Professional Behavior in Medical Practice

Abstract

Nowadays, ethical and behavioral responsibilities have been expanded in a range of individual-personal responsibilities to personal-occupational responsibilities. Professional behavior is one of the basic issues in human societies. If a comprehensive definition of ethical principles is provided, professionals in any job can decide what behavior is reasonable and unreasonable and which action is ethical and which is unethical. In the medical community, the discussion of behavior has a special place due to the importance of the medical profession, so medical ethics has a very serious and extensive scientific discussion. If the benefits of observing professional behavior are more comprehensive, the level of commitment to its principles is of a higher degree, and the more reasonable the restrictions imposed due to the principles of professional behavior, the stronger the adherence to it. In this chapter, the definition, importance, characteristics of professional behavior in medicine and its behavioral areas, as well as the methods of teaching professional behavior and its evaluation criteria are discussed. Finally, general guidelines for medical professional behavior are provided.

1. Introduction

Professionalism is not a new concept and has existed throughout the history of medicine in the form of medical oaths. What makes the doctor-patient relationship effective and is necessary for the doctor’s success in diagnosing, treating, and providing preventive services is the patient’s trust in the doctor. What makes medicine a sacred and valuable profession is the trust that the society has in the servants of this profession. Trusting that the employees of this profession have set their main goal to ensure people’s health and prioritize it over their own interests and commit to this sacred goal in the form of an oath.

The characteristics of a profession are:

1. Working in a profession generally requires specialized knowledge or skills.

2. The society grants special privileges to the members of the profession.

3. The society expects them to put the interests of the society before their own interests in providing social services [1].

The society has given the right to the health service system to decide and implement what it considers appropriate regarding the provision of health services to the patients and the society and to evaluate the correctness of the performance of its members and the processes of the health system. In order to provide their services, doctors have the privilege to ask patients for confidential information, examine the patient’s naked body, and perform procedures on the patient’s body. Of course, in return for granting this right, he expects this profession to prioritize the interests of society over all its goals and to guarantee the quality of services by training and monitoring the professional performance of its members [2]. Therefore, the health system as well as the individual members of the medical profession are committed to make their decisions and actions that serve the health of patients and prioritize the patient’s interests over their own interests.

2. Characteristics of professional behavior in medicine

Professionalism is adherence to obligations, and it is one of the most important capabilities that every medical student must acquire and demonstrate in practice and behavior. The characteristics of a person that is a manifestation of professionalism in professional behavior are:

• Altruism: The doctor is obliged to seek the best interests of the patients.

• Professional excellence: A doctor is committed to learning medical science and skills throughout his professional life.

• Conscientiousness (obligation): The doctor must be committed to serving in his profession and perform his duties completely and on time.

• Truth and honor: The doctor must be committed to observing fairness, honesty, and correctness in his interactions with patients and his profession.

• Respect for others: The doctor is obliged to respect the patients and their families, other doctors, and other team members, medical students, assistants, and fellows.

• Justice: The doctor is obliged to facilitate the fair provision of services and eliminate discrimination in the provision of services [3, 4].

Examples of each of the components of professional behavior:

2.1 Altruism

• Prioritizing the patient’s interests over his own interests.

• Showing attention to the patient’s wishes.

• Spending time and patience to explain the information to the patient.

• Spending time and patience to comfort a critical patient.

• Trying to reduce the suffering and pain of the patient in all possible ways.

• Compassionately listening to the patient’s concerns.

• Participation in local and national professional organizations.

• Offering help to other team members volunteering to do the work of another person who cannot do his work.

• Providing to others with their knowledge and skills.

2.2 Professional excellence

• Active search for feedbacks.

• Modifying one’s behavior or performance based on the provided feedback.

• A critical attitude toward oneself and the ability to identify areas of one’s ability and knowledge that need improvement.

• Knowing his limitations and getting help from others in cases where his knowledge and skills are not enough.

• Adaptability to changing conditions.

• Assessing own physical, mental, and spiritual health.

• Feeling responsible for your retraining.

• Participation in rounds, seminars, and other educational activities.

• Study based on the cases of patients who refer to him.

2.3 Conscientiousness (obligation)

• Arriving on time.

• Being reliable.

• Follow the supervisor.

• Complete the assigned duties completely and on time.

• Responding to letters, summons (pages), telephones, and emails in a timely manner.

• Compliance with rules and regulations.

• Appropriate cooperation in teamwork.

• Performing duties and being available on call.

• Accurate and complete report of the care that is done for the patient.

• Correct and complete transfer of patient care responsibility.

• Notifying others when he cannot be present to perform the duty and making sure that there is a substitute for him.

• Completing the care of patients before discharging them.

• Reporting medical errors to the team or supervisor.

• Declaration of conflict of interest to the team or supervisor.

• Identifying and reporting errors and inappropriate behavior of colleagues by avoiding unfairly discrediting their reputation.

• Participation in professional self-monitoring activities.

• Avoiding drug and alcohol abuse.

• Providing effective criticism instead of complaining.

2.4 Truth and honor

• Honest behavior: truthfulness, fairness, to be frank, keeping the promise resolving disputes in a way that respects the dignity of the other party.

• Proper behavior of medical dignity, whether in behavior, speech, or the way of dressing and grooming.

• Being honest with patients and avoiding exaggerating your capabilities.

• Encouraging the successes of your colleagues in public gatherings.

• Commenting only on the topics that are in his area of expertise.

• Nonparticipation in cheating (giving and taking) in exams.

• Accepting responsibility for your work.

• Avoid using unfair methods to improve your academic position.

