Professionalism in Medical Education

Neera KhilnaniJohn Luk

José GonzalezVirginia Niebuhr

UTMB Pediatric Grand RoundsSept 14, 2007

Case

Dr. A. Tending, a Pediatric faculty member, received her MyUTMB summative evaluation from the residents she had supervised on wards over the past year.

Her overall score is near the group mean, which pleases her.

But her score on Professionalism is a 6.7, a full point lower than the mean of 7.7.

Does this really mean she is she less professional than her colleagues?

What criteria are the residents using in rating her?

The next day, Dr. T. has an In-Box message:

“Please evaluate Dr. Rezi Dent for the rotation ending last week”

Dr. T. knows this involves the 6 ACGME competencies:Patient Care

Medical Knowledge

Professionalism

Systems Based Practice

Practice Based Learning

Interpersonal Skills/Communication

Case

She wonders how to accurately identify the professionalism competency of a resident.

Does this 9-point Likert scale suffice?

Is a radio button sufficient, or is comment needed?

It’s also time to evaluate a medical student who has just completed a 4th-year elective. One of the categories is Professionalism.

Dr. T. was only directly supervising this student for four half-day sessions.

The student was on time and very pleasant. But there must be more on which to base this evaluation.

She wonders how can she evaluate professionalism?

At Faculty meeting this week, the program director reviewed some requirements of the ACGME:

Program Directors are required to certify that each graduating resident is competent in the domain of Professionalism.

Understanding that program directors do not have opportunity to work individually with each resident in a clinical setting, Dr. T. wonders what information program directors use to certify competency in Professionalism.

The RRC also requires each program to provide:

• “documentation of teaching of Professionalism.” Dr. T. ponders “Can professionalism truly be taught, or just learned?”

• “written evaluations of a resident’s professional behavior by patients/families and members of the healthcare team based on direct observation.” Dr. T. wonders, “Are we doing this?”

• “discussion of critical incidents (especially positive or negative behaviors) must be part of the ongoing mentoring of every resident.” Again, Dr. T. considers this information.

In addition to resident requirements, the RRC has requirements for Faculty:

• The program must annually evaluate faculty performance as it relates to education.

• Evaluations should include review of faculty’s clinical knowledge, scholarly activities, and professionalism

• Evaluation must include annual written confidential evaluations by the residents

Dr. T. wonders “Do residents know how to evaluate faculty professionalism?”

Dr. T. decides to check a new resource to see if it will help her understand this pervasive concept of professionalism.

She looks at Professionalism in Pediatrics, a new resource linked to the UTMB Pediatric Medical Education website.

Professionalism

• Concept of professionalism pervades medical education from many angles

• Is it is easy as :

“You’ll know professionalism when it’s present, and

you’ll certainly recognize when it’s absent.”

• Do we really understand the concept?

Objectives for Today

Our objectives are that you will : • Consider how complex is ‘professionalism’

in medical education

• Consider how we can define “Professionalism”

• Learn something about a new resource:

Professionalism in Pediatrics

History of Professionalismin Medical Education

mid-to-late 1990’s

• recognition that medicine's commitment to the patient was being challenged by external forces of change in society (e.g. managed care, healthcare financing challenges)

• increased call for renewed sense of professionalism

Professionalism Project Amer. Board of Internal Medicine. 1990 – 94

Chair, Dr. John Stobo (later to become UTMB President)

Goals

• Define professionalism

• Raise consciousness of concept of professionalism

• Provide means for including concepts of professionalism in residency training

• Develop strategies for assessing professionalism of residents & fellows

Professionalism Charter Project 1999 – 2002

• American College of Physicians – American Society of Internal Medicine

• American Board of Internal Medicine Foundation• European Federation of Internal Medicine

Result:Physicians’ Charter, Lancet, 2002

Physicians’ Charter

Fundamental principles• primacy of patients' welfare• patients' autonomy • social justice

A set of 10 professional commitments to..• professional competence• honesty with patients• patients' confidentiality• maintaining appropriate relationships with patients• improving quality of care• improving access to care• just distribution of finite resources• scientific knowledge• maintaining trust by managing conflicts of interest• professional responsibilities

Major initiatives to teach professionalism as a core competency

and to require measurement

1. GEA (Group on Educational Affairs) of AAMC Project Professionalism: Assessment

2. ACGME (Accreditation Council for Graduate Medical Education) ACGME Outcomes Project

Major initiatives, cont.

3. ABP (American Board of Pediatrics) requires assessment of professionalism in final evaluation of residents/fellows

• separate from clinical competence • certification from program director

4. ABP requires evidence of professionalism in board re-certification process

Major initiatives, cont.

