Can the Salutogenic Model Help Improve Healthcare Professionalism and the Patient Experience?

Thursday, December 29, 2016

Since its origin, healthcare has pursued an aim morally proper for humanity. The means used by healthcare practitioners are defined by the rule of Lex Artis, which is the set of principles and methods for diagnosing the conditions, the instructions and procedures for treatment and the application of routines in performing surgeries that are commonly accepted in the literature of the corresponding medical specialty.

A Little Background

The fundamental principles of the healthcare profession have their origins in ancient Greece and Rome, based on the mythical beliefs of the “doctor-hero” or “doctor-god” Asclepius. According to that model, the image of a professional is someone with high expectations of success.

However, medicine isn´t restricted exclusively to the technical dimension. Good professionals must adopt a double personality. On one hand, they are scientists focused on the illness; on the other hand, they need to demonstrate compassion for the patient. This duality places the discipline between natural and social sciences—in other words, between Lex Artis and the Humanism.

Although physicians enjoyed great prestige and public faith for several centuries, multiple elements have modified the stage—setting an increasing displeasure with medicine. Some pundits have described modern practices as the “dehumanization of the medicine,” or what Michel Foucalt deemed the “anti-medicine.”

Enter Medical Professionalism

Reactions to this dissatisfaction seemed to begin with the postwar period. As a consequence of the Nazi experimentation’s horrors, the Code of Nuremberg (1947) was decreed, which turned out to be one of the first steps to establish the Universal Declaration of Human Rights. Many subsequent agreements formed the new medicine:

  • In 1979, bioethics Tom L. Beauchamp and James F. Childress developed four principles at the core of moral reasoning in the current regulation for research in human beings: autonomy, non-maleficence, beneficence, and justice.

  • In 1977, the American psychiatrist George Engel proposed the biopsychosocial model or participative focus of health and disease, which postulates that the biological (chemo-biological factors), psychological (thoughts, emotions, and behaviors) and social factors perform a meaningful role in the human activity, in the context of an illness or a disability.

  • In 1993, the Hastings Center in New York initiated the international project, titled “The Goals of Medicine,” under the direction of Daniel Callahan.

  • In 1999, the European and American associations of Intern Medicine defined the principles that determine the relationship doctor-patient and society: the primacy of patient welfare, patient autonomy, and social justice. This is deemed by many to be the concept of modern Medical Professionalism.

Medical Professionalism is defined as the basis of medicine’s contract with society, establishing the following commitments of the physician:

  • Professional competence: be competent and learn lifelong the Lex Artis.
  • Honesty with patients: dominate the process of informed consent, and be self-critical.
  • Patients’ confidentiality: fulfill the commitment of patient’s confidence.
  • Appropriate relationships with patients: avoid sexual advances and financial gain.
  • Improved quality of care: reduce medical error, increase patient’s safety, avoid the excessive use of resources, and optimize outcome.
  • Access to health attention: reduce barriers to an equal health care.
  • Just distribution of finite resources: wise and cost-effective management.
  • Scientific knowledge: shelter the scientific standards, promote research, create new knowledge, and ensure their proper use of research and knowledge.
  • Trust: recognize, disclose and deal with conflicts of interest.
  • Professional responsibilities: participate in the process of self-regulation and standard setting.

The goal is to improve patient experience across the continuum of care. This means providing the best clinical care and service possible to patients, making considerations for their safety and physical comfort, as well as educational, emotional, and spiritual needs.


Spreading Professionalism Through Formal Education

Incorporating Medical Professionalism into the curriculum of those pursuing careers in healthcare has been emphasized in recent years. In fact, a growing number of faculty members working health sciences programs are promoting behaviors associated with personal integrity, professional engagement, quality of attention, continual learning, and service vocation. 

Multiple efforts have been made to formalize the roles and competencies of teachers and clinical tutors teaching Medical Professionalism, through the training of specific strategies in teaching and assessment. Furthermore, programs and experiences devoted to education future healthcare practitioners about professionalism have been the goal of multiple studies in the formal curricula (as well as the hidden curricula) of various institutions around the globe.

