Professionalism in Medical Education Neera Khilnani John Luk Jos é Gonzalez Virginia Niebuhr

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

2. 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?

3. 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

4. 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?

5. 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?

6. 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.

7. 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.

8. 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?”

9. 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.

10. 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?

11. 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

12. History of Professionalismin Medical Education

13. 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

14. Professionalism ProjectAmer. 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

15. 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

16. Physicians’ Charter Fundamental principles • primacy of patients' welfare • patients' autonomy • social justice

17. 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

18. Major initiatives to teach professionalism as a core competency and to require measurement • GEA (Group on Educational Affairs) of AAMC Project Professionalism: Assessment • ACGME (Accreditation Council for Graduate Medical Education)ACGME Outcomes Project

19. 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

20. 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

21. Professionalism Initiatives at UTMB • Stobo became UTMB President 2000 UTMB Professionalism Board • clinical, administrative & educational leadership • mission: promoting culture of professionalism

22. 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)

23. 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

25. 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:

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

27. Defining Professionalism • Compassion • Honesty • Altruism • Responsibility • Aiming for Excellence • Confidentiality • Teamwork • Ethical approach • Respect

28. Compassion • Compassion (empathy; awareness of other’s feelings and experiences) • sympathetic recognition of another’s distress with the desire to alleviate it.

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

30. Altruism • Altruism • unselfish concern for the welfare of others

31. Responsibility • Responsibility • taking pro-active accountability for one’s actions and their consequences • for conduct, work obligations, and self-improvement • synonym: duty

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

33. 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)

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

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

36. 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

38. The Resource We can do better than “You’ll know it when you see it and you’ll 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

39. 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

40. CHARACTER Compassion Honesty Altruism Responsibility Aiming for excellence Confidentiality Teamwork Ethical Approach Respect

41. 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)

42. 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

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

44. A Concept within a Concept • Professionalism in Health Care • Professionalism in Medical Education

46. 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

47. 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