• Not participating in exploitative relationships with colleagues, students, patients, or their families in order to gain material, emotional, sexual, research, or educational benefits.

• Ethical conduct and honest reporting of research and proper appreciation of the participation of others in the publication of the research work.

• Avoiding plagiarism.

2.5 Respect for others

• Establishing understanding with team members.

• Maintaining the necessary privacy in occupational and educational situations.

• Introducing yourself and the team members to the patient and his family.

• Addressing the patient in an appropriate way.

• Using terms that can be understood by the patient in talking with the patient.

• Respecting and preserving the human dignity of patients and their families, whether in their presence or in their absence, in discussions with other members of the treatment team.

• Respecting the patient’s right to individual autonomy by providing information about treatment choices to them or their guardians.

• Providing advice to the patient’s family or legal guardian, when he lacks decision-making capacity.

• Respecting the confidentiality and privacy of the patient.

• Maintaining the necessary privacy in relation to the patient.

• Good and appropriate communication with subordinate students in the educational environment.

• Good and appropriate communication with professors in the educational environment.

• Good and proper communication with the staff of other health-related professions.

• Showing tolerance and patience in front of a range of behaviors and opinions.

• Nondiscrimination in your interactions with others based on things such as age, race, skin color, race, political opinions, marital status, physical and mental disabilities, gender, sexual orientation (homosexual or nonhomosexual), or criminal convictions.

2.6 Commitment to social justice

• Equitable distribution of health-care resources.

• Medicine based on cost-effectiveness.

• Taking care of health service resources.

3. Four areas of professional behavior

The behaviors that doctors may show are in a spectrum from ideal behavior to ugly behavior. Below are examples of behaviors that fall into each of these areas:

3.1 Ideal behavior

• Forgiving toward colleagues, patients, and patients’ families.

• Altruistic toward others.

• Good-natured and flexible.

• Humility toward one’s successes.

• Eager to teach students and their questions.

• Arresting patients, employees, and consultants.

• To be available and serve continuously and more than necessary.

• Quenching the anger and anxiety of patients and employees.

• Being a role model inside and outside the work environment.

• Doing the right thing only for moral reasons.

3.2 Desired/expected behavior

• Arriving on time and getting ready for work.

• Prioritizing the interests of the patient.

• Completing patient care before discharging them.

• Protecting the interests and privacy of the patient.

• Respectful treatment of patients and their families, employees, and colleagues.

• Training other team members (students, employees, and residents).

• Discussing difficult issues (treatment choices, decision-making, end of life, and telling the truth) in a kind manner with the patient, their family, and other employees.

• Open-minded acceptance of criticism from professors and staff.

3.3 Undesired behavior

• Arriving late or getting ready for work late.

• Disclosure of patients’ information.

• Failure to correctly hand over responsibility for patient care.

• Saying insulting and annoying words or information.

• Accepting significant gifts from founders or pharmaceutical companies.

• Performing nonsurgical medical procedures without valid consent from the patient.

• Self-reference.

• Discrimination between students or patients based on race, gender, religion, or other objective characteristics.

• Disrespectful interaction with patients, their families, or employees.

• Failure to properly mention the names and efforts of others when their work has been used for education or research.

• Failure to implement or respond appropriately to the professorate’s recommendations or teachings.

• Changing programs in your favor.

• Using altruism as an excuse to avoid other duties.

3.4 Ugly behavior

• Abandoning the patient.

• Unavailability during on call.

• Repeated lying, cheating, or stealing.

• Substance abuse or addiction.

• Not learning from past mistakes.

• Showing or broadcasting erotic photos and other annoying things in the work environment.

• Creating a danger that is very threatening to the health of patients or employees.

• Verbal or physical insults to patients, their families, or employees.

• Distortion in medical reports or research data.

• Theft of medicine or medical devices.

• Sexual assault on patients or colleagues.

4. Why is professional behavior important, and why should it be taught?

Today, some believe that doctors are less altruistic than in the past, and this has led to a decrease in trust in the profession. There are also threats and factors that make us pay more attention to the category of professional behavior than before. These factors and threats can be divided into two categories, internal and external. Some of the internal factors and threats of professional behavior are: abuse of power, pride, greed, providing false information (lies and fraud), lack of conscientiousness, and conflict of interests. Inadequate knowledge and expertise can also threaten the professional behavior of the doctor [5].

Among the external factors and threats to professional behavior and commitment, the following can be mentioned: Rapid growth of medical knowledge and skills, increasing media attention to health-care issues, change in the philosophy of patient care, multidisciplinary teamwork in health care, the changes made in the attitude of doctors, pressures from colleagues, and commercial and speculative view of health.

Another concern that has been created recently is the professional behavior of the doctor in the virtual space and social networks, because some doctors consider virtual space to be different from the real space and may have misbehaviors in virtual space that distorts people’s trust in the profession [6].

On the other hand, studies have shown that unfavorable practices in medicine are more caused by unprofessional behaviors than by the lack of knowledge or skills of doctors.

In a review study [7], it was shown that there is a relationship between unprofessional behavior and adverse outcomes such as patient endangerment, patient dissatisfaction, and medical malpractice lawsuits. And there are also various studies that show that students who had unprofessional behaviors during their studies continued this trend in their future performance as doctors [8]. In short, we conclude from this section that today more than in the past, paying attention to professional behavior in educational programs is important and should be taught.

5. What methods and approaches are not there for training professional commitment?

It is now clear that unprofessional behavior cannot be controlled through disciplinary measures and codes of ethics alone. Rather, active training programs should be formulated for the development of professional behavior and commitment.

