública, Prototipo de código de etica profesional. Mexico City, Mexico: Dirección General de Profesiones; 1998. 10. Core competencies at the school of Medicine Ignacio A. Santos of Instituto Tecnológico y de Estudios de Monterrey. Presented at: IAMSE 6th Annual Meeting; Guadalajara, Mexico; 2002. 11. Serrano OR, Durante MI. Seminario el ejercicio actual de la medicina. El profesionalismo en la medicina actual. UNAM 2008. Available at: http://www.medicinaysalud. unam.mx. 12. Ruiz PL, Sánchez MM. Profesión y profesionalismo en medicina. Available at: http//
www.facmed.unam.mx/eventos/seam2k1/ 2006/nov01ponencia.html. 13. Ramírez AJL, Ocampo LR, Rodríguez WF. Profesionalismo en medicina. Acta Médica Grupo Angeles 2008;6:133-7. 14. Profesionalismo en medicina orientado hacia una especialidad, la radiología. Available at: http://www.conamed.gob.mx/prensa/ 2009/prof_radiologia.php. 15. Fajardo-Dolci GE, Rodriguez-Suarez J, Aguirre Gas H, et al. Recomendaciones generales para mejorar la calidad en la practica de la radiología e imagen. Mexico City, Mexico: National Commission for Medical Arbitration; 2007. 16. Profesionalismo en medicina. Taller de planeación estratégica en el Hospital Angeles del Pedregal. Acta Médica Grupo Angeles 2010;8:52-8. 17. Accreditation Council for Graduate Medical Education. Advancing education in medical professionalism. Available at: http://www. acgme.org/outcome/implement/profm_ resource.pdf. Accessed October 4, 2004.
18. Radiological Society of North America. RSNA statement on professionalism. Available at: http://www.rsna.org/About/ professionalism.cfm. Accessed May 16, 2008. 19. Clinger NJ, Hunter TB, Hillman BJ. Radiology reports: attitudes of referring physicians. Radiology 1998;169:825-6. 20. Collins J. Education techniques for lifelong learning. Radiographics 2004;24: 1483-9. 21. American College of Radiology. ACR practice guideline for communication of diagnostic imaging findings. Available at: http://www. acr.org/SecondaryMainMenuCategories/ quality_safety/guidelines/dx/comm_diag_ rad.aspx. Accessed August 9, 2010. 22. Berlin L. Communication of the significant but not urgent findings. AJR Am J Roentgenol 1997;168:329-31. 23. Stern DT, Papadakis M. The developing physician— becoming a professional. N Engl J Med 2006;355:1794-8.
José Luis Ramírez-Arias, MD, is from Hospital Angeles del Pedregal, School of Medicine, National Autonomous University of Mexico, Mexico City, Mexico. José Luis Ríos-Reina, MD, is from Hospital Angeles Mocel, School of Medicine, La Salle University Mexico, Mexico City, Mexico. Germán Fajardo-Dolci, MD, is from the National Commission for Medical Arbitration, Mexico City, Mexico. José Luis Ramírez-Arias, MD, Hospital Angeles del Pedregal, School of Medicine, National Autonomous University of Mexico, Medano 31, 04530 Mexico City, DF, Mexico; e-mail: [email protected].
BIRGIT ERTL-WAGNER, MD
Radiology in Mexico: Professionalism and High-Quality Radiology Practice José Luis Ramírez-Arias, MD, José Luis Ríos-Reina, MD, Germán Fajardo-Dolci, MD The World Health Organization organized a meeting [1] in 1999 in Geneva, Switzerland, to address education and training for medical imaging worldwide. One of the conclusions that emerged was that because of the low percentage of gross national product invested in medical care in most Latin American countries, including Mexico, the medical infrastructure is weak in many cities. This is especially true in small cities. Capitals and larger cities usually have better equipped public and private hospitals and are more likely to be involved in academic medicine, including radiology. This form of centralism is related to the number of inhabitants. The size of the population is closely related to the budget for postgraduate education for all specialties, and radiology is no exception. Well-equipped hospitals and radiology departments generally have well-trained radiologists, and many are interested in scholarly activities, as these departments are frequently linked to university programs in which radiology residents are trained. Mexico is a Latin American country with 107 million inhabitants, 50% of whom live in the 10 largest cities, including Mexico City, Monterrey, and Guadalajara. The Human Development Index report for 2009 [2] lists the following demographics for Mexico: ● ● ●
814
a life expectancy at birth of 71 years; 5.8% of gross national product invested in medical care; a Human Development Index ranking of 53;
●
●
14.9% of adults (aged ⱖ 25 years) with higher education attainment; and total population in 1990, 2007, and 2020 (projected) of 83.4 million, 107.5 million, and 119.7 million.
