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Professionalism in Medical Training: How We Can Challenge the Hidden Curriculum Karen Adams, MD Andrea S. Cedfeldt, MD Josh Kornegay, MD
Professionalism in Medical Training:
How We Can Challenge
the Hidden Curriculum
Karen Adams, MD
Andrea S. Cedfeldt, MD
Josh Kornegay, MD
Josh Kornegay, MD
Josh Kornegay, MD
• Sepsis
Josh Kornegay, MD
• Sepsis
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Josh Kornegay, MD
• Sepsis
• Aortic Catastrophe
• Thoracotomy
Josh Kornegay, MD
• Kung Fu with my Kid !!!
Karen Adams, MD
Karen Adams, MD
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Karen Adams, MD
• Preeclampsia
• Benefit of PAP smears
Karen Adams, MD
• Preeclampsia
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from oxycodone
Karen Adams, MD
• Cute Little Babies!!!
Andrea Cedfeldt, MD
Andrea Cedfeldt, MD
• Renal Tubular Acidosis
Andrea Cedfeldt, MD
• Renal Tubular Acidosis
• Histiocytosis X
Andrea Cedfeldt, MD
• Renal Tubular Acidosis
• Histiocytosis X
• Multiple Systems involved
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Andrea Cedfeldt, MD
• Why are these diseases so
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Josh Kornegay, MD
Karen Adams, MD Andrea Cedfeldt, MD
Josh Kornegay, MD
Karen Adams, MD Andrea Cedfeldt, MD
Professionalism !!!
Goals:
• By end of this workshop you will be able to:
– Define professional and unprofessional
behavior
– Recognize the importance of addressing
professionalism among trainees
– Define individual and institutional factors that
affect professional behavior
– Identify strategies to evaluate and deliver
feedback on non-professional behavior
– Consider alternate ways of teaching
professionalism to trainees
Talk to Your Neighbor:
• Introduce yourselves and your roles at
OHSU
• How do you define professionalism?
http://www.abimfoundation.org/Professionalism/~/media/Images/word
-cloud.ashx
Professionalism is the basis of medicine’s
contract with society ___________________________________________________________________________________________________________________
___________
• Placing interest of patients above those of
the physician
• Setting and maintaining standards of
competence and integrity
• Providing expert advice to society on
matters of health
Principles
• Primacy of Patient Welfare (oldest)
– Dedication to serving the interest of the
patient
• Patient Autonomy
– Patient decisions of care are paramount
• Social Justice
– Promote fair distribution of health care
resources
– Eliminate discrimination in healthcare
Professional Responsibilities
1. Professional Competence
2. Honesty with patients
3. Patient confidentiality
4. Maintaining appropriate relations with patients
5. Improving quality care
6. Improving access to care
7. Just distribution of finite resources
8. Scientific knowledge
9. Maintaining trust by managing conflicts of interest
10. Professional responsibilities – Work collaboratively and respectful; participate in self-
regulation, including remediation and discipline; define and organize educational and standard-setting for current and future members
ACGME Definition
• Commit to high standards of professional
conduct, demonstrating altruism,
compassion, honesty and integrity. Follow
principles of ethics and confidentiality and
consider religious, ethnic, gender,
educational and other differences in
interacting with patients and other
members of the health care team
Why is it important?
• Unprofessional behavior in
training predicts future difficulties
Why is it important?
• Communication scores on OSCEs were
predictive of future complaints to Canadian
regulatory authorities
• Unprofessional behavior in medical school
has been shown to predict disciplinary
action by state medical boards
Student Unprofessional Behavior
• Reviewed graduates of three medical schools disciplined by 40 state medical boards over a 13-year period
• 74% of disciplinary actions were due to deficiencies in professionalism
• These graduates were three times as likely to have negative comments regarding professionalism in medical school as controls
Papadakis et al, NEJM 2005
Predicting Future Behavior
Student issues:
• Irresponsibility
• Diminished capacity for self-improvement
• Immaturity, anxiety, nervousness, insecurity
• Poor initiative
• Impaired relationships
– Other students, residents, or faculty
– Nurses
– Patients and families
Why is it important?
• Students and residents who exhibit
unprofessional behavior can go on to
become what JCAHO calls “disruptive
physicians”
• Unprofessional behavior can be passed
from teacher to learner through role
modeling
Personal Factors that Influence
Professionalism
• Personal Well-Being – Quality of Life
– Balance between personal/professional life
– Burnout/Depression/Stress
– Addiction/Substance Abuse
• Individual Characteristics – Motivation
– Work ethic
– Integrity
– Personality traits • Narcissism, Perfectionism
Personal Factors cont.