Of course, there were discussions in the past on whether it is possible to teach professional behavior and commitment at all. Considering the large amount of evidence available, the inclusion of professional behavior in competency frameworks and curricula in medical education is in no doubt. What is being discussed is the correct method of teaching and evaluating professional behavior and also acknowledging this point that due to multifaceted and context-dependent professional behavior, teaching it is not easy compared to teaching medical knowledge and skills. In this section, we discuss different methods, approaches, and opinions regarding professional behavior training. The meaning of education is its more general concept, not a teaching method [9].

6. Professional behavior training: explicit or implicit?

In the past, there was a debate on whether professional behavior should be explicitly taught or implicitly taught [10]. But it seems that nowadays, the approach is to use both types of education. First, it is better to clarify a concept:

Three levels or three types of curriculum can be imagined in medical schools.

1. The declared curriculum or the written program: it is designed by the faculty or the ministry and is announced for implementation.

2. The taught curriculum: it is what happens in practice.

3. Learned curriculum: it is what students do not learn. Students do not just learn from the taught curriculum; they learn things that the faculty did not intend to teach them. Experts call this type of curriculum as hidden curriculum.

Therefore, the hidden curriculum is the learning that the faculty did not intend to teach, but the students have learned during their education. Skiles simply states that in the hidden curriculum, students learn something that comes from the difference between our behavior and speech (teachers, managers, etc.) [11]. Therefore, for professional behavior training to be effective, both explicit training and implicit training are necessary in the formal curriculum. Of course, it is important to mention that the professional identity is formed during the course of medical education and the educational intervention should be integrated into the entire training course. Therefore, it is necessary for all lecturers and professors to transfer this concept and improve its application in decisions that have an active and effective clinical role [12]. Integrated education is not discussed in this chapter, and only effective educational methods are examined.

7. Teaching professional behavior in the formal curriculum

Professional behavior has a cognitive dimension or basis, and it can be done directly using him taught different methods. First, it should be ensured that the learners understand the nature of professional behavior, the reasons and why to observe it, and its features and examples. The goal is for them to reach a common language of concepts and examples of professional behavior. In the basic cognitive training of professional behavior, a variety of common methods can be used, such as interactive lectures, case-based learning, teaching in small groups, e-learning, and so forth. [11]. But if the training is only limited to defining professional behavior and listing a series of characteristics and behaviors that follow from it, then only theoretical knowledge has been provided to the learners, and as a result, the impact of the provided training will be much less. Therefore, to internalize those traits and values, other educational methods are needed.

7.1 Reflection

Experiential learning is a process that a person learns through experiencing. However, experience alone is not enough for effective learning. Experience must be integrated into one’s existing knowledge structure and interpreted accordingly in order to generate new knowledge or expand existing knowledge. Reflection is critical to this active learning process [13].

Reflection is “a conscious examination of the ideas, feelings, meaning, and meaning of learning experiences.” There are different models and theories in the field of reflection.

But the reflection process can be simply summarized in these three steps:

1. Doing (gaining experience).

2. Evaluation and analysis of that experience.

3. Planning for future performance.

These steps continue cyclically. Reflection is used for various purposes, but in the case of professional behavior, it is at the heart of many educational programs [14]. Reflection transforms experience into greater understanding and makes a person reach higher levels of learning. Reflection helps students to integrate theoretical knowledge and knowledge gained from experience and can plan to improve their future performance.

In the training of professional behavior, critical incident report and narration is used as a stimulus for formal reflection. However, during clinical encounters, depending on the situation and event that happens to the learners, the professor and the tutor can encourage the learner to think and guide him to achieve the educational result hidden in the situation. Critical incidents are difficult situations that students experience or unexpected consequences that result from individual student performance. These events are usually associated with feelings such as anger, frustration, excitement, and so on.

In various studies, the effectiveness of reflection in professional behavior training has been investigated, and reflection has been reported as one of the main and effective methods in the professional behavior training program [15].

7.2 Other specified training methods of professional behavior

There are other ways to teach professional behavior that we only mention their titles below.

• (Role-playing) performance

• Use of film

• Simulation-based training

• Journal club

• Team-based learning

• Learning based on problem solving

• Educational folder.

7.3 Implicit training of professional behavior

7.3.1 Role modeling

In a qualitative study using the grounded theory method, surgical assistants stated that they learn professional behavior through the following sources and methods:

• Personal values and family upbringing.

• Behavior patterns.

• The structure of the surgical residency course.

• And their formal training with role models.

For centuries, behavioral patterns have been the responsibility of transmitting medical attitudes and values. Undoubtedly, behavior patterns play an important role in the formation of students’ professional personality [16].

Now the question that arises is who are role models? In response, it should be said that all professors play the role of models for learners to some extent. Is this a positive thing?

The answer must be absolutely no! Because negative behavior patterns are abundant in the university and hospital environment and students may imitate their negative behaviors.

Therefore, there is a need for positive behavior patterns in educational environments. These patterns have a series of characteristics that Passi et al. [17] classified into three categories in the BEME systematic review guide number 27, which can be seen in Table 1.

Category	Examples
Clinical qualification	High level of knowledge and clinical skills; Patient-centered approach; Human behaviors such as empathy, respect, and compassion
Teaching skills	Giving relaxation to learners; Creating a positive and supportive educational environment; Designing and using special teaching methods; Committed to the growth of learners; Providing the opportunity for students to interact with patients at the bedside; Conscious pivot pattern
Personal characteristics	Effective interpersonal skills; Having a positive attitude and perspective; Honesty; Leadership skills; Committed to excellence; Honest, polite, enthusiastic, and inspiring to students

Table 1.

Characteristics of a good role model.

