Introduction
The overall purpose of developing competence as an ophthalmologist is to improve the physician-patient relationship and the medical care that accompanies that relationship. Competent ophthalmologic practice requires both technical and ethical competencies. Technical competencies comprise the knowledge and skills required to practice medicine, especially ophthalmology, according to current standards of care. Ethical competencies are demonstrated by (1) acting as an agent of each patient, (2) developing a caring relationship with patients, and (3) appreciating clinical ethical problems.
Background
The American Academy of Ophthalmology is dedicated to providing ophthalmologists with information and the education necessary to provide optimal ophthalmic care to the patient. The quality of such care is based on competence achieved through training, professionalism, and continuing education. The Academy's Code of Ethics, which serves as a standard for exemplary professional conduct, requires that an ophthalmologist be competent by virtue of specific training and experience (Rule 1). However, the rules of the Academy's Code of Ethics specify neither the components of competence nor the skills that compose it. Competence for medical (ophthalmologic) practice does not occur in the abstract. Physician competence exists for the purpose of advancing the best interests of the patient as a person with sensitivity and with respect for and understanding of the patient’s sovereignty, needs, and wants.
(For the purposes of this discussion,) The word “ethics” generally refers to professional principles and “morals” generally refers to how an individual applies those principles in his or her own behavior. Ethical competencies are those that preserve, protect, and advance the best interests of the patient through the practice (a process) of applying knowledge, skills, and attitudes that resolve the human conflicts and dilemmas of clinical and scientific endeavor on principled bases.
Ophthalmologic Competence
Both ethical and technical capacities are necessary components of ophthalmologic competence. Ophthalmologic competence is a continuing process of self-development that involves acquiring and refining the knowledge, skills, values, and expectations that allow for the provision of quality patient care. This acquisition process, of necessity, must proceed along two paths:
1) an outward-directed process of study and instruction in the vocabulary, concepts, case studies, negotiation strategies, and so on, that concern ethical and technical competencies, and
2) an inward-directed process of personal experience and insight that integrates personal and professional development as well as ethical and technical competencies.
Ethical Competence
Ethical competence follows from understanding the purpose of medical care, and it calls upon the physician to practice moral discernment, moral agency, and caring in relationships.
Moral discernment is the ability to recognize, confront, discuss, and resolve the ethical considerations in a clinical encounter. In particular, it is the ability of the physician to
• use the vocabulary and concepts of ethical and moral reasoning to place a moral dilemma in perspective;
• respect the cultural, social, personal beliefs, expectations, and values that the patient brings to the therapeutic setting;
• respect the patient's chosen lifestyle and acknowledge the conditions and events that have helped to shape that lifestyle;
• confront his or her own beliefs, expectations, and values when faced with different perspectives; and
• reflect on the causes and consequences of his or her moral decisions.
Moral agency is the ability to act on behalf of the patient—to act with respect for social, religious, and cultural differences that may exist between physician and patient. It is the ability of the physician to
• consider the possible consequences of his or her actions and to act to affect consequences that are in accord with his or her own values and those of the patient;
• resolve differences on the basis of principle rather than power;
• provide medical care that is both professionally appropriate and socially responsible;
• genuinely engage the patient as a fellow human being;
• keep the confidences of the patient; and
• resolve dilemmas in favor of his or her agency to the patient and recognize that extreme or unusual circumstances (e.g., war or epidemics) may require placing greater emphasis on appropriate interests of society over those of the patient.
A caring and healing relationship between physician and patient is the foundation of medical care. Such a relationship is characterized by the ability of the physician to
• acknowledge the patient's right to self-determination in the process of participating in his or her own care;
• avoid conflicts of interests in his or her own personal, professional, and financial relationships with patients, colleagues, and other members of the health care community;
• provide the patient complete, accurate, and timely information about treatment options in the best spirit of informed consent;
• share his or her weaknesses and limits as well as strengths and virtues; and
• strive to be compassionate through progressively deeper understandings of others' behavior.
Technical Competence
Technical competence consists of the knowledge and skills necessary to diagnose and treat disease and disability according to the precepts of medical science, especially of ophthalmology, and to assist in the maintenance of health. Technical competence is a comprehensive construct, but it should include the ability of the physician to
• apply principles of ophthalmic care;
• differentiate normal and pathological anatomy and physiology of the eyes and visual system;
• understand the relationships between ophthalmic and systemic health and disease;
• perform skills intrinsic to medicine in general and to ophthalmology in particular;
• provide necessary and sufficient medical care;
• develop, critique, and present appropriate therapeutic options;
• provide timely, complete, and accurate documentation about patient care and communicate appropriately with other members of the medical community and the health care system;
• acknowledge his or her limitations in skill and knowledge; and
• make a commitment, through study, instruction, and experience, to keep his or her medical skills and knowledge current.
We acknowledge the importance of ethical commitments and technical skills to the education, practice, and credentialing of ophthalmologists. Further, we believe that the curriculum of ophthalmology should specifically address both the ethical and technical competencies and the two paths (i.e., the outward- and inward-directed processes) to developing them, and it should be defined further for purposes of assessment and accountability.
Approved by: Ethics Committee, January 1991
Revised & Approved by: Ethics Committee, February 1999
Revised & Approved by: Ethics Committee, June 2004
Revised & Approved by: Ethics Committee, July 2008
Revised & Approved by: Ethics Committee, June 2013
Revised & Approved by: Ethics Committee, July 2018
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