• Interpersonal Qualities/Skills
– Communication skills
– Compassion
– Cynicism
– Detachment
Environmental Factors • Institutional Culture/Customs
– Focus on needs of patient
– Relative values placed on research, education,
and pt care
– Commitment to charitable care
– Organizational relationships with industry
• Formal/Informal/Hidden Curricula
– Didactic training
– Institutional Policies
– Mentoring
– Modeled Behavior
Environmental Factors cont.
• Practice Characteristics/Environment
– Autonomy
– Specialty
– Workload
– Work content
– Patient characteristics
– Practice environment
• What is definition of professionalism?
• How is unprofessional behavior addressed?
• Does bad behavior gets desired results?
Role of Conflict in
Evaluating Professionalism • Criteria for Assessing professionalism
– Incorporate assessments from multiple raters
– In realistic settings
– That regularly involve conflict
– Over time
Stern DT, ed. Measuring Medical Professionalism. New York, NY:
Oxford University Press Inc; 2006:8-12
Small Groups
• Reflect on a time when:
– You acted unprofessionally or
– You observed unprofessional behavior in a
trainee
1) Identify/define the unprofessional
behavior
2) List potential contributing factors
How We Learn Professionalism
“The Hidden Curriculum”
How We Learn Professionalism
Why is Professionalism Hard to Teach?
-Not to be taught in a lecture hall
-Best taught by role modeling, engaging
in discussions, and making commitments
How We Learn Professionalism
Why is Professionalism Hard to Teach?
-Our daily working environment does not
help (Busy, Tired, Overworked, Difficult
Situations)
How We Learn Professionalism
“In an overworked, high pressure
environment our message may fail to
reflect our professional ideals.”
Gofton W, Clin Orthopedics 2006
What Does the Evidence Show?
1994 Study by Feudtner in Academic Medicine:
-98% of medical students from 6 different
medical schools report witnessing
unprofessional behavior from faculty
-Medical Students reported that they were
more likely to engage in this behavior if they
were exposed to it.
-”Behavior begets like behavior”
Teaching Professionalism:
Idealism vs Realism
• Faculty believe we are better at giving
unambiguous feedback in the moment
than we actually are
Teaching Professionalism:
Idealism vs Realism
• Reasons for not responding
– If student/resident is “good,” don’t want to discourage
or frustrate
– If student/resident is “bad,” why bother?
– Sympathy for resident stress
– Short time with resident
– Hesitation to give feedback publicly
Teaching Professionalism:
Idealism vs Realism
• Reasons for not responding
– Assume residents are young, naive, have narrow
social backgrounds
– Believe residents’ personalities are largely fixed by
this point
– Reluctance to “preach”, alienate, offend = negative
teaching evaluations
Teaching Professionalism:
Idealism vs Realism
• Reasons for not responding
– Negative feedback is difficult and unpleasant
– No training to give negative feedback, try to avoid it
– Did not feel supported or rewarded in cost-conscious
environment for trying to teach attitudes
– Believed doing so would not advance their academic
success and might even expose them to personal or
legal risk
Teaching of Professionalism
• Identification of unprofessional behavior
challenges teachers and leaders to take
action
• Most have little or no training in how to
address such problems
• Allows unprofessional behaviors to
persist, escalate and spread
Evaluation and Feedback
on Professionalism • Evaluating professionalism
– Who should do it?
• colleagues, faculty, nursing- “multi-source
evaluation”
– When?
• Formative vs. Summative
• Providing feedback on professionalism
– Why is it hard?
– Do we do it?
– Who should do it?
Evaluation of Professionalism
• Self-rating
• Peer review
• Supervisor review
• Patient assessment
• Standardized patient encounters
• Responses to clinical vignettes
• Portfolio development
• “Humanism connoisseurs”
Feedback on Professionalism:
Barriers • TIME
• Requires direct observation
• It is not quantifiable
• Is it really a problem?
• Hierarchy/Fear of retribution
• Uncomfortable in ongoing relationship
• Someone else will/should do it
Feedback on Professionalism
• Describe the specific behaviors you have
observed • “I notice that you have come in late the past few
days….” NOT “You don’t seem to care about patients.”
• Tell learner why performance/behavior is
professional/non-professional • “Being honest is an important tenet of professionalism,
when you say you reviewed the labs and you haven’t,
you are not behaving professionally.”
