professionalism and the education of masterful physicians ... · of masterful physicians: the next...

Accreditation Council for Graduate Medical Education

Professionalism and the Education of Masterful Physicians: The Next Accreditation System, Milestones

& You

Timothy P. Brigham, M. Div., Ph.D.March 7, 2013

Disclosure

• Senior Vice President, Education, Chief of Staff, ACGME

• Associate Professor of Medicine, Jefferson Medical College (volunteer)

• No conflicts of interest to report

• The ACGME receives no funds from any corporate entity other than accreditation fees related to ACGME accreditation services

• The Journal of Graduate Medical Education permits only advertizing of classified position in academic institutions

• The ACGME Annual Educational Conference is entirely self sufficient, has no external sponsors, advertisers, or displays, and uses no accreditation fee revenue for support

• ACGME International is a Not-for-Profit entity

What are we trying to do?

MASTERY

“We improve healthcare by assessing and advancing the quality of resident physician’s education through accreditation”

ACGME Mission Statement

Our Social Contract Compels Medical Educators to Design Educational Programs that:

• result in graduates whose outcomes manifest the values and virtues of professionalism, including excellence in clinical practice, and meet society’s needs

• deliver safe, affordable, quality care in a fashion that models these values and virtues, and that meet society’s evolving needs

Thomas J. Nasca, MD, MACP

What do we do? (sometimes)

Empathy Erosion

Ethical Erosion in Third Year Medical Students (N=665)

58% believed they had done something unethical52% believed they had misled a patient98% had heard physicians refer to patients

derogatorily62% had observed unethical behavior by a clinical

team member. (54% felt like accomplices)67% had felt bad or guilty about something they did

as clerks62% felt that some of their ethical principles had

eroded

Feudtner et al. ACAD. MED 69(1994):670-9

Classmates Residents At least one source

Alcohol or drug abuse 55% 36% 56%

Sexual Misconduct 32% 39% 48%

Cover-up of mistreatment of patients 27% 40% 43%

Falsifying information 28% 31% 39%

Cover-up of mistreatment of others 23% 31% 35%

Cover-up of unethical behavior 23% 29% 35%

Cheating in research 9% 7% 12%

Percent of students Reporting at Least One Episode of Observing What They Believed to Be Ethical or Professional Misconduct

Sheehan et al. JAMA 1990;263:533-7

Ethical and Professional Environment of Residency Training

Observations of others 1989N=571

1999N=

2009*N=

Falsification of medical records 45.8% 33.9% 17.6%

Mistreatment of Patients 73.8% 54.4% na

Working in Impaired Condition 72.8% 53.2% 52.1%

Threats to Reputation or Career 31.6% na na

Taking Credit for Resident’s work 50.1% na na

Tasks for Punishment 39.8% na na

Unethical Immoral Demands 24.7% 11.2%

* Not Directly Comparable

Ethical and Professional Environment of Residency Training

Personal Experience 1989N=571

1999N=

2009*N=

Psychological Abuse (Humiliation and Belittlement)

86.4% 79.3% 65.4%

Physical Abuse (slap, kick, hit) 38.5% 19.1% -Sexual HarassmentWomenMen

30.4%63%

15.3%

-35.3%10%

---

Racial/Ethical DiscriminationWhiteNon-White

25.4%--

26.5%14.4%46.2%

---

*Not Directly Comparable

House Officer Syndrome

• Episodic cognitive impairment• Chronic anger and resentment• Family discord• Pervasive cynicism

Gary W. Small, MDPsychometrics House Officer SyndromeOctober 1981

Discord

Brief History

• Late 1990’s – ACGME/ABMS Competencies developed• ACGME requires:

• Competency framework for curriculum• Phased incorporation of competency evaluation• Culminates in “competency based accreditation”• The “field” left to develop “tools” for the “toolbox”

• ABMS organizes individual certification in Competency framework• Initial Certification• Maintenance of Certification• Tools developed that may be relevant in GME phase

T. Nasca, MD, MACP, 2011

General Competences• Patient Care and Technical Skill

• Compassionate, appropriate, effective

• Medical Knowledge • Know and can apply• Do and apply

• Practice-Based Learning and Improvement• Assessment of own patient care, evidence-based approaches, improvement

• Interpersonal and Communication Skills

• Professionalism• Committed to professional responsibilities, ethical principles and sensitivity to

diverse patient populations

• Systems-Based Practice• Awareness and utilization of the larger context and system of healthcare in

providing optimal patient care

Outcomes Project

What happened?