Students are more influenced by professors’ behavior than their words. Therefore, the ideal would be that the words of teachers are the same as their behavior (good words, good deeds). Some believe that for role models to be more effective, they need to know what behavior or role they are modeling. Or in other words, they should know what kind of behavior is modeled on them by the students. This points to the importance of empowering faculty members, which we will discuss in the relevant section.

It seems that students are even more influenced by negative behavioral patterns than by positive behavioral patterns [13]. The recommendation is to remove such patterns from the educational environment if possible, and if this is not possible, we should inform the students and give them feedback so that they recognize the negative behavior patterns and use it as an effective educational experience.

In general, model-oriented is a very effective method for creating professional identity in students, but it is not enough in any way. In the past, professors had a lot of interaction with students and there were fewer challenges for professional performance, but nowadays, the contact between professor and student of general medicine course has decreased and there are many obstacles for professional performance.

Therefore, there is a need for other methods to teach professional behavior, some of which we mentioned. An appropriate balance must be struck between explicit and implicit teaching of professional behavior [18]. The next important point is the empowerment of faculty members, because for the success and effectiveness of any educational program, it is necessary to empower faculty members. First, professors should be familiar with the definition, nature, importance, and components of professional behavior and commitment (cognitive basis (and then learn the appropriate methods of teaching and evaluating it.

7.3.2 Empowerment

To advance each of the goals of improving professional behavior, it is necessary to increase human capital and bring faculty members together. This can be delegated to the center for studies and education development of the university. One of the most important goals of the center for the study and development of medical education in universities is to design, implement, and evaluate programs to create, maintain, develop, and improve the capabilities and strengthen the scientific power and practical skills of professors in order to improve the quality of education and teaching of the university to meet the changing needs of the societies, health systems, and educational needs of its members [3].

As stated, the behavior and performance of professors can play a key role in shaping the professional behavior of students. One of the most important functions of professors is how to communicate with patients. Doctor’s interaction with the patient is one of the necessities of the medical profession, and communication with the patient is a basic clinical skill and the most important characteristic required for professors and doctors.

On the one hand, the professors will be responsible for the correct transmission of scientific concepts, and on the other hand, they will be the practical and human model of moral values in the work environment [2]. Professional behavior can be done through the exemplary role of professors in the educational environment in an inconspicuous way that should be taught to students through performance.

8. Evaluation of medical professional behavior

Professional medical behavior is one of the most important competencies that should be studied in medical students. Evaluation of professional behavior helps us to know the current situation and know where we are going so that we can help it to grow and excel.

The assessment of this competence can be implemented at different stages. The most ideal situation is for it to take place at the beginning of entering the university, but this issue is not applicable in practice and we still do not have a suitable tool for this evaluation. The content of professional behavior assessment includes both personality and performance of people and does not only include a checklist of personal and behavioral characteristics.

Another important point is that according to the stages of change and progress of education, the evaluation should be individualized and should be done according to the strategies of each educational level [19]. For example, knowledge should be evaluated for lower level students, and performance should be checked for higher levels. The last point is that effective evaluation should be in two ways: providing feedback or adding a score and feedback should be considered constructive and not punitive.

8.1 Criteria for evaluating medical professional behavior

In the discussion of evaluating the professional behavior of doctors, two categories of skills are mentioned:

1. Cognitive skills include gathering information, diagnosis, management, performing procedures, and application of technology.

2. Noncognitive skills include:

   • Communication (language, sympathy, integrity, and empathy).

   • Interaction (responsibility, respect, and performance of duties).

   • Continuous improvement (recognizing limitations and motivating progress).

In the literature review, long lists of competencies were examined as criteria for professional behavior, which include the following:

Having professional relationships; appropriate behavior with other people; righteousness and honesty; empathy; the lack of influence of the doctor’s bad mood on the patient’s treatment; matching with the patient’s level of understanding; having interest in the patient; flexibility; friendliness; commitment to maintaining the progressive flow of medical progress and excellence (pursuing life-long knowledge acquisition); effective patient communication; respect for patients’ autonomy; teamwork; communication skills; respect; responsibility; transferring knowledge and skills to the next generation and serving the society and the general public; informed consent; altruism,;spending time to care for the patient despite the risks; identifying mistakes; being a person of scientific research and publication; efforts to increase the quality of care, honor, and punctuality; paying attention to the culture, age, gender, and disabilities of the patients and establishing a suitable verbal relationship with them; being humble, polite, and well-spoken; being a good listener; time management; having a supportive attitude; complete and accurate documentation of patient care and learning activities; being self-motivated; using learning opportunities; providing constructive feedback; appropriate appearance; paying attention to the organization’s goals; adapt to changes in problem-solving; critical thinking; crisis management and challenges such as having little time to implement things; social justice; talking to the patient with expressive language and friendly behavior; creating a positive learning environment; social responsibility toward being strong toward patients and accepting their mistakes and apologizing; sharing the best professional judgment; and leadership [20, 21].

8.2 Medical professional behavior measurement tools.

The most difficult step in the assessment of professional behavior is the selection of tools. Professional behavior evaluation tools are very wide such as: self-evaluation, simulation like the Objective Structured Clinical Examination (OSCE); direct supervision like multiple feedback, patient opinion, and role model evaluation (learners’ evaluation of their teacher as a role model); evaluation with the help of standard patient; evaluation of professional environment (evaluation of the learning environment or the work environment and not a specific individual review); multiple choice question; and video and scenario analysis.

Among other very valuable methods, evaluation of professional behavior is a 360-degree method [1]. But the drawback of this method is that it is not used in terms of patients. Despite the fact that the core of medical professional behavior is the doctor–patient relationship and the “patient” is at the center of the doctor’s philosophy of existence and professional presence, paying attention to the opinion of patients is neglected in this field.

