5/6/2011
Professionalism Training in Medical Education
•Saroj Misra, DO
•St. John Providence Health System-Dept. of Family Medicine
Do you know this doctor??
“I have an M.D. from Harvard, I am board certified in cardio-thoracic medicine and trauma surgery…So I ask you; when someone goes into that chapel and they fall on their knees and they pray to God …that their daughter doesn't bleed to death or that their mother doesn't suffer acute neural trauma from postoperative shock, who do you think they're praying to?...if you're looking for God, he was in operating room number two on November 17, and he doesn't like to be second guessed. You ask me if I have a God complex. Let me tell you something...
I AM God.
Worrying Incidents
Photos of drinking, grinning aid mission doctors cause uproar
San Juan, Puerto Rico (CNN) -- A humanitarian mission to aid Haitian
earthquake victims turned into a major embarrassment in Puerto Rico on Friday
as pictures emerged of doctors drinking, mugging for cameras and brandishing
firearms amid the victims' suffering.
February 3, 2010 12:20 p.m. EST
5/6/2011
‘We’ve had a monster living in our midst’
-Philadelphia Mayor Michael Nutter• Kermit Gosnell, MD
• Arrested Jan. 2011
• Charged with 8 counts of murder (7 infants)
• Grand jury report cited ‘lack of inspection’
• Other physicians implicated in ‘cover-up’
How many of you have…• Heard a resident discussing a patient with terms
like ‘crazy’ or ‘stupid’?
• Had residents from one specialty disparage another specialty?
• Seen residents behave inappropriately to students, ancillary staff or one another?
• Miss something critical because they didn’t take the time?
Introduction & RationaleThe concept of medical professionalism is of increasing importance in determining how physicians should interact with the community.
Studies have shown that unprofessional behavior in formative years may increase the likelihood of disciplinary action during practice.1
Numerous perceived barriers exist in the minds of both educators and learners in regards to ‘teaching’ professionalism
1. Unprofessional Behavior in Medical School Is Associated with Subsequent Disciplinary Action by a State Medical Board, Papadakis et al, Academic Medicine, Vol. 79‐3
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Introduction & RationaleNational Need
AOA & ACGME – Core Competency
Department of Health & Human Service ‘Healthy People 2020’
‘Better communication with patients’
Despite This…
• Formal literature review conducted in 2009-2010
• NO formalized curriculum for addressing medical professionalism
• ‘Hidden Curriculum’
• ‘I know it when I see it’ – Potter Stewart
• Numerous perceived barriers
The $50,000 Question…
• Can we teach ‘The Unteachable’??
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Introduction & RationaleContext
St. John Providence Health System
Located in SE Michigan
Diverse, suburban patient population
Osteopathic Family Medicine Residency
Introduction & RationaleLocal Need
Need for education on professionalism identified
‘Unprofessional behavior and attitude’
‘Lack of accountability’
‘Perceived lack of compassion for the patient’
Development Challenges
• Defining professionalism
• Creating context for the definition
• ‘Resident ownership’
• What areas/fields need to be addressed?
• Measurement (does it work?)
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Introduction & RationaleFormat
2 Units (3 lessons per unit)
2 1-hour sessions per month (4 months total)
Curriculum presented by two faculty members
Curriculum DevelopmentNeeds assessment was done
Course goal and structure were created
Specific unit/lesson structure was developed
IRB approval was granted
Expert review was obtained
Sample lesson was pilot tested
Curriculum implemented
Curriculum OverviewOverall Structure
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Curriculum Overview
Unit 1
Lesson 1-Defining Medical Professionalism
4 principles of professionalism (HEAAL)
10 responsibilities/commitments of the physician
(Charter on Medical Professionalism)
Curriculum Overview
Unit 1
Lesson 2-Identifying Exemplars
Apply HEAAL/Charter
Observation followed by group discussion
Opportunity to identify potential leaders/role models for future development
Curriculum Overview
Unit 1
Lesson 3-Creating the ‘Class Oath’
Defines/creates accountability
Class Oath checklist
Class Oath examples
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Curriculum OverviewContent
Unit 2
Lesson 1-Interacting with Patients
Communication skills
Inductive learning
Communication tool creation
Curriculum OverviewContent
Unit 2
Lesson 2-Interacting with Peers
Conflict Resolution
The ‘Five A’s’ of Conflict Management
Curriculum OverviewContent
Unit 2
Lesson 3-Interacting with Oneself
Personal reflection
‘The Healer’s Art’ for residents
Dr. Rachel Naomi Remen
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Pilot UnitStructure
Pilot UnitLesson 1 Goal & Objectives
Goal
The resident will be able to identify examples of the four principles of medical professionalism and the ten responsibilities of the medical profession that utilize these principles
Pilot UnitLesson 1 Goal & Objectives
Objective
Given a series of simulated written case scenarios involving patient and peer encounters that evoke the principles and responsibilities of medical professionalism, the resident will identify applicable medical principles and responsibilities and create potential solutions to these scenarios
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A Combined Model of Professionalism• Principles (HEAAL)
• Humanism Excellence Accountability Altruism
• Responsibilities
Sample LessonInstructional Strategies
Article (reviewed prior to didactic sessions)
Professionalism and Medicine (Mackenzie)
Medical Professionalism in the New Millennium (ABIM)
Presentation on principles/responsibilities (1 Hour)
Answer Sheets for practice & learner evaluation
Sample LessonPractice & Evaluation Strategies
Written clinical scenarios (Identify & Solve)
Practice – small group
Evaluation - Individual
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Written Case Example
A patient expires and the on-call intern pronounces the patient. He then makes a call to the family to notify them of the death.