“Professionalism is anchored in values and
expressed in behaviors.” -Barry Egener, MD
Feedback on Professionalism
• Engage the resident/student
– Elicit their reaction to feedback
• What do you think about what I’ve just told you?
• Do you agree?
– Identify personal factors
• Are you struggling in any areas in your personal
life that could be contributing to these behaviors?
– Develop an action plan together
• How are you going to change your behavior?
• How can I help you?
Feedback on Professionalism • Show empathy and respect for resident while
correcting behaviors and attitudes
– “I remember as an intern I also felt frustrated by
patients who came back to the hospital because they
didn’t follow our medical advice. BUT, you are still
their doctor, and it is your professional responsibility
to show respect and compassion to all your patients.”
• Allow resident to think through how they might
change a behavior, and give them a chance to
try it with the patient
– “How might you do a better job negotiating with Mr.
Smith? Would you like to try again?”
Active Reflection
• TIME OUT
• Name the emotion(s)
• Diffuse the emotion with empathy
• Validate emotion if appropriate
• Identify if emotion is inappropriate
• Brainstorm with learner:
– Identify contributing personal factors
– Strategies to address damage done and
prevent future lapses
Potential Reactions to
Feedback on Professionalism
• Anger
• Denial
• Minimize
• Blame others
Anticipate Your Responses
• “In spite of others’ actions or mistakes-
there are professional and unprofessional
ways to respond”
• Put yourself in the shoes of the…
– Patient, family member, nurse, student, intern,
etc.
• Do you remember what you wrote in your
medical school application essay?
Small Group Role-play Reflect on a time when you observed
unprofessional behavior in a trainee and
you did not provide feedback OR use the
provided cases
ROLE-PLAY!!
• One person behaves unprofessionally, the
other gives feedback
• Provide behavioral feedback regarding the
lack of professionalism
• Others in group be observers
• Group reflect on how it went/provide
feedback
Teaching of Professionalism:
• Role modeling
• Role playing
• Simulation
• OSCE’s
• Didactics
• Humanities
• Ceremonies
How We Teach Professionalism
Role Modeling
-behavior begets like behavior
We must role model the behavior that we
want from our learners.
“This is the single most effective method
in changing behavior”
How We Teach Professionalism
Get Innovative
Lectures and Powerpoints are not the
best platform for this topic
Asynchronous Curriculum
• Primarily online- Sakai and Access EM
– Self directed learning
– CME activities, board review and quizzes
– EM training blogs
• Sometimes in real life
– Trauma conference
– Journal club (quarterly)
• Residents have a choice of activities
Asynchronous Curriculum
• Sakai is our platform:
-allows grouping of all exercises
-allows submission of assignments
-allows links to other sites (Access EM)
-allows continuous forum for discussion
Asynchronous Curriculum
• Most Importantly:
-It allows residents to identify areas of
weakness/interest and further learning on
there own time.
The Professionalism Module
• Moderated discussion forum
• Series of 4 discussions -Definition of Professionalism
-Loss of Empathy
-Medical Disparities
-Use of Online Social Networking
The Professionalism Module
• Each topic is based on a Keystone Article
across multiple disciplines in medicine
• The article serves as a launching pad for
the discussion
• The real enrichment comes from
experiences!!!
The Professionalism Module
• Evaluation Tool
• Residents can provide feedback
• Measurable outcomes: conference
attendance, in-service exams,
professionalism scores on evaluations.
Turn to Your Neighbor
•Challenge yourself to take 1 suggestion
or goal from this conference back to your
practice and stick to it
•Share that commitment with your
neighbor
Acknowlegements
• Thank you for participating!
• Thanks to the Professionalism Week
Planning Committee and Chuck Kilo for
the institutional commitment
References • ABIM foundation. Medical professionalism in the new millennium: A
physician charter. Ann Intern Med 2002;136:243
• Dorotta I et al. Teaching and evaluating professionalism for
anesthesiology residents. J Clinical Anesthesia 2006; 18:148
• Hickson GB et al. A complementary approach to promoting
professionalsim: identifying, measuring and addressing
unprofessional behaviors. Acad Med 2007;82(11):1040
• Papadakis M et al. Performance during internal medicine residency
training and subsequent disciplinary action by state licensing
boards. Ann Intern Med 2008;148:869
• Reed DA et al. Behaviors of Highly professional resident physicians
JAMA 2008; 300(11):1326
• West CP et al. The Influence of personal and environmental factors
on professionalism in medical education. BMC Medical Education
2007; 7:29