The Mexican health system has two social security institutions, one for nongovernment workers, which covers about 50% of the population, and one for government workers and their families, which has a coverage of about 5 million. There are also the military and marine health services and some other state-owned institutions for people without any other source of medical coverage. Private practice is a crucial component of the Mexican health system. Nationwide, small offices with general practitioners and specialists take care of an important number of non–government-insured patients, some of them with private medical insurance. High-technology medical equipment, including medical imaging equipment, is situated in both public and private offices in most states’ capital cities, including the largest cities, Mexico City, Monterrey, Guadalajara, Mérida, Toluca, and Chihuahua. In all of Mexico, there are nearly 250 MRI scanners and about 1,000 CT scanners. RADIOLOGY IN MEXICO The first radiology organization in the country was the Mexican Electro-Radiology Society, founded in 1926 in Mexico City. The name of the society was later changed to the Mexican Society of Radiology and Imaging. In 1972, this society and
the 30 state societies were united as the Mexican Federation of Radiology and Imaging. In the same year, the Mexican Council of Radiology and Imaging was established and began to certify radiologists by oral, written, and film-reading examinations. This certification is valid for 5 years. After this period, recertification can be obtained, once again by examination or by academic points accumulated through participation in continuing medical education programs, publications, and other academic activities. In parallel, government offices also can give general practitioners and specialists official documents that authorize them to practice. The Mexican Federation of Radiology and Imaging has 3,500 certified radiologists registered in Mexico. As noted above, most practice in the larger cities. For the most part, certification is specialty specific. However, general practitioners are allowed to practice diagnostic ultrasound after taking a non– university-based course organized by any group, although they are not necessarily registered by a radiology ultrasound society. There is no mechanism to determine if this practice poses a problem. There are likely about 1,000 ultrasonographers in the country. The postgraduate division of the School of Medicine of the National Autonomous University of Mexico unified the radiology programs in 1991 [3]. We now have a 4-year program that comprehensively prepares trainees for contemporary practice and also includes the fundamentals of molecular imaging.
© 2010 American College of Radiology 0091-2182/10/$36.00 ● DOI 10.1016/j.jacr.2010.05.004
A View From Abroad 815
Because of different hospital and radiology departments’ infrastructures, radiology education can be dissimilar. Therefore, radiologists, after finishing their training, may have variable levels of knowledge even after passing the Mexican Council of Radiology and Imaging examination. Trained and council-certified radiologists, as well as radiology residents, must understand that continuing radiology education is essential. We have considered that professionalism can be an important way to make radiologists aware of this condition and incorporate the work of others that may improve quality in radiology practice. PROFESSIONALISM IN RADIOLOGY Medicine worldwide has witnessed tremendous advances in technology, which have been considered essential for a better approach to diagnosis and for the treatment of many diseases. However, the real challenge is ensuring that the humanistic practice of medicine does not fade away. The dehumanization of medical practice is approaching rapidly, but it must be avoided at all cost [4]. We address this concern through the adoption of professionalism. The term professionalism is used frequently in Mexico by people in relation to good performance or good service, for example, “The waiter was very professional; he served us very well”; “In that office, the secretaries are very professional and efficient”; or “The people working in that bank are highly professional, and you never have to wait long in lines.” The term medical professionalism is known only by few, though much is known and commented on regarding medical ethics, humanism, high quality and excellence in
medical practice, good background medical education, patients’ rights, informed consent, medical conflict, malpractice, confidentiality, altruism, and similar concepts. Distinguished Mexican physicians have written papers and book chapters on these issues. Ignacio Chávez, MD, (18971979) was a prominent cardiologist known worldwide, founder of Instituto Nacional de Cardiologia (the National Cardiology Institute), dean of the National Autonomous University of Mexico, and doctor honoris causa of the University of Oxford and of the University of Paris. He was also one of the most illustrious humanists in Mexico. His concepts and thoughts [5,6] were frequently directed toward ethics, humanism, patients’ rights, and the responsibility and duty of studying and applying the best of knowledge on behalf of patients. All these points are part of the modern concept of professionalism. The pneumologist Octavio Rivero Serrano, MD, (born 1929) is also a past dean of the National Autonomous University of Mexico. He was president of the National Academy of Medicine in 1977 and served the government as Mexico’s ambassador to Italy for 5 years. Dr Serrano has focused his humanistic interests on ethics and has published several books on this topic [7,8]. He has also promoted ethics at meetings, conferences, and medical seminars, most at the School of Medicine of the National Autonomous University of Mexico. Dirección General de Profesiones (the Professions’ General Direction), an office of the public education secretary, regulates all professions in Mexico. After finishing correspondent studies, a professional must obtain a license from this office called cédula de profesiones (a profes-
