Collegial Conversations 2: Evaluating Undergraduate Students

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Collegial Conversations 2Evaluating
Undergraduate Students

• Monica Branigan MD, MHSc
• Undergraduate Theme Coordinator Ethics and
  Professionalism

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Objectives

• 1. Discuss the rationale for evaluation
• 2. Review how to complete the Professionalism
  Evaluation form
• 3. Identify the process by which lapses and
  critical incidents are dealt with

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Rationale

• A student needs feedback on what they did well
  and what could be improved to become a
  professional
• Completion of the Professionalism Evaluation form
  could be such formative feedback
• This should be a judgement about behaviours in
  context and not assumptions about character

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Bottom line

• We have evidence that unprofessional behaviour in
  medical school is associated with subsequent
  disciplinary action
• This may represent 1-3 of students
• Unprofessional behaviour in medical school.
  board
• Papadakis et al
• Academic Medicine 2004 79 244-9

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Clerkship Professionalism Evaluation Form

• Organized around the values of
• Altruism
• Duty
• Excellence
• Respect
• Honour and Integrity
• Behaviours identified that reflect these values
• Two purposes
• Education
• Identify unprofessional behaviour

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Is noting behaviours enough? The issue of context

• Underlying assumption is that observing
  behaviours enables judgement of professional
  and unprofessional
• Behaviours may not always reflect underlying
  motivation

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Basing the evaluation of professionalism on
observable behaviours a cautionary tale.
Ginsburg et al. Acad Med 2004 79 S1- S4

• 30 faculty responded to 5 videos of challenging
  situations
• Little agreement about what students should or
  should not do
• Need to incorporate reasoning and motivation in
  evaluation

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So how should I fill in the evaluation form?

• Approach it as a collegial conversation
• 1. Identify a behaviour issue
• 2. Create safety
• 3. Explore context and motivation
• 4. Consider professional relationships
• 5. Clarify learning issues
• 6. Make judgement about evaluation

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Identify a behaviour issue

• CHOOSE SUCCESSES AS WELL AS LAPSES
• Frame it as learning issue
• Use your own issues and challenges in the
  conversation
• Invite feedback on your perceived professionalism
• Toward an informal curriculum that teaches
  professionalism.
• Suchman A et al.
• J Gen Intern Med 2004 19 501-4

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Create safety

• Use judgement about timing
• At the time
• Later
• Consider privacy and respect
• Consider your own intention
• Am I angry?
• Am I reacting as teachers in my past have reacted
  to me?
• Do I want to be punitive?

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Explore context and motivation

• INTENTION AND IMPACT
• How did you decide to.
• What were hoping to achieve when you
• What do see as your role/responsibilities here?
• Why did you.
• I would like to understand why.
• What was your intention.

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• What do think the consequences were?
• Was there a positive outcome?
• Were there any negative impacts?

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Consider professional relationships

• Physician/Self
• How do I feel about this?
• Is this action an appropriate reflection of my
  values say?
• Physician/Patient
• What is right for the patient?
• Beneficence
• Nonmalificence
• Autonomy
• Justice

• Physician/Colleagues
• Are there guidelines to help me?
• Are there professional policies?
• What would my colleagues
• Physician/Community
• What are the applicable laws?
• What would a member of the public think?

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But.

• Careful exploration may reveal higher incidence
  of burnout and depression in learnerss with
  professional lapses
• Consider lapse as a kind of medical error and
  approach as a systems issue rather just than an
  individual behaviour
• Expect resistance and anger

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Clarify learning issues

• If you had to do this again, would you change
  anything?
• What are you taking away from this encounter?
• Is there another/more effective way to accomplish
  your intention?
• What support would you need to do this?
• Did you identify any systems issues?

