|ORIGINAL RESEARCH ARTICLE
|Year : 2017 | Volume
| Issue : 1 | Page : 11-18
“In our own words”: Defining medical professionalism from a Latin American perspective
Klaus Puschel1, Paula Repetto2, Margarita Bernales2, Jorge Barros1, Ivan Perez1, Linda Snell3
1 Department of Family Medicine, School of Medicine, Pontificia Universidad Católica de , Santiago, Chile
2 Department of Health Psychology, School of Psychology Pontificia Universidad Católica de , Santiago, Chile
3 Centre for Medical Education, McGill University, Montreal, Québec, Canada
|Date of Web Publication||13-Jul-2017|
Lira 44, 2° Piso, Santiago, Región Metropolitana, Chile
Source of Support: None, Conflict of Interest: None
Background: Latin America has experienced a tremendous growth in a number of medical schools, and there are concerns about their quality of training in critical areas such as professionalism. Medical professionalism is a cultural construct. The aim of the study was to compare published definitions of medical professionalism from Latin American and non-Latin American regions and to design an original and culturally sound definition. Methods: A mixed methods approach was used with three phases. First, a systematic search and thematic analysis of the literature were conducted. Second, a Delphi methodology was used to design a local definition of medical professionalism. Third, we used a qualitative approach that combined focus groups and personal interviews with students and deans from four medical schools in Chile to understand various aspects of professionalism education. The data were analyzed using NVivo software. Results: A total of 115 nonrepeated articles were identified in the three databases searched. No original definitions of medical professionalism from Latin America were found. Twenty-six articles met at least one of the three decisional criteria defined and were fully reviewed. Three theoretical perspectives were identified: contractualism, personalism, and deontology. Attributes of medical professionalism were classified in five dimensions: personal, interpersonal, societal, formative, and practical. Participants of the Delphi panel, focus groups, and personal interviews included 36 medical students, 12 faculties, and four deans. They took a personalistic approach to design an original definition of medical professionalism and highlighted the relevance of respecting life, human dignity, and the virtue of prudence in medical practice. Students and scholars differed on the value given to empathy and compassion. Discussion: This study provides an original and culturally sound definition of medical professionalism that could be useful in Latin American medical schools. The methodology used in the study could be applied in other regions as a basis to develop culturally appropriate definitions of medical professionalism.
Keywords: Definition, Latin America, medical professionalism, mixed methods
|How to cite this article:|
Puschel K, Repetto P, Bernales M, Barros J, Perez I, Snell L. “In our own words”: Defining medical professionalism from a Latin American perspective. Educ Health 2017;30:11-8
|How to cite this URL:|
Puschel K, Repetto P, Bernales M, Barros J, Perez I, Snell L. “In our own words”: Defining medical professionalism from a Latin American perspective. Educ Health [serial online] 2017 [cited 2018 Feb 25];30:11-8. Available from: http://www.educationforhealth.net/text.asp?2017/30/1/11/210510
| Background|| |
Medical education in Latin America has experienced tremendous growth in the past two decades. Countries such as Brazil, Ecuador, Colombia, and Chile have led this growth, experiencing a 3- to 5-fold increase in the number of medical schools. In 2015, there were 548 medical schools in Latin America, a number that was similar to the 541 schools reported in Europe but much larger than the 193 institutions reported in Canada and the United States. The quality standards of these new institutions and specifically the development of medical professionalism during the formative process have been a matter of great concern for many academic leaders in the region.,,
Concerns on medical professionalism training in Latin America have grown due to a number of factors. First, evidence on the association between inappropriate behaviors at medical school and subsequent patient safety care problems and disciplinary actions against practicing physicians has been recognized.,,, Second, there has been an increase in the number of medical malpractice trials in Latin America, growing about 10%–15% annually, which has been partially linked to a lack of appropriate professionalism training at medical schools., Third, a growing process of accreditation of medical schools in Latin America has identified a lack of formal professionalism training., The Pan-American Federation of Medical Schools has identified training of medical professionalism as a main priority in medical education in the region for the next decade.
