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A Practical Approach to Developing a Professionalism Curriculum. MAME Workshop May 23, 2012. Disclosure. Drs. Frohna and McGregor have no conflicts of interest to report. Objectives for this Session. List the key elements of professional behavior, as identified in the “Physician Charter.”

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a practical approach to developing a professionalism curriculum

A Practical Approach to Developing a Professionalism Curriculum

MAME Workshop

May 23, 2012

disclosure
Disclosure
  • Drs. Frohna and McGregor have no conflicts of interest to report
objectives for this session
Objectives for this Session
  • List the key elements of professional behavior, as identified in the “Physician Charter.”
  • Describe three interactive methods for teaching professionalism to residents/fellows.
  • Use a tool to create learning cases.
  • Identify useful online resources for teaching and evaluating professionalism.
  • Discuss evaluation strategies for a professionalism curriculum in your home program.
my favorite great lake is
My favorite Great Lake is
  • Huron
  • Ontario
  • Michigan
  • Erie
  • Superior
my educational domain
My Educational Domain
  • Institutional
  • Program
  • Undergraduate Medical Education
  • Nursing Education
  • Faculty Development
  • Other
what is your discipline
What is your discipline?
  • Anesthesiology
  • Family Medicine
  • Internal Medicine
  • Neurology
  • OB-Gyn
  • Ophthalmology
  • Pediatrics
  • Psychiatry
  • Surgery
  • Other
what is your best method for evaluating your residents
What is your best method for evaluating your residents?
  • Critical event documentation
  • Global evaluation forms
  • Multisource feedback
  • OSCE
  • Peer evaluation
  • Professionalism mini-evaluation exercise (P-MEX)
  • Small group faculty evaluation
what is the next best method for evaluating your residents
What is the next best method for evaluating your residents?
  • Critical event documentation
  • Global evaluation forms
  • Multisource feedback
  • OSCE
  • Peer evaluation
  • Professionalism mini-evaluation exercise (P-MEX)
  • Small group faculty evaluation
have you previously attended a workshop on developing a professionalism curriculum
Have you previously attended a workshop on developing a professionalism curriculum?
  • No
  • Yes, at my institution
  • Yes, with my program director association
  • Yes, at another site
small groups
Small Groups
  • Brainstorm characteristics of unprofessional behavior
  • Establish the elements that define professionalism
  • Report out
your definition of professionalism
Your Definition of Professionalism
  • Accountable
  • Respectful
  • Compassionate
  • Humility
  • Approachable
  • Dress
  • Punctual
  • Adaptable
  • Ethical
  • Integrity
  • Responsible
  • Ambassador
  • Hardworking
  • Emotional Intelligence
  • Ownership of Pts
  • Positive Attitude
  • Responsive
  • Lifelong Learner
  • Interacting Well with Staff, Patients, Families
six step approach to curriculum development
Six Step Approach to Curriculum Development
  • Problem Identification and General Needs Assessment
    • Health Care Problem
    • Current v Ideal Approach
  • Targeted Needs Assessment
    • Learners
    • Learning Environment
  • Goals and Objectives
  • Educational Strategies
    • Content
    • Method
  • Implementation
    • Resources
    • Barriers
    • Delivering Curriculum
  • Evaluation and Feedback
    • Learners
    • Program

Curriculum Development for Medical Education: A Six-Step Approach

Eds. Kern, Thomas, Hughes. 2009

step 1 problem identification
Step 1: Problem Identification
  • Residents must be educated in a humanistic educational environment that protects their safety, and nurtures professionalism and the effacement of self interest that is the core of the practice of medicine and the profession in the United States.
                • Nasca 2010, Open Letter
step 2 targeted needs assessment
Step 2: Targeted Needs Assessment
  • Shared definition at an institutional level
  • Defining the local issues
    • Remediating unprofessional behavior
    • Advancing professionalism
your definition of professionalism1
Your Definition of Professionalism
  • Accountable
  • Respectful
  • Compassionate
  • Humility
  • Approachable
  • Dress
  • Punctual
  • Adaptable
  • Ethical
  • Integrity
  • Responsible
  • Ambassador
  • Hardworking
  • Emotional Intelligence
  • Ownership of Pts
  • Positive Attitude
  • Responsive
  • Lifelong Learner
  • Interacting Well with Staff, Patients, Families
stern s definition of professionalism
Stern’s Definition of Professionalism
  • “Professionalism is demonstrated through a foundation of clinical competence, communication skills, and ethical understanding, upon which is built the aspiration to, and wise application of the principles of professionalism: excellence, humanism, accountability, and altruism.”