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Take action where appropriate

• Praise and acknowledgement are powerful
• Acknowledge when behaviour is unacceptable
• Make a judgement
• Minor lapse
• Major lapse
• Critical incident

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Minor lapse

• In general, a minor lapse is one that was done
  inadvertently and/or did not cause any
  substantial harm.
• We are all human and do make mistakes.
• These mistakes are usually minor and, if
  addressed properly, can lead to improved
  professional conduct

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Major lapse

• A major lapse is one that does cause harm and/or
  there is evidence of full knowledge that this
  action was not right
• The faculty should clearly document why a lapse
  was categorized as a major lapse. In these
  situations, students will be asked to submit
  their version of events in writing.
• The course director will then decide whether or
  not this is a major or minor lapse.

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Critical Incidents 1

• Referring to oneself as, or holding oneself to be
  more qualified than one is
• Participating in a conflict of interest
• Theft of drugs
• Violation of the criminal code
• Failure to be available while on call
• Failure to respect patient's rights
• Breach of confidentiality

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Critical Incidents 2

• Failure to provide transfer of responsibility for
  patient care
• Failure to keep proper medical records
• Being disrespectful to patients and other
  professional staff
• Falsification of medical records
• Assaulting a patient 
• Sexual impropriety with a patient
• Being under the influence of alcohol or drugs
  while participating in patient care or on call
• Any other conduct unbecoming of a practicing
  physician

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How is unprofessional behaviour handled?

• The evaluation forms are mainly to be used for
  education and thus faculty will indicate minor
  lapses as areas for improvement.
• The only exception is a consistent pattern of
  minor lapses over time. More serious breaches
  (e.g. major lapses or critical events) of
  professionalism are reviewed by the course
  director.
• Evidence of these lapses is passed on to the
  PreClerkship and/or Clerkship director for
  review.

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• Information on professional misconduct appears on
  the student's transcript only if designated by
  the Board of Examiners and a comment on
  professionalism will only be put on the Dean's
  letter by the Vice Dean.
• Hence evidence of lapses will be reviewed at
  least three times before any recordings can be
  put on the Dean's letter or transcript and
  students have an opportunity to state their
  version of events

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What about student appeals?

• The process of evaluating the completed
  professionalism forms is one of repeated
  assessments at higher levels.
• For serious lapses of professionalism the student
  will be asked to submit their version of events
  in writing.
• Thus information will become part of the file. It
  is possible for a student to thus make their
  views and version of events known at each step.

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• After final adjudication by the Board of
  Examiners, an appeal is possible in two ways. The
  first is to appeal to the Appeal Board as per
  faculty policy.
• The second way is to allow the assessment to
  stand for a year or so, stay free from any lapses
  in professional conduct and then appeal to the
  Board of Examiners to have this information
  removed from a student's transcript.

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Our experience so far

• Faculty appear to be reluctant to indicate minor
  lapses.
• The highest area of concern is attendance issues
  BUT this is selected as a minor lapse less than
  1 of the time
• Anecdotal evidence suggests that this number
  should be much higher AND the focus of collegial
  conversations
• The forms are invaluable for documenting major
  lapses and critical events

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• Professionalism is a community learning issue
  rather than an individual competency.

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• We learn professionalism most powerfully in the
  informal or hidden curriculum.

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• If we dont talk about our real successes and
  challenges, we cant learn.

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Implications of evaluation for professionalism

• This is a form of self-regulation
• What does this mean about our ability/need to
  role model
• Do we only talk about our own successes?
• Can we create safety to talk about mistakes?
• Finally, perhaps the most important type of
  modeling is to treat learners with the compassion
  and respect with which we wish them to treat our
  patients. Burack

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• Do we only have collegial conversations with
  students and residents, or do we have them with
  peers as well?
• If we dont have conversations with our peers,
  how will we be evaluated for our professionalism?

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• If we approach it as a problem to be solved by
  raising the ethical bar- exhorting each other
  to jump higher and meting out tougher penalties
  to those who fall short- we may feel more
  virtuous for a while, but we will not address the
  problem at its source.
• Parker Palmer