Professionalism in Medical Education

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• Professionalism in Medical Education
• Neera Khilnani
• John Luk
• José Gonzalez
• Virginia Niebuhr
• UTMB Pediatric Grand RoundsSept 14, 2007

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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?

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Case

• 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

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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?
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• Its 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?
  

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• 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.

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• 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 residents 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.

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• 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 facultys
  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?

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• 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.

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Professionalism

• Concept of professionalism pervades medical
  education from many angles
• Is it is easy as
• Youll know professionalism when its present,
  and youll certainly recognize when its absent.
  
• Do we really understand the concept?

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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

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History of Professionalismin Medical Education
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mid-to-late 1990s

• 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

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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

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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
• ResultPhysicians Charter, Lancet, 2002

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Physicians Charter

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

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• 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

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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

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Major initiatives, cont.

• ABP (American Board of Pediatrics) requires
  assessment of professionalism in final
  evaluation of residents/fellows
• separate from clinical competence
• certification from program director
• ABP requires evidence of professionalism in
  board re-certification process

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Major initiatives, cont.

• 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

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Professionalism Initiatives at UTMB

• Stobo became UTMB President
• 2000 UTMB Professionalism Board
• clinical, administrative educational leadership
• mission promoting culture of professionalism

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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)

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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

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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

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Defining Professionalism

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

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Defining Professionalism

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

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Compassion

• Compassion (empathy awareness of others
  feelings and experiences)
• sympathetic recognition of anothers distress
  with the desire to alleviate it.

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Honesty

• Honesty (truthful and sincere)
• fairness and straightforwardness of conduct
• includes admission of mistakes/errors

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Altruism

• Altruism
• unselfish concern for the welfare of others

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Responsibility

• Responsibility
• taking pro-active accountability for ones
  actions and their consequences
• for conduct, work obligations, and
  self-improvement
• synonym duty

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Aiming for Excellence

• Aiming for excellence
• striving to perform at the highest standards of
  the profession
• in self, others, and the system of healthcare

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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)

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Teamwork

• Teamwork
• combining individual efforts in a synergistic
  way to reach the common goal of thorough, quality
  patient care

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Ethical Approach

• Ethical approach
• adherence to ethical principles of
• patient autonomy
• beneficence
• non-maleficence
• justice

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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

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The Resource
We can do better than Youll know it when you
see it and youll know when it is absent.

• Rationale
• Goals
• a resource to promote thinking about concept of
  professionalism
• promoting the practice of reflection
• an outcome possibly useful for evaluating
  professionalism
• Galveston-Austin collaborative

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• 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

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CHARACTER

• C ompassion
• H onesty
• A ltruism
• R esponsibility
• A iming for excellence
• C onfidentiality
• T eamwork
• E thical Approach
• R espect

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Design and Access

• Nine Modules
• one for each letter of CHARACTER 
• thought-provoking readings
• accessible from WebCT Pedi 1001 Professionalism
• Synthesis/Application/Challenge Activities
• submitted through WebCT Assignment Drop-Box
• contributors can expect feedback from the authors
• Observations Reflections
• Challenge to identify, for each of the nine
  components, examples of professional behavior or
  lapses of professionalism (in self or others)

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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

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• link to Pediatric Education Page
• link to Professionalism in Pediatrics
• WebCT

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A Concept within a Concept

• Professionalism in Health Care
• Professionalism in Medical Education

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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

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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
  tomorrows doctors.

www.aamc.org/residentcompact
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