Stern DT (ed.), Measuring Medical Professionalism, Oxford University Press, 2006

slide21

Professionalism

Excellence

Humanism

Accountability

Altruism

Ethical and Legal Understanding

Communication Skills

Clinical Competence (Knowledge of Medicine)

Stern DT (ed.), Measuring Medical Professionalism, Oxford University Press, 2006

step 3 goals and objectives
Step 3: Goals and Objectives
  • The Physician Charter
  • ABIM: Project Professionalism
  • ABP/APPD: Teaching and Assessing Professionalism
  • Royal College of Physicians
  • ACGME
physician charter
Physician Charter
  • Three Fundamental Principles
  • Ten Professional Responsibilities with Commitment to:
    • Professional competence
    • Honesty with patients
    • Patient confidentiality
    • Maintaining appropriate relations
    • Improving quality of care
    • Improving access to care
    • Just distribution of finite resources
    • Scientific knowledge
    • Maintaining trust by managing conflicts of interest
    • Professional responsibilities

Medical Professionalism in the New Millennium: A Physician Charter. Ann Intern Med 2002;136:243-6.

the charter as a blueprint for program directors
Promoting Professionalism: A Definition

Professionalism in Patient Care

Professional competence

Honesty with patients

Patient confidentiality

Maintaining appropriate relations

Professionalism With Physician Colleagues and Other Health Professionals

Improving quality of care

Professional responsibilities

Teamwork

Stress and Its Impact on Professionalism

Professional responsibilities

Self-Awareness

Balancing Personal and Professional Commitments

Professionalism and Society

Improving access to care

Just distribution of finite resources

Scientific knowledge

Maintaining trust by managing conflicts of interest

Professionalism Beyond Residency

Professional competence

The Charter as a Blueprint for Program Directors
step 4 educational strategies
Step 4: Educational Strategies
  • Setting Expectations
    • Ceremonies, Policies, Orientation, Charters
  • Providing Experiences
    • Formal, Informal, Hidden Curricula
    • Context
    • Developmental Process
  • Evaluating Outcomes
    • Assessments before residency
    • Multiple perspectives
context
Context
  • Does professionalism represent a set of stable traits of the individual?
  • Disconnect between how education approaches knowledge and skills versus behavior
  • Tied to role responsibilities

Ginsburg S, Regehr G, Hatala R, et al. Context, conflict, and resolution: A new conceptual framework for evaluating professionalism. Acad Med 2000;75:S6-11.

developmental achievement levels
Developmental Achievement Levels
  • Professional Identity Among Cadets
    • Early: Professional values and standards as rules to be followed
    • Transition: Internalize profession’s values as internal qualities
    • Later: Own the values, can assess them, and are able to reconcile conflicts

Forsythe GB, et al. Making Sense of Officership: Developing a Professional Identity for 21st Century Army Officers. In: The Future of the Army Profession. New York: McGraw-Hill, 2002.

developmental achievement levels1
Developmental Achievement Levels
  • Professional Identity Among Residents
    • Early: Explicit rules to be followed, attendance, finishing dictations, sign outs
    • Transition: Internalize profession’s values class rules, creed of accepted conduct
    • Later: Own the values, can assess them, seniors assess interns

Forsythe GB, et al. Making Sense of Officership: Developing a Professional Identity for 21st Century Army Officers. In: The Future of the Army Profession. New York: McGraw-Hill, 2002.

