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