sional license) that allows professional practice. The Professions’ General Direction also recognizes and regulates professional colleges, understanding that they are civil associations that have the mandate of supervising professional practices according to article 5 of the Mexican constitution. Colleges can also promote the expedition or modification of laws to improve and adapt professions to modern times. In medicine, for example, the Professions’ General Direction recognizes specialties’ certification councils (boards). The Professions’ General Direction published in 1995 the code of professional ethics [9] that lists the following obligations: ● ● ● ● ●
professional obligations, obligations to colleagues, obligations to clients, obligations to the profession, and obligations to society.
In relation to professional obligations, the code of ethics aims to encourage professionals to perform their trades with honesty, legitimacy, and morality on behalf of society, and it also mentions that professionals must apply the best of scientific knowledge and technical resources to the exercise of their professions and that their practices should be honest, just, diligent, loyal, responsible, formal, discrete, honorable, sincere, and, in addition, performed with dignity, good faith, and strict observation of legal and ethical standards. It also enumerates the human rights of clients, colleagues, and society in general. In the section on obligations to colleagues, the code appeals to the respect that must exist toward opposing ideas and the support that should be given when injustices are committed against a peer. With regard to obligations to clients, the code of ethics points out
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the importance of professional relationships, which must be conducted with honesty and respect. It also states that in case of activity that is any less than diligent, mistakes, damages, or injuries thus arising should be recognized. The section on obligations to the profession mentions that professionals must always be up-to-date on scientific and technical advances so that they may provide the highest quality service possible. It also states the moral obligation of transmitting experience, knowledge, and skills to students and colleagues. The contribution of research to dignifying the profession is also part of this section. The fundamental obligations to society mentioned in the code are the moral necessity to support government authorities and educational institutions in whatever needs they have. Also mentioned are the importance of professionals as promoters and transmitters of cultural and national values and the responsibility to contribute to national development. In medicine, there are codes of ethics or charters of integrity in many medical colleges. Radiology, for example, has Colegio Mexicano de Médicos Especialistas en Radiología e Imagen (the Mexican College of Physicians Specializing in Radiology and Imaging). In the statutes of this body, a code of ethics is included that is similar to that of the Professions’ General Direction with some adaptations to radiologists. Two universities have began to work in medical professionalism— the School of Medicine of Instituto Tecnológico de Estudios Superiores de Monterrey and the School of Medicine of the National Autonomous University of Mexico. The first has analyzed in different forums how the practice of medicine has changed in the past 30 or 40
years, how technology has influenced medical practice, and, also, how physicians have begun to shed the social commitments of their profession, affecting patients’ interests. They have suggested that commitment to standards of medical professionalism can help avoid or diminish this serious problem. They have emphasized in addition the importance of teaching medical professionalism to medical students. Because of this necessity, the university created in 2001 a professionalism committee [10]. The program of this committee is founded on setting standards of professionalism as competencies directed toward medical students. They must acquire, among the most important, altruism, knowledge, skill, and the moral obligation to honor commitments. Some competencies also mention the importance of subordination of physicians on behalf of patients, the adherence to morals and ethics, the response to social necessities, and the obligation to perform their duties with honesty, integrity, values, warmth, compassion, empathy, and respect to others and that they must also be inspirers of confidence. They promote as well that students should always be committed to excellence, and they do not omit the obligation to transmit knowledge to others. All these professionalism concepts are evaluated periodically in conjunction with the medical topics of the career. The National Autonomous University of Mexico’s School of Medicine has also been very interested in promoting professionalism and has published medical professionalism seminars [11,12]. The authors mention that society has expressed a preoccupation with physicians’ conduct, seeing them as less committed than they should be to patients’ interests, blam-