In speaking to a family member, he realizes that he has called the family of the expired patient’s roommate. He debates what to do next.
‘Resident makes a wrong call’
Accountability
Humanism
Excellence
Honesty
Quality of care
The physician should
immediately offer an apology
followed by an explanation of the error and a
promise to improve the process to ensure this
doesn’t happen to
others
ResultsProfessional review
Conducted by 3 recognized experts
Jonathon Rohrer, Ph.D – Statewide Campus System
Ernest Yoder, MD – Central Michigan University
Dr. Kent Sheets – University of Michigan
Train faculty in course curriculum
Include learner pre-test
Consider more quantifying evaluations
Future implementation of behavioral/outcome changes
Resident Pre-Test Score
Post-Test Score
Difference(% Gain)
1 1/15 5/15 +26.7%
2 1/15 14/15 +86.7%
3 1/15 13/15 +80%
4 1/15 9/15 +53.4%
5 1/15 8/15 +46.7%
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Survey Question Pre-Curriculum Post-Curriculum
Strongly AgreeAgree
NeutralDisagree
Personal understanding 5→5 0→0
Personal use 5→5 0→0
Awareness of tools 0→5 5→0
Professionalism in program 5→5 0→0
Professionalism in institution 1→1 4→4
Need for program didactics 2→5 3→0
Need for institution didactics 5→4 0→1
DiscussionResults
58.7 % improvement in test scores
Residents were more aware of:
Tools for evaluating professionalism
A need for program didactics…
…but not institution didactics (???)
Residents Liked it!
‘I haven’t seen anyone define professionalism in a way I can use’
Discussion
Limitations
Curriculum validation
Small sample size
Reaction/Knowledge versus Behavior/Results
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DiscussionFuture Considerations
Longitudinal evaluations to assess behavioral change
Patient evaluations of professionalism
Future implementation
Statewide Campus System
Summary
• Professionalism is an important component of graduate medical education and needs to be taught and evaluated at the resident level
• A curriculum designed to teach aspects of professionalism can be effective and enjoyable
Most importantly…
5/6/2011
‘The practice of medicine is not a business and can never be one ... Our fellow creatures cannot be dealt with as a man deals in corn and coal; the human heart by which we live must control our professional relations’-Sir William Osler, MD, MC
Founder-John Hopkins Medical School
‘Professionalism is medicine’s most precious commodity’
Richard Horton, FRCP FMedSci-Editor-in-Chief Lancet
Resources1. Project Professionalism (ABIM) www.abimfoundation.org
2. Virtual Mentor (AMA) http://virtualmentor.ama-assn.org/
3. R Mackenzie, MD, (2007) Professionalism and Medicine, Hospital for Special Surgery, June 2007
4. G Harris, MD MS (2004) Professionalism – Parts I & II, Family Medicine, 36 (5, 6), 314-315; 390-392
5. D Stern, MD PhD, M Papadakis MD (2006) The Developing Physician – Becoming a Professional, NEJM, 355; 1794-9
6. E Pellegrino, MD (2002) Professionalism, Profession and the Virtues of the Good Physician, The Mount Sinai Journal of Medicine, 69 (6); 378-84
7. N Bostick, MA MPP (2006) For what ends do we promote medical professionalism?, Virtual Mentor, 8 (7); 459-63