One of the most effective ways to discover unprofessional behaviors can be the eyes and ears of patients and their families, and with this perspective, in addition to using the comprehensive opinion, colleagues, professors, and so forth in the evaluation of professionalism, also is using in the opinion of patients.

One of the practical questionnaires in evaluating medical professionalism is the professional questionnaire of the American Board of Internal Medicine [22] (ADIM) that assesses professionalism in the form of 7 areas and 36 items and provides a valuable 360-degree assessment of the hidden curriculum [23].

In order to achieve the goals of medical professionalism and the correct training of future doctors, it is necessary that the curriculum based on medical professionalism be implemented in all universities of every country and continuously evaluated and modified. According to the studies conducted in the discussion of medical professionalism in order to deepen the education of this category, it is appropriate to study the strategies of integrating professionalism in the medical education curriculum and the causes of professionalism fatigue in the medical staff and the solutions to solve it [24].

9. General guide of professional medical behavior

Today, several factors have caused the need to introduce new and updated ethical standards to activities in this field. Scientific and technological advances in methods of prevention, diagnosis, treatment, and rehabilitation of patients and other recipients of health services have led to many new situations and questions that have never been seen before in the history of medical ethics.

The emergence of new concepts such as “brain death” and “organ transplant,” the possibility of diagnosing diseases and abnormalities before birth, the dramatic expansion of genetic technologies, the possibility of predicting diseases using genetic information and creating the possibility of modifying the human genome in the initial stages, and many other scientific and technological developments have led to the creation of fundamental questions in the field of end-of-life care, abortion, and manipulation of the human genome.

Establishing the “right to health” for all citizens and the moral duty of governments to provide for health-related needs has led to the creation of large and complex health systems, in which the development of medical technologies adds to this complexity every day. The creation of these large and complex health systems, with their diverse components (including the pharmaceutical industry and medical equipment, politicians and health policymakers, and managers of different levels), has changed the position of medical and related professionals from direct and individual providers of health services to people who are in the framework. The health system and interaction with other stakeholders have changed.

This change of position has also brought new ethical requirements for this group and has made the need to provide new behavioral standards to help the medical professionals to adjust their relationships with the various elements of the health system a special necessity.

The specialization and superspecialization of health services is another change that creates some special ethical requirements for medical professionals. This phenomenon requires the aforementioned group to have specific norms for interaction with other specialists, colleagues, and members of treatment teams and various governmental and nongovernmental sectors of the health system. The change in the pattern of diseases from infectious diseases to chronic diseases, the increase in the average lifespan of humans, and the aging of societies in recent decades have also led to a serious change in the way medical professionals communicate with patients, and it has resulted in many moral consequences that originated from the long continuity of communication between patients and the professionals of this profession.

The general guide to the professional behavior of medical professionals includes a set of values, norms, principles, and ethical rules that were compiled based on the principle of human dignity, and all the items in this guide have the same importance and should be considered as a set.

9.1 General assignments

• Medical professionals must refrain from doing any act that is known to be against professional ethics, that is, that causes disrespect to the medical profession or harms the public trust in doctors.

• The use of tobacco, drugs, psychotropic substances, and alcohol in clinical environments and addiction to alcohol, narcotic drugs, and psychotropic substances are among the cases of professional misconduct.

• Taking a medical oath means accepting a permanent obligation to provide diagnostic and treatment services to all people, to the best of one’s ability.Medical professionals must provide health services to all referring patients regardless of any discrimination related to gender, nationality, race, ethnicity, religion, social, political and economic status, or type of disease.

• In dealing with patients, their companions and colleagues at different levels, and commenting on people, ethnicities, and social groups, it is necessary to respect the human dignity of people, social etiquette, and general politeness and avoid any act that includes insults, humiliation, and labeling.

• Medical professionals are responsible for ensuring compliance with professional ethics standards by their subordinates, including assistants, employees, and other people who are in contact with patients due to cooperation with professionals (such as office clerks), as much as possible.

• It is necessary for medical professionals to maintain their composure and calmness at all times, especially when they are angry.Those medical and allied professionals, who, for any reason, may lose control when angry, need to take preventive measures in this regard. In any case, it is necessary to refrain from any forceful and disrespectful behavior outside the framework of politeness, even in response to insults and verbal insults.

• Medical professionals should treat patients and their companions with kindness, altruism, and compassion as much as possible, and health professionals should do their best to improve their personal capacity to empathize with patients.

• It is necessary to avoid actions that involve the expression of emotions out of proportion to the situation, such as joking with other colleagues in situations where patients or patients’ companions are in a state of extreme anxiety and worry (such as during cardiopulmonary resuscitation(.

• It is necessary in dealing with patients, besides physical health, other dimensions of the patient’s health, including the psychological dimension (including possible concerns) and social dimension (including family and friendly relations, lifestyle, and interpersonal communication); they should take into account the spiritual dimension of the patients as well as other possible psychological and social contexts in which the disease has occurred and provide them with the necessary recommendations by mentioning the reason for the connection of such factors with the disease of people.

• It is necessary to take all the necessary and possible measures to minimize the pain and suffering of the patients. In all stages, it is necessary to use standard palliative methods, along with performing diagnostic, therapeutic, and rehabilitation interventions for patients.

• In addition to the human dignity of people during their lifetime, the body of a dead person is respected.

• It is necessary to refrain from any action that is considered as “desecration of the dead” and also from taking pictures and filming of corpses, except for legitimate reasons. Compliance with this issue is more important for those medical professionals who work in the process of autopsy of deceased people.