case of jm1
Case of JM
  • Jeopardy call rules – available on-site within three hours.
  • She is on jeopardy call and tests her luck by going two hours away on a workday.
this is a serious lapse in professional behavior
This is a serious lapse in professional behavior
  • Strongly Agree
  • Agree
  • Somewhat Agree
  • Neutral
  • Somewhat Disagree
  • Disagree
  • Strongly Disagree
case of jm2
Case of JM
  • Jeopardy call rules – available on-site within three hours.
  • She is on jeopardy call and tests her luck by going two hours away on a workday.
  • She is away because she is looking for a place to live for her fellowship, which begins in a month.
this is a serious lapse in professional behavior1
This is a serious lapse in professional behavior
  • Strongly Agree
  • Agree
  • Somewhat Agree
  • Neutral
  • Somewhat Disagree
  • Disagree
  • Strongly Disagree
case of jm3
Case of JM
  • Jeopardy call rules – available on-site within three hours.
  • She is on jeopardy call and tests her luck by going two hours away on a workday.
  • She is away because she is looking for a place to live for her fellowship, which begins in a month.
  • Several classmates note a photo of her new apartment on her Facebook dated the day of her scheduled call.
this is a serious lapse in professional behavior2
This is a serious lapse in professional behavior
  • Strongly Agree
  • Agree
  • Somewhat Agree
  • Neutral
  • Somewhat Disagree
  • Disagree
  • Strongly Disagree
thoughts about jm
Thoughts about JM?
  • Is it a professionalism issue if she tests limits and is not called in?
  • What if she is scheduled to graduate in 4 weeks and needs to relocate for fellowship?
  • What if she had tried to trade call unsuccessfully?
  • What about stretching the rules and electronically documenting her behavior?
    • Unprofessional?
    • or just not so smart?
jm facts
JM facts
  • She does get called in.
  • When reached, she denies she knew she was on call.
this is a serious lapse in professional behavior3
This is a serious lapse in professional behavior
  • Strongly Agree
  • Agree
  • Somewhat Agree
  • Neutral
  • Somewhat Disagree
  • Disagree
  • Strongly Disagree
jm facts1
JM facts
  • She does get called in.
  • When reached, she denies she knew she was on call.
  • She calls back and says she was indeed aware but cannot return within 3 hours to take call. “Just call in the back-up jeopardy person.”
this is a serious lapse in professional behavior4
This is a serious lapse in professional behavior
  • Strongly Agree
  • Agree
  • Somewhat Agree
  • Neutral
  • Somewhat Disagree
  • Disagree
  • Strongly Disagree
jm facts2
JM facts
  • She does get called in.
  • When reached, she denies she knew she was on call.
  • She calls back and says she was indeed aware but cannot return within 3 hours to take call. “Just call in the back-up jeopardy person.”
  • She had an appointment with the school district about her special needs son’s placement.
this is a serious lapse in professional behavior5
This is a serious lapse in professional behavior
  • Strongly Agree
  • Agree
  • Somewhat Agree
  • Neutral
  • Somewhat Disagree
  • Disagree
  • Strongly Disagree
d nouement
Dénouement
  • Back up called
  • She had to pay back call to back up
  • Professionalism sign off deferred until six months into fellowship
  • Precedent set
designing professionalism cases
Designing Professionalism Cases
  • Select a case
  • Prepare for discussion
  • Decide how to reveal the case and the conflicts
  • Prepare a short discussion
designing professionalism cases1
Designing Professionalism Cases
  • Select a case
    • Tell a story
    • Ok to merge cases
    • Identify context and key conflicts
  • Prepare for discussion
  • Decide how to reveal the case and the conflicts
  • Prepare a short discussion
designing professionalism cases2
Designing Professionalism Cases
  • Select a case
  • Prepare for discussion
    • Adapt to levels of learners
    • Anticipate issues that may arise
    • Generational issues
    • Re-evaluate case
  • Decide how to reveal the case and the conflicts
  • Prepare a short discussion
designing professionalism cases3
Designing Professionalism Cases
  • Select a case
  • Prepare for discussion
  • Decide how to reveal the case and the conflicts
    • Create tension!
    • Highlight competing conflicts in the case
  • Prepare a short discussion
designing professionalism cases4
Designing Professionalism Cases
  • Select a case
  • Prepare for discussion
  • Decide how to reveal the case and the conflicts
  • Prepare a short discussion
    • Review learning objectives
    • Tie back to Physician Charter
    • Summarize discussion
small groups1

Small Groups

Design your own case!!!