In spite of the importance of professionalism in medical training, there seems to be low level of scholarly reflection of this topic in the Latin American region. A systematic review conducted by Birden et al. in 2014 performed an extensive search to identify how professionalism was defined in the medical literature. Their final selection of 195 articles did not include any articles from Latin America with a definition of medical professionalism. The lack of a culturally specific definition of medical professionalism is a significant problem in that it prevents the development and assessment of a set of essential attributes to be acquired by medical students. These attributes have been considered to be highly context dependent and strongly related with the identity of medical practice.,,
There is extensive literature showing the complexity of defining medical professionalism. The available evidence shows that there are important differences among cultures in the definition of medical professionalism and also significant differences in the perspectives of students and faculties.,, A disconnection between students' and faculties' perspectives on the concept of medical professionalism could impair the formative process of physicians.
The expansion of medical education in Latin America requires a local scholarly reflection of medical professionalism as a key component of medical training. A culturally appropriate definition of professionalism is essential to know what to train students in this dimension. This study applied a mixed methods approach to develop a culturally appealing definition of medical professionalism and explored the meaningfulness of this definition in a diverse group of medical students and academic leaders in Chile.
| Methods|| |
The study used a mixed methods approach that included three phases. First, a comprehensive review with a systematic search of the literature was conducted to analyze published definitions of medical professionalism. Second, a culturally appropriate definition of medical professionalism was developed using a Delphi method approach based on an expert panel opinion. Finally, a qualitative design based on the framework model  was applied to critically analyze the locally developed definition of medical professionalism. [Figure 1] summarizes the design steps of the study.
The systematic literature search was conducted in English and Spanish and included three databases as well as a handsearching of article references and books. The databases used in the search were PubMed, Lilacs, and the World Health Organization Database (WHOLIS). Lilacs is the most important and largest health science database in Latin America and the Caribbean and contains journal articles, regional reports, and government documents. The search included publications in the databases through June 30, 2014. The English key terms used were “medical professionalism” and “definition.” The search was expanded in Spanish to increase sensitivity and included the key words “profesionalismo médico.” Articles that focused their analysis in definitional issues were selected for a final full review. The inclusion criteria were any of the following: the article provided a new definition of medical professionalism, it added attributes to a definition already existent, or it analyzed a definition already existent.
The literature review information was analyzed using a thematic analysis approach. This method has been developed to summarize qualitative and quantitative information and is based on the identification of prominent and recurrent themes in the literature. The information was organized in a hierarchical order through topic headings, main themes, and specific attributes associated with the identified themes.
The thematic analysis was applied using a predefined framework that included three hierarchical dimensions: (1) the ethical or predominant philosophical perspective used in the definition or description of the concept of medical professionalism; (2) the main themes that supported the concept; and (3) the key attributes associated with the definition or description of medical professionalism.
Consensus method: Delphi panel
In the second phase of the study, an expert panel of 12 faculties and four resident learners participated in a Delphi three-round strategy to develop a definition of medical professionalism based on the principal themes and concepts that emerged in the literature review.
The First round started with a semi-structured questionnaire that provided information on three common definitions of medical professionalism published in the literature.,, Participants were asked to identify theoretical principles and attributes found in the definitions and to add new attributes not included in the definitions provided. Then, they were asked to briefly define the main attributes selected and to support their choices. An iterative process of new definitions and attributes was analyzed and ranked by the panel participants. A consensus approach was used to select the theoretical perspective and to define the key attributes of the new definition. This approach used face-to-face meetings to reach consensus in addition to the formal iterative ranking system of the Delphi model.
In the third phase of the study, a group of deans from four Chilean medical schools participated in personal in-depth interviews analyzing the definition of medical professionalism developed by the expert panel. The deans represented a variety of Chilean medical schools including traditional institutions such as the Pontificia Universidad Católica de Chile (PUC) and the Universidad Austral de Chile and the new academic centers of the Universidad Diego Portales and the Universidad del Desarrollo. [Table 1] summarizes the characteristics of participant institutions. In addition, a group of 32 undergraduate and graduate students at PUC participated in four focus groups and analyzed the definition of medical professionalism developed in the Delphi phase of the study.
The analysis of the third phase was conducted based on the framework method.,, The method was selected for its capacity to analyze data based on a predefined set of themes and categories (framework). The framework used was the definition of medical professionalism designed by the experts in the Delphi phase of the study. Participants of the interviews and focus groups could add, change, eliminate, or create a new definition of medical professionalism. The analysis was based on the full transcription of the audio-recorded interviews and focus groups. NVvivo software (QSR International) program  was used for the analysis. It included a sequential process that started with an open and axial coding followed by the identification of nodes (key concepts) that were grouped in wider categories (dimensions). The program also provided information on the resource density, i.e., the number of participants that refer to a particular concept and the conceptual density, i.e., the number of references that participants made respect to a particular concept.