9.2 Providing services standard and high quality

• Medical professionals are obliged to use the maximum possible effort to provide the best health services to their patients within the limits of their legal and professional duties and available facilities.

• In cases where medical professionals realize that they do not have the necessary scientific and practical qualifications to start or continue the process of providing health services, they should use the advice of other colleagues or refer the patient to a qualified institution or professional.

• In cases where the patient’s life is in serious and imminent danger due to a medical emergency, the medical professionals are obliged to do their utmost to stabilize the patient’s condition at the same time or before consulting or referring the patient.

• Health care should be provided based on appropriate and up-to-date diagnostic and treatment methods available and based on scientific evidence and current medical knowledge.

• Providing any service outside of approved clinical guidelines, approved or specialized scientific references, under any title, as well as referring patients to people who claim treatment with nonscientific methods and non-reputable centers by medical professionals is prohibited. It is clear that if the safety and effectiveness of any treatment claim is proven during standard research, these cases will be considered part of modern medical science.

• Merely having a medical degree or other related professional qualifications at any stage does not justify any type of medical intervention. Medical professionals are allowed to treat patients only in the areas where they have received formal training and acquired the necessary scientific and practical skills. The authority for determining acceptable training is the organization of the medical system.

9.3 Priority of the patient’s interests

• It is necessary to prioritize the interests of the patient over any other benefit (including benefits that may accrue to the family or relatives by ignoring the patient’s interests) in offering any health intervention to patients (including all diagnostic and therapeutic measures).

• It is necessary to avoid imposing any unnecessary or unfounded costs on patients, in any form and title.To encourage patients to use unnecessary services, reasons such as self-defense against a possible patient complaint or benefiting a third person or institution are not justified.

• Medical professionals, in cases where they accept the responsibility of providing services to patients and other recipients of health services, are responsible for the continuation of the patient’s treatment, to the extent of their ability and expertise.

• Failure to accept patients is only acceptable due to the existence of justified limitations (such as lack of time and suitable facilities or lack of sufficient technical and scientific ability).

• It is necessary for medical professionals to act based on the priority of the patient’s interests in situations that may put their interests in conflict with the interests of patients (including participation in any agreement or contract).

• It is necessary to prioritize the patient’s interests and medical resources in referring patients to other medical and allied professionals or para-clinical institutions, such as imaging centers, pharmacies, hospitals, laboratories, and the like; all referrals should be in the benefits of patients, according to accepted scientific standards and based on the professional competence and ability of the health service provider or the quality of the centers providing diagnostic and therapeutic services to which the patient is referred.

• Receiving and granting any rewards or points, including cash, gifts, discounts on rent or office fees, requests for cross-referrals of patients, and the like, in exchange for referring patients to other medical and allied professionals or to diagnostic and treatment centers, hospitals, laboratories, imaging centers, rehabilitation centers or medical equipment companies, pharmacies, and the like are prohibited.

• Doctors should not in applying and using diagnostic and therapeutic equipment in the office or clinic (such as echocardiography, endoscopy, electroencephalogram, electrocardiogram, etc., which are allowed in the office according to professional rules and regulations) prefer their interests over the interests of patients.

• It is necessary to refrain from accepting any type of gift from the patient and his companions that affects the professional judgment and the process of providing services to the patient. Accepting conventional gifts with little financial value (such as flowers, sweets, and certificates of appreciation given by patients) is fine. It is necessary to not accept the gift in a suitable way that does not cause resentment or embarrassment to the patients, and the reason for not accepting the gift should be explained to the patient.

• Medical professionals are obliged to act in relation to the pharmaceutical industry and medical equipment in such a way that their professional judgment and loyalty to scientific principles are not affected.

• Medical professionals should refrain from writing advertising recommendations regarding the value or usefulness or superiority of the exclusive products of companies and industries, upon the request of these companies and institutions.

• Unless the publication of research results that have been approved by an ethical committee in valid research and during which the benefits of a specific drug or product are reported.

• It is necessary for doctors to be appropriately available throughout the diagnosis and treatment period for the patients they are treating, and how to reach them or their assistants with scientific and practical qualifications to establish contact and obtain guidance in emergency situations should be provided to patients. In cases where medical professionals are out of reach for any reason, including travel and the like, it is necessary to provide the necessary arrangements to replace someone with acceptable scientific and practical qualifications. This replacement must be appropriately written and informed to the patients.

• Guiding patients from government, government-affiliated, and charitable health-care institutions to private sector (both hospitals and clinics and vice versa) for financial use by medical professionals is prohibited.

• Abandoning patients who need to receive health services, without handing over the patient to another qualified professional, for reasons such as the end of the work shift, is not acceptable in any way. It is necessary for medical professionals to ensure that the patient is not abandoned after the end of their shift and transfer the responsibility of his care to other doctors who are qualified for this.

• Proposing or establishing any personal or sexual emotional relationship with patients and their companions as long as there is a professional and therapeutic relationship with the patient is prohibited for medical professionals. Doctors are obliged to refrain from using their position as a therapist for any exploitation (such as sexual, economic, and administrative exploitation) of the patient and his companions.

• Commercial advertising of medical and pharmaceutical products by medical professionals, directly or indirectly (including the installation of promotional announcements in the workplace that has a commercial aspect or the presentation of promotional speeches for commercial products), is not allowed.

9.4 Fairness and impartiality

• Medical professionals should not engage in actions such as delaying appointments, providing faster services, and so on, in providing services to patients, with financial and nonfinancial incentives or for reasons such as financial affordability of some patients, because this is discrimination among patients.