step 5 implementation
Step 5: Implementation
  • Political Support/buy-in
  • Resources
    • Faculty
    • Time
  • Implementing, Sustaining, and Improving the Curriculum
teaching strategies
Teaching Strategies
  • Setting expectations
  • Appreciative inquiry
  • Cultural norm setting
    • Retreats, Play of the Week
    • P.A.D.S.
  • Lectures/Curriculum
  • Reflective exercises
  • Professionalism series
st christopher s hospital for children
St. Christopher’s Hospital for Children
  • Target audience –clinical fellows
  • Three, small group didactic – followed by case-based reflection (90 minute sessions)
  • Curriculum – 1/3 of ABP/APPD Guide per session
  • Evaluation – Retrospective pre-test and post-test
university of wisconsin
University of Wisconsin
  • Noon conference facilitated discussions, focusing on each of the sections of the APPD-ABP book:
    • Content discussion (5 min)
    • Vignettes
    • Longer cases
newer strategies
Newer strategies
  • Peer review system (Bonder J, Elwood D, Heckman J, et al. PM&R 2010;2(2):117-24)
  • Reader’s Theatre – scripted faculty development (Bell SK, Wideroff M, Gaufberg L. Pt Ed & Couns 2010;80(3):354-7.)
  • Wikis - (Varga-Atkins T, Dangerfield P, Brigden D. Med Teach 2010;32(10):824-9.)
step 6 evaluation and feedback
Step 6: Evaluation and Feedback
  • The Learners
    • Evaluations can also help set professionalism expectations
    • Role of reflection
  • The Program
evaluating learners
Evaluating Learners
  • 360 or multi-source evaluations
  • Nursing evaluations
  • Peer evaluations
  • Small groups*
  • Professionalism mini-evaluation exercise (P-MEX)**

*Haidet et al. The Role of the Student-Teacher Relationship in the Formation of Physicians The Hidden Curriculum as Process. J Gen Intern Med 2006; 21:S16–20.

**Cruess R, McIlroy JH, Cruess S, Ginsburg S, Steinert Y. The professionalism mini-evaluation exercise: A preliminary investigation. Acad Med 2006;81:S74-8.

evaluating learners cont
Evaluating Learners (cont)
  • Critical events & reflection
  • Professionalism Series
  • Conscientiousness index*

*McLachlan JCP, et al. The conscientiousness index: A novel tool to explore students’ professionalism. 2009 Acad Med 84:559-565

importance of reflection
Importance of Reflection
  • Faculty and residents need to gain additional experience in observing and reflecting on their own and others’ behavior
  • Learners should be encouraged to share their stories during all teaching sessions
evaluating the curriculum
Evaluating the Curriculum
  • Satisfaction
  • Examine trends on global, peer, 360 evaluations over time
  • Changes in behaviors (need mechanism to monitor)
  • Reflections
six step approach to curriculum development1
Six Step Approach to Curriculum Development
  • Problem Identification and General Needs Assessment
    • Health Care Problem
    • Current v Ideal Approach
  • Targeted Needs Assessment
    • Learners
    • Learning Environment
  • Goals and Objectives
  • Educational Strategies
    • Content
    • Method
  • Implementation
    • Resources
    • Barriers
    • Delivering Curriculum
  • Evaluation and Feedback
    • Learners
    • Program

Curriculum Development for Medical Education: A Six-Step Approach

Eds. Kern, Thomas, Hughes. 2009

curriculum
Curriculum
  • 233 program directors surveyed
    • 1/3 no curriculum or formal professionalism experience
    • ~1/3 combined with ethics
    • ~1/3 independent curriculum
  • Barriers –
    • Faculty expertise / Need for faculty development
    • Curricular crowding

Lang CW et al. Ethics and Professionalism in the Pediatric Curriculum: A Survey of Pediatric Program Directors Pediatrics 2009.

philadelphia professionalism series
Philadelphia Professionalism Series
  • Children\'s Hospital of Philadelphia (CHOP) Residents
  • St. Christopher’s Hospital for Children (SCHC) Fellowships
chop model
CHOP Model
  • Ten, monthly sessions at 7:30-8:30 AM
  • 20-24 house staff and 3-4 preceptors
  • Ten major themes (6 from the ABP/APPD Guide)
chop series
CHOP Series
  • All sessions rated “very helpful, helpful” by at least 50%
  • Attendance mean – 5.0 (range 1-9)
  • Numbers per group – 9.43 (range5-10)
  • Qualitative outcomes – global –societal topics not as well received
  • Best received
    • Fatigue and Burnout and Their Impact on Clinical Care**
    • Coping with Medical Errors*
  • Small group important
  • ** Designed internal module
slide75
SCHC
  • 75% attendance
  • Likert scale 4.2 acceptance
  • Pre-post test scores still being processed
  • Adding similar sessions for the residents
  • Fellows may function as teachers in next year’s iteration
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