ing in part patients’ legitimate medical requirements and the availability of resources. They analyzed the important increases in health care costs and the impact on government and private medical institutions. They also stated that physicians are confused and afraid of losing the social and economic privileges they were used to, and frequently they do not understand thoroughly the difference between traditional and administrative medicine. In these seminars, it was also noted that medical students must have in addition to their medical vocation attributes of professionalism, among the most important the capacity to acquire and apply the necessary knowledge and skills in good medical practice. They must also have open minds and good judgment, with a capacity to establish adequate communication with patients, family, and peers. The seminars promote the important concept that all medical activities be performed with honesty, ethics, integrity, compassion, justice, and confidentiality. Because all these concepts are known to be related to excellence in medicine, professionalism seminars have been incorporated in all university specialty programs. One problem for the incorporation and follow-up of the recommendations of these seminars, for example, in radiology postgraduate programs, is the lack of knowledge of academic radiologists of concepts of medical professionalism. Frequently, few will be interested in reading about this subject, constituting a real challenge for the advancement of a more humane radiology practice. Only one paper has been written referring to professionalism in our specialty [13], in which the authors emphasize the importance of adequate communication between clini-
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cians, referring physicians, and radiologists. Some other subjects of professionalism are also mentioned. Also in 2009, a symposium devoted to medical professionalism in radiology was organized by the National Academy of Medicine and the National Commission for Medical Arbitration [14]. The program included topics on communication, with Leonard Berlin, MD, as a speaker, as well as high quality in radiology, with the participation of distinguished radiologists from the Mexican Federation of Radiology and Imaging. Legal issues in radiology, including malpractice, were also part of the program in which government medical officers participated. The National Commission for Medical Arbitration has also published several guidelines related to the quality of care in different medical areas. Such is the case of the “General Recommendations to Improve the Quality of Care in Radiology and Imaging” [15], which are based on medical complaints received at the commission regarding problems in radiologic and imaging procedures. Five main points are raised in this document—the need to always perform within the legal framework of medical practice; collaborate with treating physicians in the study and integral diagnosis of patients; avoid unnecessary risks during invasive radiologic and imaging procedures; guarantee patients professional medical attention before, during, and after studies; and obtain informed consent in writing before doing any procedure that may involve risk to a patient. A more recent activity was a medical professionalism workshop organized by Hospital Angeles del Pedregal in September 2009 [16], with the participation of 35 specialists, including radiologists. Other participants were educational authorities and
medical division chairs. The main objective of this workshop was to analyze how to improve quality and security standards in hospital medical practice. After an introduction, the coordinator made reference to the new concepts of professionalism published in 2002 [17], emphasizing the principles of professional competence, ethics, good medical practice, and patients’ rights. The welfare and autonomy of patients were also noted, and finally, moral commitments were mentioned, including professional competency, honesty, confidentiality, maintaining good relationships with patients, improving quality in medical practice, improving access to health services, a just distribution of medical resources, medical knowledge, maintaining confidence in conflicts, and professional responsibility. The coordinator also stated the importance of having a code of ethics in every specialty college or society. He presented as an example the code of the Radiological Society of North America [18], which incorporates many of these concepts, among the most important setting and maintaining standards of competency and integrity, providing expert advice to the society on matters of health, and good medical practice, ethics, knowledge, values, and communication. When discussion was opened to the participants at the workshop, the following points were considered as capable of compromising medical professionalism standards: incompetence, abuses of power, rancor among colleagues, fraud and lying, inadequate communication, conflicts, and arrogance. It was also stated that medical professionalism involves not only physicians but also residents, medical students, nurses, paramedical personnel, and administrative health personnel.