5. ABP Program Directors Committee &APPD (Assoc. of Pediatric Program Directors) developing a resource document to include …

– issues relevant to professionalism in clinical care

– statements describing exemplary conduct & lapses in professionalism

– objectives related to professionalism in the curriculum

– teaching strategies

– methods & tools for assessing professionalism

Professionalism Initiatives at UTMB

1997 Stobo became UTMB President

2000 UTMB Professionalism Board • clinical, administrative & educational leadership• mission: promoting culture of professionalism

Professionalism Initiatives at UTMB, cont.

• Diversity Council

• Matriculation Ceremonies – Student Honor Pledge Day

– White Coat or Pin Ceremonies

• Graduation Activities – SON: Florence Nightingale Ceremony

• UTMB Professionalism Charter (2005)

• Gold Humanism Honor Society Chapter (2005)

• Professionalism Project Awards (2006)

Professionalism Award to Dept. Pediatrics

• Team: Niebuhr, Khilnani, Luk, Gonzalez

• Goal: to develop a resource which might help improve our evaluation of professionalism

• Awarded Summer 06

• First step in our process - defining the term

Defining Professionalism

Be Specific:

• We advise parents to avoid a vague requirement to “be good”

• Similarly, should we avoid a vague expectation to “be professional”?

Prism Analogy:

Defining Professionalism

 

Nine constructs, drawn from• the ACGME• the Gold Humanism Foundation • UTMB Professionalism Charter 

Defining Professionalism

• Compassion • Honesty • Altruism • Responsibility • Aiming for Excellence • Confidentiality • Teamwork • Ethical approach • Respect

Compassion

• Compassion (empathy; awareness of other’s feelings and experiences)

– sympathetic recognition of another’s distress with the desire to alleviate it.

Honesty

• Honesty (truthful and sincere) – fairness and straightforwardness of

conduct

– includes admission of mistakes/errors

Altruism

• Altruism – unselfish concern for the welfare

of others

Responsibility

• Responsibility – taking pro-active accountability for

one’s actions and their consequences

– for conduct, work obligations, and self-improvement

– synonym: duty

Aiming for Excellence

• Aiming for excellence– striving to perform at the highest

standards of the profession

– in self, others, and the system of healthcare

Confidentiality

• Confidentiality – to hold secret all information relating to

a patient (unless consents to disclosure)

– recognizing the importance of privacy of patient information,

– adhering to rules of discretion regarding patient information (e.g. HIPAA)

Teamwork

• Teamwork– combining individual efforts in a

synergistic way to reach the common goal of thorough, quality patient care

Ethical Approach

• Ethical approach– adherence to ethical principles of

• patient autonomy

• beneficence

• non-maleficence

• justice

Respect

• Respect – to show politeness or deference to

patients/families, colleagues, team members and faculty

– to show regards for or to have an appreciation of someone or something

– includes respect for diversity

The Resource

• Rationale

• Goalso a resource to promote thinking about

concept of professionalism o promoting the practice of reflection o an outcome possibly useful for

evaluating professionalismo Galveston-Austin collaborative

We can do better than “You’ll know it when

you see it and you’ll know

when it is absent.”

• Desired or Required Elements – Integrated

(not a rotation or specifically scheduled)– Any-time, any-place– For faculty and residents– Involving reflection: private and public– With a system for tracking utilization

CHARACTER

C ompassionH onestyA ltruismR esponsibilityA iming for excellenceC onfidentialityT eamworkE thical ApproachR espect

Design and Access

1. Nine Modules• one for each letter of CHARACTER • thought-provoking readings• accessible from WebCT: Pedi 1001 Professionalism

2. Synthesis/Application/Challenge Activities • submitted through WebCT Assignment Drop-Box• contributors can expect feedback from the authors

3. Observations & ReflectionsChallenge to identify, for each of the nine components,

examples of professional behavior or lapses of professionalism (in self or others)

Participants

• Residents:– adopted as required competency demonstration

for interns in our UTMB Pediatric residency programs: – Categorical Pediatrics - UTMB-Galveston

– Categorical Pediatrics - UTMB-Austin

– Combined Medicine-Pediatrics

– Combined Pediatrics-Dermatology

• Faculty – encouraged to complete series within one year

of beginning participation in Residency education

• link to Pediatric Education Page

• link to Professionalism in Pediatrics

• WebCT

A Concept within a Concept

• Professionalism in Health Care

• Professionalism in Medical Education

Return to Case

• 2 months later….– Dr. T had time to reflect on the CHARACTER

acronym

– She helped her resident mentee complete Professionalism in Pediatrics

– She now feels more comfortable with the concept of Professionalism

– She discovered and read the AAMC Resident/Faculty Compact and shared it with her department

AAMC Resident-Faculty Compact

• A pledge and a reminder….

The purpose of the Compactis to provide institutional GME sponsors,

program directors and residents with a model statement

that will foster more open communication, clarify expectations and

re-energize the commitment to the primary educational mission

of training tomorrow’s doctors.” www.aamc.org/residentcompact