But this task has been neither easy nor useful. In fact, the scientific evidence in medical/healthcare education reveals that there is much confusion in the interpretation of this construct among the educators. What’s more, many programs focus on technical medicine competencies (knowledge, skills, and attitudes) in an entirely independent way from professionalism. And most learning and assessment strategies are implanted in a separate, hierarchical way that overvalue medicine practices that are solely based on science. Consequently, it’s going to be hard to promote the “re-humanization of medicine.”

Adding to the problem are changes in social and political context of that have increased responsibilities and work demands healthcare providers. This requires them to develop new competencies to improve decision making problem solving under uncertain and risky situations. In addition, there is much evidence that many students and healthcare professionals have high levels of stress and burnout, anxiety and depression disorders, job dissatisfaction, and low quality of life. These psycho-affective states, which produce adverse biological responses, also affect empathy, engagement, and professionalism. In turn, this has an impact on the patient's experience.

Promoting the Salutogenic Model

What can educators do to help doctors and healthcare professionals? One theory promoting the integration of physical, mental, and social components of healthcare is the Salutogenic Model. Created by Aaron Antonovsky, this model makes several key assumptions:

  • emphasis is made on the origins of health and welfare
  • principal preoccupation is centered on maintaining and highlighting well-being
  • rejects the notion that stress is intrinsically harmful and opens the possibility that some stress may have healthy or beneficial consequences, depending on their features and whether people can manage it.

Part of this model is the General Resources of Resistance (GRRs), which are biological, material, and psychosocial elements that help people sense their life as coherent, structured, and understandable. The typical GRRs are money, knowledge, experience, self-esteem, healthy habits, commitment, social support, cultural capital, intelligence, traditions, and a person’s vision of life. When people have these resources at their disposal, they are more apt to face the challenges in life and build coherent experiences.

However, beyond simply acquiring GRRs, it is important to have the ability to use them. This is what Antonovsky called the Sense of Coherence (SOC), which is comprised of three key components:

  1. comprehension (cognitive component)
  2. manageability (behavior component)
  3. significance (motivational component).

This means that people not only understand how their lives are organized and where they stand in the world, but also how to handle life situations and work toward goals they want to reach.

Moving Forward

For those working in healthcare, a major challenge is finding balance between being competent, being satisfied with the work, and managing stress. There is growing evidence that the Salutogenic Model is a health-promoting resource that improves the quality of life and wellbeing. There is even evidence in the development of a Sense of Coherence in Teaching Situations (SOCITS).

As educators, we should strengthen our own knowledge on the constructs of Medical Professionalism and incorporate the Salutogenic Model into the purpose of training. We need to center the teaching process on the construction of being—stimulating reflection at the intrapersonal level as an additional tool in medicine, and facilitating processes that enable students to achieve high levels of manageability and understanding about the significance of their personal and professional lives. In this scenario, modeling is a fundamental teaching strategy, which in turn constitutes a benefit for the one who teaches. Doing so can produce a virtuous circle that improves the healthcare professionalism and the patient experience.

About the Author
Liliana Ortiz, MD, is the program director of the Master’s degree in medical education at the University of Conception, Chile. She works in curriculum development in health education and teaches ethics in research, bioethics, and medical humanities to medical students.  Her research interests are student’s well-being, education environment, professionalism in medicine, and self-directed learning. Currently, she is developing an interprofessional education project to stimulate outcomes to improve research and innovation in healthcare. Liliana Ortiz es médica  de la Universidad de Concepción, Chile, Diplomada en Bioética Clinica de la Pontificia Universidad Católica de Chile, Magister en Educación Médica de la Universidad de Concepción y candidata a doctora en Ciencias Biomedicas del Instituto Universitario del Hospital Italiano, Buenos Aires, Argentina. Actualmente es Directora del Magister en Educación Médica de la Universidad de Concepción, donde enseña gestión educativa, ética de la investigación en seres humanos, Bioética y humanidades médicas. Sus líneas de investigación y desarrollo son el curriculum en Educación médica y las humanidades médicas. En el último periodo ha investigado sobre bienestar académico, ambiente educativo, profesionalismo en medicina y aprendizaje autodirigido.Además, se encuentra liderando un proyecto multiprofesional para desarrollar pensamiento creativo y perfil innovador en  estudiantes universitarios.  
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