Funding and ethical review
The study was funded by an Educational Grant for Teaching (FONDEDOC #26-1-2013) provided by the Pontificia Universidad Católica de Chile. The study was reviewed and approved by the Ethical Committee at the Facultad de Medicina Pontificia Universidad Católica de Chile.
| Results|| |
A total of 115 nonrepeated articles were identified in the systematic search. Of those, 75 articles were identified in PubMed, 38 in Lilacs, and 2 in WHOLIS. The handsearching process identified ten additional articles and two chapter books. Twenty-six articles met at least one of the three decisional criteria defined previously and were included in the final analysis. [Table 2] summarizes the thematic analysis of the articles included in the final review. Most articles presented definitions from North America and Europe. There were no articles from Latin America that provided a new definition of medical professionalism. All Latin American articles analyzed previous definitions from North American or European origin. Three predominant theories emerged from the studies reviewed: contractualism, personalism, and deontology.
|Table 2: Theories, themes, dimensions and attributes associated with professionalism|
Click here to view
The attributes associated with the concept of medical professionalism were grouped into three main dimensions: personal, interpersonal, and societal. Similar dimensions were used in the systematic review conducted by Van De Camp et al. As presented in [Table 3], Latin American and non-Latin America scholars share many of the personal attributes associated with medical professionalism such as knowledge and clinical competence but differ in the relevance of others such as honesty. In the interpersonal and societal perspectives, respect and accountability appeared as essential attributes by both Latin American and non-Latin American scholars. Compassion and empathy were recognized as relevant attributes by most Latin American scholars, but there were not as significant for non-Latin American authors. Justice was identified as a relevant attribute of medical professionalism by only a minority of authors.
|Table 3: Dimensions and concepts identified by deans and students about medical professionalism|
Click here to view
Consensus method: Delphi panel
After considering the literature and their own experiences, the expert panel decided to take a personalistic perspective to design the local definition of medical professionalism. The decision was strongly influenced by the perspectives and definitions provided by Epstein and Hundert, the Association of American Medical Colleges, and the analysis conducted by Pellegrino. A personalistic approach is based on virtue ethics principles and focused on the values expressed during the personal interaction between physicians and patients in medical practice. It was preferred over a contractualistic approach that emphasizes the theoretical contract of the medical profession with the society or the deontological approach that focuses on the norms and duties that professionals have to follow during their praxis.
The expert panel defined medical professionalism as the medical conduct of excellence based on the respect of life and human dignity and in the virtues of benevolence, compassion, prudence, and justice.” In Spanish, it reads as: “Actuar medico de excelencia basado en el respeto a la vida y dignidad humana y en las virtudes de benevolencia, compasión, prudencia y justicia.”
There is no ideal translation for the Spanish expression of “actuar medico.” The emphasis of the expression is in the personal action. It refers to a way of doing, not just the “doing” alone. The panel considered that the emphasis in excellence was in line with the personalistic approach founded in the old Greek Hippocratic tradition of virtues rather than in principles or norms. The excellence as a way of practice reflects fulfilling one's potential. Therefore, it contains the attributes of knowledge and clinical competence necessary to all professionals but set a higher standard, i.e., the search of one's full professional capacity. Participants emphasized that the interpersonal dimension of medical practice, specifically with respect of life and human dignity, had precedence over other personal or societal attributes of the medical profession.
The panel preferred to include in the definition of the virtue of benevolence over the principle of beneficence given that it is centered on the person, the subject who is going to act (with virtue), rather than the act itself. Compassion was identified by the majority of experts as an essential element of the definition. However, there was a minority that preferred to include empathy instead. Both concepts express the ability of physicians to situate themselves in the place of their patients. Most experts considered that the concept of compassion included an affective dimension to the interaction with patients that was essential in good medical care and was not fully captured by the concept of empathy.
Prudence and humility were two related concepts that the panel debated whether to include in the definition. Both highlighted the importance of physicians being conscious of their own limitations and to be honest about them in their interactions with patients and health team members. Both concepts emphasized the relevance of avoiding overconfidence, a well-known source of medical error in clinical practice. The majority of participants preferred to include prudence because it was a virtue with an interpersonal emphasis directed to the benefit of the other (e.g., patient and health professional). It reflected the capacity of balancing all possible courses of action and choosing the one with the greatest benefit for the patient.