• While observing fairness and justice among patients, it is necessary to pay special attention to people who are in vulnerable groups, including children, pregnant women, the elderly, mental patients, prisoners, mentally and physically disabled, and people without guardians.

• Medical professionals are obliged to provide health services to people suffering from certain diseases, including diseases that have a risk of transmission, in compliance with the rules and principles of safety like other patients. It is forbidden to dissuade patients from requesting health services in any way.

9.5 Honesty and integrity

• Medical professionals should try to maintain patients’ trust in the profession and health professionals. In this context, it is necessary to provide the necessary information to the patients with complete honesty in all stages of diagnosis and treatment and avoid direct or indirect speech or behavior that involves deceiving the patients (even with the intention of benefiting the patient).

• Medical professionals, for the well-being of patients and their companions, should do their best to adjust the patient’s time as accurately as possible during patient visits and respond to their needs as quickly as possible. In cases where patients have to wait to see the professionals providing health services for any reason, they should be provided with essential amenities (such as water, chairs to sit, and toilets) as much as possible.

• It is necessary for the medical professionals to give realistic hope and information to the patient, his family, and relatives while making a compassionate effort to alleviate the worries and fears of the patients and refrain from giving them false promises or hopes.

• Medical professionals are obliged to refrain from attracting patients with methods that require misleading advertisements, providing false or exaggerated information, or in any way that is against professional affairs.

9.6 Respecting the right to choose the recipients of health services

• It is necessary to respect patients’ personal and religious beliefs in providing health services.

• All the information related to the patient that is necessary to know for the patient to make decisions about how to continue the diagnostic and treatment process and other life decisions should be provided to the patient or his substitute decision-makers based on the patient’s level of literacy and condition, in a way that is understandable to the patient.

• In cases where the presentation of disease-related information includes bad news about the patient’s health, it is necessary to give information to the patient using standard methods of “giving bad news”. However, it is not justified to limit the patient’s right to know all the information related to his health.

• It is necessary for medical professionals to guide patients to the best of their ability to obtain information about the criteria and foreseeable costs in the process of diagnosis and treatment.

• In addition to performing diagnostic and therapeutic interventions, it is necessary to provide necessary training in the field of how to continue the treatment, how to take the drugs, follow up the disease, the time of the next visits, the side effects of taking the drugs, the cases where the patient should go to the doctor or the emergency room of the hospital, lifestyle modification, and so forth. It should be provided to the patient.

• Medical professionals are obliged to respect the right of patients to freely and consciously choose the treatment method.The choice of patients in this field is limited to choosing among the options that are logical and correct from the scientific and technical point of view. However, respecting the patients’ right to choose does not mean that the members of the organization must comply with every request of the patient; rather, it refers to the patient’s right to choose from among the correct options available.

• Medical professionals are obliged to respect the patient’s right to refuse the proposed treatments.The use of methods that require dishonest behavior to persuade the patient to accept treatment is prohibited.

• In cases where the patient does not accept life-sustaining treatments and may die or suffer serious injuries as a result of refusing treatment, the attending physician is obliged to use all his efforts to convince the patient. And finally, if the patient is not satisfied, he should inform the relevant authorities, including the hospital’s ethics committee, about the matter. Critical emergency cases in which it is not possible to exchange information and obtain consent from the patient or his/her substitute decision-maker due to the urgency and risk of the patient’s life are excluded from the inclusion of this issue.

• Medical professionals are obliged to prioritize saving the patient’s life over other ethical rules, including the need to obtain informed consent, and provide services without wasting time in emergency cases where the patient’s life is in danger. In emergency cases where the patient refuses to accept life-saving treatment despite the existence of a serious threat to his health and life, medical professionals are obliged to use their utmost efforts to convince the refusing patient to accept the treatment.

• To perform any medical intervention, if the person has reached the legal age and has the authority to make decisions, the informed consent of the person is sufficient and the consent of another person is not required. Cases of nontherapeutic medical intervention that has a serious and irreversible effect on a person’s fertility or his marital relationship or with the possibility of a weak and long-term return, if the person is married, will be subject to the consent of the spouse.However, no medical treatment should be dependent on the consent of a person other than the patient or his/her substitute decision-maker.

9.7 Confidentiality and privacy

• Medical professionals are obliged to respect the patient’s right to the confidentiality of all his information, including sensitive and nonsensitive information that is collected in any form, in different stages of diagnosis and treatment, or is provided to the treatment team in any way.

• Medical professionals are obliged to respect patients’ privacy. Respecting patients’ privacy requires refraining from all activities that patients consider to be a violation of their privacy. In this context, the members of the organization should refrain from actions such as examining the patient in the presence of other people, asking sensitive questions to the patients in the presence of others in a way that causes embarrassment to the patients, and unnecessary observation or touching of the patients, especially in the case of non-same-sex patients.

• Medical professionals are obliged to refrain from any investigation into the personal and family affairs of patients. It is necessary to avoid asking patients personal questions unrelated to the diagnosis and treatment of the disease. If it is necessary to ask questions that the patients may consider as an invasion of their privacy, for diagnosis and treatment, the necessity of the questions should be informed to the patients in simple and understandable language.

• Doctors are obliged to refrain from examining and visiting several patients at the same time in the examination room.

• Carrying out any kind of photography and filming of patients with the aim of preparing educational content, using in the research process (such as reporting specific cases) or treatment (such as photos taken for cosmetic surgery), preparing a movie, documentary, or news program and the like, is only allowed after obtaining permission from the patients.

  In cases where the identity of the person is known, the obtained consent must be written.

  The responsibility of any misuse of the video or images taken for the purpose of education or research is the responsibility of the medical and allied professionals who took the said video or photo.