The workshop participants were divided into groups for analysis and discussion of topics regarding professionalism. ●
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Commitment to improving quality in health care: Among the important conclusions reached was the necessity of maintaining competence. Commitment to confidence and trust: Ethics and integrity were mentioned in the discussion, as well as the importance of good communication to avoid medical conflicts. Commitment to scientific knowledge: This topic, although related to medical competence, also involves the importance of maintaining certification and the responsibility of hospital accreditation committees for strict and rigid medical registration. Participants also discussed the necessity and moral obligation of transmitting knowledge and skills to students and colleges. Commitment to confidentiality: Participants felt that this concept must be strictly adhered to, particularly today, when frequently medical records can be electronically acquired or transmitted.
The final remarks made at this workshop addressed the importance of following recommendations of hospital medical committees, among the most important are those of infection, ethics, and morbidity and mortality committees. The participants considered that the fulfillment of medical professionalism standards is to the benefit of quality and secure health care and therefore all physicians registered in a hospital must adhere to the Decalogue Hospital Code of Ethics, which among its most important concepts states that the aim of medicine will always be to provide services to individuals and society with principles of benevolence
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and beneficence toward patients and colleges. Also, part of this code is the patients’ rights, including the rights to receive information about their diagnoses and prognoses so that they can decide and accept through informed consent the procedures to be performed. The professional secret, patient autonomy, and human medical practice are also parts of this code. In radiology, the principles of professionalism mentioned must be applied, and in this paper, some considerations are made. Frequently, while undergoing imaging studies, patients are not in contact with radiologists because radiologic technicians are the ones who, most of the time, perform the broad range of imaging procedures. Unfortunately, radiologists may seem more interested in their workstations and films than in the sick patients under their care. In this event, patients are often denied the benefit of clinical radiology consultation. This is wrong. Most patients are sick and frightened. Physicians should be sensitive to their feelings, providing them the best of their knowledge and kindness, always bearing in mind patients’ rights and having their best interests at heart [19]. As mentioned earlier, ethics and integrity are essential components of medical professionalism and key to radiologists’ understanding of how our knowledge and skills in radiology benefit our patients, as well as how our lack of them could be harmful to our patients’ interests. Radiologic competence is essential to good patient care, making it vital to remain up-to-date in our specialties or subspecialties. This underlines the importance of holding and maintaining certification, which is supported by enrolling in continuing medical education programs based on the concepts of life-
long learning and adult learning [20]. Access to large image and associated other databases, along with participation in workshops to improve their skills, can help radiologists stay current in their knowledge and skills. Research is also a very important part of education, and its promotion and improvement must be encouraged. Good communication among radiologists, technicians, and patients is imperative in a professional radiology practice [21,22]. Patients benefit when radiologists have the essential clinical information that supports and enhances the radiology report. Clinical information must come from referring physicians as part of their imaging requests. When this is not enough, it is necessary for radiologists to obtain the information directly from patients’ records or from patients themselves. High-quality radiology practice also requires improved administrative activities within radiology departments. Reception personnel, in charge of appointments and providing patients with instructions for studies, as well as radiology technicians, must be well trained and sensitive to providing careful and courteous attention. They must always report if patients are not feeling well or seem to need special or urgent care. Informed consent is an essential part of professionalism. As radiologists, we should evaluate and discuss with referring physicians and sometimes with patients themselves the best imaging procedures, taking into consideration associated risks and costs. Given that we are in troubling financial times, many patients, especially those who are retired or unemployed, can be seriously affected. Departments must make sure patients are always fully and clearly informed about the di-
agnostic procedures to be performed, especially when risk is involved (eg, when there is a need to use iodinated contrast medium or with interventional procedures). Patients must make important decisions to preserve or recover their health. It is important to have very good patient-physician relationships. Openness, honesty, and integrity are essential. Patients will appreciate them and will be thankful for warm, respectful, and courteous attention. The quality of care should be determined by the suitability of such care, professional competence, safety, and ethics toward the fulfillment of patients’ health needs and expectations. High-quality radiology practice performed by committed radiologists gives them the satisfaction of providing professional medical attention. It is important for radiologists to promote among radiology residents the practice of our specialty with honesty, integrity, and all other principles of medical professionalism [23]. REFERENCES 1. WHO (World Health Organization) Meeting on Training and Education in Diagnostic Imaging, Geneva, May 31 - June 3 1999. WHO/HQ (Headquarters). 2. United Nations Development Programme. Human development report 2009: Mexico: the Human Development Index— going beyond income. Available at: http://hdrstats. undp.org/en/countries/country_fact_sheets/ cty_fs_MEX.html. Accessed August 9, 2010. 3. Plan único de especializaciones médicas, radiología e imagen. Mexico City, Mexico: Facultad de Medicina, Universidad Nacional Autónoma de México; 2003. 4. Sox CH. Professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243-6. 5. Chávez I. Grandeur and poverty of medical specialization. Aspiration toward a new humanism. Circulation 1959;20:481-9. 6. Chávez I. Professional ethics in medicine in our time. JAMA 1964;190;226-31.