Justice was recognized as a relevant concept to include in the definition of medical professionalism by the majority of the panel. It reflected a contribution of medical profession to reduce social health disparities. However, there was a disagreement in the application of this concept in medical practice. Some participants considered that physicians should serve socially vulnerable patients as part of their routine practice; others emphasized that physicians should be involved in health policies to reduce health inequalities.
[Table 3] shows the results of the qualitative analysis based on the information collected from focus groups and interviews developed with students and deans. The information about professionalism was classified in six main dimensions: conceptual, formative, practical, personal, interpersonal, and societal. These dimensions included the categories defined by Van De Camp et al. but added the conceptual, formative, and practical dimensions.
In the conceptual dimension, students emphasized the complexity of the idea of medical professionalism, whereas most deans highlighted its essential value in the medical profession. Both agreed on the importance of having a local definition, which refers to a definition developed in “our own words.” There was a high agreement between students and deans on the relevance of including medical professionalism on the formal curriculum and the importance of role modeling as a key formative strategy.
In line with the definition provided by the expert panel, prudence was recognized as an essential component of medical practice both by students and faculty. Furthermore, in the same line, altruism was not identified as an essential component of medical professionalism by any group. However, there was a disagreement on the importance of compassion versus empathy. Students tend to value empathy higher than compassion. Finally, justice was recognized as the most important component in the societal dimension of medical professionalism.
[Table 4] summarizes the dimensions and attributes of medical professionalism identified by scholars in Chile, Latin America, North America, and Europe. It compares the information obtained in the literature review with that collected through focus groups and individual interviews.
|Table 4: Comparative perspectives on key dimensions and attributes associated with medical professionalism|
Click here to view
| Discussion|| |
This study provides an analysis and original definition of medical professionalism from a Latin America perspective. Our study confirms the lack of original work on medical professionalism in Latin America. The results of our systematic search of the literature were similar to the findings of the systematic review conducted by Birden et al. which also did not find Latin American studies with an original definition of medical professionalism. Furthermore, no original definitions were found when searching regional databases. The lack of original definitions on medical professionalism in Latina America is a delicate situation given the tremendous increase in the number of medical schools in the region,, the importance of professionalism in medical education,,, and the significant cultural variations of this concept across cultures.,
The results of this study show that most definitions of medical professionalism can be grouped in three ethical perspectives: contractualism, personalism, and deontology. Most studies combine ethical perspectives but recognize one of them as the starting point. Contractualism and personalism were the predominant theories analyzed in most Latin American studies. From an ethical perspective, both theories consider the person within a community as the central agent that defines the appropriateness of a medical action. However, both perspectives lack the categorical certainty found in the deontological perspective, which is centered in the norm of practice rather than the person. Social contracts are virtual contracts not fully enforceable by the community., On the other hand, personalism is highly hermeneutical and exposed to diverse interpretations for similar situations when defining an appropriate course of action. There seems to be no ideal perspective, but in the majority of cases, Latin American scholars preferred the uncertainty of social contract or personalism rather than the rigidity of deontology.
When comparing the dimensions and attributes of medical professionalism identified by scholars in Latin America, there was a high level of agreement on most attributes. The most significant difference was the importance given by Chilean scholars to the virtue of prudence. Prudence has not been identified as a key component in most definitions of medical professionalism conducted in North America or Europe.,,, The emphasis in prudence clearly reflects the personalistic approach of our medical community. In this approach, potential courses of medical actions are balanced to select the one that better protects human dignity. It follows a traditional Aristotelian tradition based on the value of “phronesis,” the practical wisdom that allows physicians to combine intellectual knowledge (“episteme”) with the praxis (“techne”) of the medical profession., In this study, most Chilean scholars considered prudence to better express the value of clinical competence given that it includes the necessary judgment that needs to be applied in medical practice, especially when facing uncertain clinical scenarios.
In a changing Latin American culture where social accountability to the medical profession is increasing and where management regulations on physicians are higher, prudence seems to be a particularly sensitive attribute for good medical praxis.,, Lack of prudent medical care has been identified as one of the main sources of medical errors, especially in systems with lax clinical regulations., Medical training in Latin America should probably prioritize prudence as an essential dimension of professionalism and should integrate that dimension with a competence-based model.