• Information and samples related to the patient’s body, such as radiographs, tissue samples, blood and biological fluids, and genetic content extracted from the body, are part of the patient’s privacy, and their use is allowed for various purposes, such as medical and research purposes. Either the owner’s consent has been taken, or the information and samples have been anonymized in a way that cannot be attributed to their owners.

9.8 Management of medical errors

• Medical professionals are obliged to use all their efforts to provide standard health services free from medical errors. In this context, it is necessary for all members to do their best to be aware of the common errors in their field of work and to prevent these errors as much as possible.

• Based on the right of patients to know information related to their health, medical professionals should accept the responsibility of their actions in case of an error that leads to damage and while apologizing and taking corrective and preventive measures, the origin of the error and the details related to it, including the causes and complications caused by the error to reveal to the patients.

• In order to maintain the mutual trust of the society and the medical profession, it is necessary for medical professionals, in cases of errors that lead to any kind of physical, psychological, social, and economic damage to patients, while avoiding any kind of concealment, with the agreement of the patient and voluntarily, for compensate for the damage caused by their mistake.

• Medical professionals are obliged to continuously monitor themselves in terms of physical and mental capabilities necessary to perform their professional duties correctly and completely. If for any reason, including fatigue, physical weakness, or mental weakness, the patient is likely to be harmed, they should refrain from performing the mentioned intervention as much as possible.

9.9 Communication with other colleagues

• Medical professionals are obliged to respect the rights of other colleagues and members of the medical team at all levels and to observe the utmost courtesy in their interactions with them.

• It is necessary for medical professionals to help their colleagues and other professionals providing health services as much as possible in order to solve the problems that arise in the field of professional behavior, clinical practice, and health.

• Medical professionals are obliged to teach their colleagues and other members of the health service team their knowledge and experience as much as possible. In cases where colleagues ask for advice from any member of the organization, it is necessary to give the answer of the professionals being consulted as soon as possible, in the best way and in such a way that the colleague seeking advice, upon receiving the advice answer, can clearly understand its content and use it in the course of providing the service.

• Medical professionals are obliged to refrain from any unconstructive criticism, mistakes, insults, and humiliation of other professionals, in any case and especially in the presence of patients and their companions.

• It is necessary for medical professionals to give priority to prevention over treatment in performing their professional duties and provide necessary preventive training to the recipients of health services.

9.10 Medical education and research

• It is necessary for medical professionals to make the improvement of human health along with respecting their dignity and rights as their main goal in research on human participants and prioritize the health and safety of the research participants during and after the research over all other interests.

• Medical professionals should only conduct human research in cases where they are confident that they have the necessary and relevant clinical expertise and skills for this work. The design and implementation of researches that are conducted on humans should be consistent with accepted scientific principles based on current knowledge and based on a complete review of available scientific resources and previous researches.

• If medical professionals who conduct human research realize during the research that the risks of participating in the research for the participants are greater than its potential benefits, the research must be stopped immediately.

• Medical professionals are required to obtain written informed consent from participants or their substitute decision-makers for research on humans.

• Medical professionals must make sure that the obtained consent is informed.

• For this purpose, they are obliged to inform the research participants of all the information that can be effective in their decision-making in an appropriate way.

• The informed consent form must be written for the participants in a simple and understandable language and contain the following information: “Research Title and Objectives,” “Research Duration,” “Research Method,” “Funding Sources,” “Any Possible Conflict of Interest,” “Researcher’s Organizational Affiliation,” and “Profits and Losses that the Research is Expected to Include”. Also, research participants should know that they can withdraw from the study at any time.

• Medical professionals must ensure that the consent obtained is free. Any behavior that includes threats, seduction, deception, or coercion for patients or other people in order to participate in the research is prohibited. Considering the need of the patients for their doctor, this issue should be considered more carefully about the patients being treated by the medical and allied professionals who intend to conduct therapeutic research on their patients.

• Medical professionals who are interested in research should do their best to respect the privacy and confidentiality of all the information of patients and participants in the research and prevent the unjustified dissemination of the information obtained and collected during the research.

• -Medical researchers are obliged to take all necessary measures to compensate for any possible damage to patients caused by participating in the research. In cases where the research is supported by pharmaceutical companies, it is necessary to ensure the full insurance coverage of the participants from the financial sponsor and then start the research.

• Medical research professionals are required to cover all the costs of actions that are purely research-related, from the research budget, and refrain from imposing any research costs on patients or using their health insurances.

10. Conclusion

In this chapter, the domains of professional behavior in medicine are briefly reviewed and important cases of these indicators are stated. Professional behavior in almost all general and specialized medical education capability frameworks exists, and most medical schools have included it in their curricula, but they still have challenges in teaching it. What emerges from the evidence is that model-oriented and rethinking are the most effective methods for teaching professional behavior. Educational methods will be effective when the educational environment (university and hospital) encourages professional behavior and prevents unprofessional behavior of people. It seems that a mentoring system is very necessary in the structure of general medical education to guide the formation of professional identity. By holding regular and continuous meetings with a fixed group of learners, the mentors provide feedback and guide their rethinking of their clinical experiences, and on the one hand, they help the learners adapt to the conditions of uncertainty, stress, and problems that occur to them and rehabilitate, and it helps to correct their behavior. In addition, mentoring helps to identify the challenges of the educational system that created the hidden curriculum. In a structure where students have short-term rotations in specialized and superspecialized departments, one cannot hope for effective training of professional behavior except with the mentoring system. Supportive environment and incentive policies, helping learners in resilience, and improving their personal growth are also other measures that can be effective in improving the professional behavior of learners.