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7. Serrano OR, Durante MI. Tratado de etica médica. Mexico City: México Editorial Trillas; 2009. 8. Serrano OR, Paredes SR. Etica en el ejercicio de la medicina. Mexico City, Mexico: Editorial Médica Panamericana; 2006. 9. Dirección General de Profesiones. Secretaría de Educación Pública, Prototipo de código de etica profesional. Mexico City, Mexico: Dirección General de Profesiones; 1998. 10. Core competencies at the school of Medicine Ignacio A. Santos of Instituto Tecnológico y de Estudios de Monterrey. Presented at: IAMSE 6th Annual Meeting; Guadalajara, Mexico; 2002. 11. Serrano OR, Durante MI. Seminario el ejercicio actual de la medicina. El profesionalismo en la medicina actual. UNAM 2008. Available at: http://www.medicinaysalud. unam.mx. 12. Ruiz PL, Sánchez MM. Profesión y profesionalismo en medicina. Available at: http//
www.facmed.unam.mx/eventos/seam2k1/ 2006/nov01ponencia.html. 13. Ramírez AJL, Ocampo LR, Rodríguez WF. Profesionalismo en medicina. Acta Médica Grupo Angeles 2008;6:133-7. 14. Profesionalismo en medicina orientado hacia una especialidad, la radiología. Available at: http://www.conamed.gob.mx/prensa/ 2009/prof_radiologia.php. 15. Fajardo-Dolci GE, Rodriguez-Suarez J, Aguirre Gas H, et al. Recomendaciones generales para mejorar la calidad en la practica de la radiología e imagen. Mexico City, Mexico: National Commission for Medical Arbitration; 2007. 16. Profesionalismo en medicina. Taller de planeación estratégica en el Hospital Angeles del Pedregal. Acta Médica Grupo Angeles 2010;8:52-8. 17. Accreditation Council for Graduate Medical Education. Advancing education in medical professionalism. Available at: http://www. acgme.org/outcome/implement/profm_ resource.pdf. Accessed October 4, 2004.
18. Radiological Society of North America. RSNA statement on professionalism. Available at: http://www.rsna.org/About/ professionalism.cfm. Accessed May 16, 2008. 19. Clinger NJ, Hunter TB, Hillman BJ. Radiology reports: attitudes of referring physicians. Radiology 1998;169:825-6. 20. Collins J. Education techniques for lifelong learning. Radiographics 2004;24: 1483-9. 21. American College of Radiology. ACR practice guideline for communication of diagnostic imaging findings. Available at: http://www. acr.org/SecondaryMainMenuCategories/ quality_safety/guidelines/dx/comm_diag_ rad.aspx. Accessed August 9, 2010. 22. Berlin L. Communication of the significant but not urgent findings. AJR Am J Roentgenol 1997;168:329-31. 23. Stern DT, Papadakis M. The developing physician— becoming a professional. N Engl J Med 2006;355:1794-8.
José Luis Ramírez-Arias, MD, is from Hospital Angeles del Pedregal, School of Medicine, National Autonomous University of Mexico, Mexico City, Mexico. José Luis Ríos-Reina, MD, is from Hospital Angeles Mocel, School of Medicine, La Salle University Mexico, Mexico City, Mexico. Germán Fajardo-Dolci, MD, is from the National Commission for Medical Arbitration, Mexico City, Mexico. José Luis Ramírez-Arias, MD, Hospital Angeles del Pedregal, School of Medicine, National Autonomous University of Mexico, Medano 31, 04530 Mexico City, DF, Mexico; e-mail: [email protected].