This study has important limitations. In spite the fact that we conducted a systematic search of three databases, it is certainly possible that various academic communities in Latin America have gone through reflections and generated local definitions on medical professionalism that are not widely or formally disseminated. Another limitation is that the qualitative phase of our study explored the perceptions of students of one medical school (PUC) which might not reflect the perceptions of students of other institutions. Furthermore, the perceptions of the Chilean deans interviewed might not reflect those of other academic leaders in Latin America. To face these limitations, we contrasted our findings with the existent Latin America publications and the most prominent international publications to get a comprehensive perspective of similarities and differences around the concept of medical professionalism.
| Conclusion|| |
This study shows that there is a concerning lack of definitions and systematic reflection on medical professionalism in Latin America. It provides a new definition of medical professionalism based on a personalistic approach that emphasizes the value of human dignity and the virtues of medical practice. The definition highlights the relevance of prudence as the practical wisdom that should guide clinical competence in the frequent uncertain scenarios of medical practice. The methodological approach used in this study could be applied by scholars in other regions who wish to develop a culturally appropriate definition of medical professionalism.
Financial support and sponsorship
The study was funded by an Educational Grant for Teaching (FONDEDOC #26-1-2013) provided by the Pontificia Universidad Católica de Chile.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Foundation for Advancement of International Medical Education International (FAIMER). Medical Education Directory; 2015. Available from: http://www.faimer.org/resources/imed.html
. [Last cited on 2016 Feb 09].
Pulido MP, Cravioto A, Pereda A, Rondón R, Pereira G. Changes, trends and challenges of medical education in Latin America. Med Teach 2006;28:24-9.
Salazar ZC, Cardemil MF, Peña HJ. Current state and implicancies of accreditation of medical schools in Chile. Rev Med Chil 2009;137:1126-7.
Walton M, Woodward H, Van Staalduinen S, Lemer C, Greaves F, Noble D, et al.
Republished paper: The WHO patient safety curriculum guide for medical schools. Postgrad Med J 2011;87:317-21.
Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med 2004;79:244-9.
Teherani A, Hodgson CS, Banach M, Papadakis MA. Domains of unprofessional behavior during medical school associated with future disciplinary action by a state medical board. Acad Med 2005;80 10 Suppl:S17-20.
Wynia MK, Papadakis MA, Sullivan WM, Hafferty FW. More than a list of values and desired behaviors: A foundational understanding of medical professionalism. Acad Med 2014;89:712-4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24667515
. [Last cited on 2015 Nov 06].
Asociación Civil de Actividades Médicas Integradas (ACAMI). IX Congreso Argentino de Salud. Puerto Iguazú, Misiones, Argentina; 2010.
Rios A, Fuente del Campo A. Alcances legales en el ejercicio de la medicina. Una visión comparada en latinoamérica. Perf Cienc Soc 2015;2:12-45.
Goic A. Proliferation of medical schools in latin America. Causes and consequences. Rev Med Chil 2002;130:917-24.
Pulido MP. Desafíos de la educación en ciencias de la salud en las Américas. Cartagena de Indias 7-9 de Junio de 2011. Panam Fed Assoc Med Sch Fed Panam Assoc Fac Med; 2011.
Birden H, Glass N, Wilson I, Harrison M, Usherwood T, Nass D. Defining professionalism in medical education: A systematic review. Med Teach 2014;36:47-61.
Sox HC. The ethical foundations of professionalism: A sociologic history. Chest 2007;131:1532-40.
van Mook WN, van Luijk SJ, O'Sullivan H, Wass V, Harm Zwaveling J, Schuwirth LW, et al.
The concepts of professionalism and professional behaviour: Conflicts in both definition and learning outcomes. Eur J Intern Med 2009;20:e85-9.
Cruess RL, Cruess SR, Boudreau JD, Snell L, Steinert Y. Reframing medical education to support professional identity formation. Acad Med 2014;89:1446-51.
Cuesta-Briand B, Auret K, Johnson P, Playford D. 'A world of difference': A qualitative study of medical students' views on professionalism and the 'good doctor'. BMC Med Educ 2014;14:77.
Hur Y. Are there gaps between medical students and professors in the perception of students' professionalism level? – Secondary publication. Yonsei Med J 2009;50:751-6.
Adkoli BV, Al-Umran KU, Al-Sheikh M, Deepak KK, Al-Rubaish AM. Medical students' perception of professionalism: A qualitative study from Saudi Arabia. Med Teach 2011;33:840-5.
Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol 2013;13:117.
Dixon-Woods M, Agarwal S, Jones D, Young B, Sutton A. Synthesising qualitative and quantitative evidence: A review of possible methods. J Health Serv Res Policy 2005;10:45-53.
Swick HM. Toward a normative definition of medical professionalism. Acad Med 2000;75:612-6.
Medical Professionalism Project. Medical professionalism in the new millennium: A physicians' charter. Lancet 2002;359:520-2.
Pope C, van Royen P, Baker R. Qualitative methods in research on healthcare quality. Qual Saf Health Care 2002;11:148-52.
Püschel K, Thompson B, Coronado G, Gonzalez K, Rain C, Rivera S. 'If I feel something wrong, then I will get a
mammogram': Understanding barriers and facilitators for mammography screening among Chilean women. Fam Pract 2010;27:85-92.
Welsh E. Dealing with data: Using NVIVO in the qualitative data analysis process. Forum Qual Soc Res 2002;3:26.
Van De Camp K, Vernooij-Dassen MJ, Grol RP, Bottema BJ. How to conceptualize professionalism: A qualitative study. Med Teach 2004;26:696-702.
Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002;287:226-35.
Pellegrino ED. Professionalism, profession and the virtues of the good physician. Mt Sinai J Med 2002;69:378-84.
Duvivier RJ, Boulet JR, Opalek A, van Zanten M, Norcini J. Overview of the world's medical schools: An update. Med Educ 2014;48:860-9.
Kirch DG, Gusic ME, Ast C. Undergraduate medical education and the foundation of physician professionalism. JAMA 2015;313:1797-8.
Cruess R, Cruess S, Ginsburg S, Kearney R, Ruhe V, Ducharme S, et al
. Teaching, Learning and Assessing Professionalism at the Post Graduate Level. The Association of Faculties of Medicine of Canada; the College of Family Physicians of Canada; Le Collège des Médecins du Québec; and, the Royal College of Physicians and Surgeons of Canada; 2011. Available from: https://www.afmc.ca/pdf/fmec/20_Cruess_Professionalism.pdf
. [Last cited on 2015 Nov 03].
Cruess SR, Cruess RL, Steinert Y. Linking the teaching of professionalism to the social contract: A call for cultural humility. Med Teach 2010;32:357-9.
Chandratilake M, McAleer S, Gibson J. Cultural similarities and differences in medical professionalism: A multi-region study. Med Educ 2012;46:257-66.
Graham G. Theories of Ethics: An Introduction to Moral Philosophy with a Selection of Classic Readings. New York: Routledge; 2011.
Puschel K, Rojas P, Erazo A, Thompson B, Lopez J, Barros J. Social accountability of medical schools and academic primary care training in Latin America: Principles but not practice. Fam Pract 2014;31:399-408.
Vanlaere L, Gastmans C. A personalist approach to care ethics. Nurs Ethics 2011;18:161-73.
Cruess SR, Johnston S, Cruess RL. “Profession”: A working definition for medical educators. Teach Learn Med 2004;16:74-6.
Davis FD. Phronesis, clinical reasoning, and Pellegrino's philosophy of medicine. Theor Med 1997;18:173-95.
McGee G. Phronesis in clinical ethics. Theor Med 1996;17:317-28.
Moreno Villares JM. Phronesis: Medicine's indispensable virtue. Cuad Bioet 2014;25:105-10.
Valenzuela C. Medical error and malpractice: Medical responsibility. Caudernos Médicos Soc 2009;49:178-83.
Siurana Aparisi JC. The principles of bioethics and the growth of an intercultural bioethics. Valparaíso: Veritas, Pontificio Seminario Mayor San Rafael; 2010. p. 121-57.
Tonkin-Crine S, Yardley L, Little P. Antibiotic prescribing for acute respiratory tract infections in primary care: A systematic review and meta-ethnography. J Antimicrob Chemother 2011;66:2215-23.
Murphy JG, Stee L, McEvoy MT, Oshiro J. Journal reporting of medical errors: The wisdom of Solomon, the bravery of Achilles, and the foolishness of Pan. Chest 2007;131:890-6.
[Table 1], [Table 2], [Table 3], [Table 4]