Brief History

Mid-late this decade:• Competency evaluation stalls

• “Where are the tools You promised”• The process of accreditation

• MedPac, IOM, and others question the quality of preparation of graduates for the “future” health care delivery system

• House of Representatives codifies “Physician Competencies” in original Health Care Reform Package

• MedPac calls on CMS to modulate IME payments to hospitals based on competency outcomes

• Macy issues 2 reports (2011)• Another IOM report! T. Nasca, MD, MACP, 2011

Suffice it to say that there is sufficient motivation,

internal and external to the ACGME, and all involved in GME,

for change.

How are we going to accomplish this task?

“Every system is perfectly designed to yield the result it produces.”

Edwards Deming?Donald Berwick?

Paul Batalden?

“One definition of insanity is doing the same thing over and over again,

but expecting different results.”

Rita Mae BrownSudden Death, 1983. p. 68

Fundamental Transformative

Change

The 2005 ACGME Strategic Plan1: Emergence of “The New Accreditation Model”

“At its November 2005 retreat, the ACGME Executive Committee endorsed four strategic priorities designed to enable emergence of the new accreditation model:

• Foster innovation and improvement in the learning environment• Increase the accreditation emphasis on educational outcomes• Increase efficiency and reduce burden in accreditation• Improve communication and collaboration with key internal and

external stakeholders “

1 ACGME 2005 Strategic Plan: Emphasis Added, TJN


2009-2010 ACGME “Duty Hours Task Force” changed to “Task Force for Quality Care and Professionalism”. The actions of the

ACGME must fulfill the social contract, and must cause sponsors to maintain an educational environment that assures:

• the safety and quality of care of the patients under the care of residents today

• the safety and quality of care of the patients under the care of our graduates in their future practice

• the provision of a humanistic educational environment where residents are taught to manifest professionalism and effacement of self interest to meet the needs of their patients

© 2012 Accreditation Council for Graduate Medical Education (ACGME)

Nasca, T.J., Day, S.H., Amis, E.S., for the ACGME Duty Hour Task Force. Sounding Board: The New Recommendations on Duty Hours from the ACGME Task Force. New England Journal of Medicine. 362 (25): e3(1-6). 2010. June 23, 2010.

At its meeting of February 7, 2012, the ACGME Board of Directors unanimously adopted the following resolution:

WHEREAS, the ACGME Board of Directors expects the highest degree of professional behavior to be modeled by Residency Program Directors and Faculty, and;

WHEREAS, the ACGME Board of Directors has endorsed standards of Resident professionalism in the core competencies for more than 10 years, and therefore;

WHEREAS, the ACGME Board of Directors reaffirms its expectation that Designated Institutional Officials, Program Directors, Faculty, and Residents must demonstrate the core elements of professional behavior in all aspects of their clinical and educational activities;

RESOLVED, that it directs the ACGME to review its standards, and recommends any modifications of these standards and their enforcement required to assure that these expectations are met.

ProfessionalismACGME

Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate:• Compassion, integrity, and respect for others;• Responsiveness to patient needs that supersedes self-

interest;• Respect for patient privacy and autonomy;• Accountability to patients, society and the profession;

and, • Sensitivity and responsiveness to diverse patient

population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation

The Next Accreditation System

1 Nasca, T.J., Philibert, I., Brigham, T.P., Flynn, T.C. The Next GME Accreditation System: Rationale and Benefits.

New England Journal of Medicine. Published Electronically, February 22, 2012. In Print, March 15, 2012. DOI:10.1056/nejmsr1200117 www.nejm.org .

NEJM. 2012.366;11:1051-1056.

Goals of The “Next Accreditation System”

• To begin the realization of the promise of Outcomes

• To free good programs to innovate

• To assist poor programs to improve

• To reduce the burden of accreditation

• To provide accountability for outcomes to the Public


What will be the essential elements/ingredients/ principles of “The Next” Accreditation System?

• Continuous Accreditation

• Increased Outcomes/Decreased Process Based Standards• Demonstration of Desired Outcomes (Milestones)

• Enhance flexibility/agility of programs to innovate/create/react

• Standardization Balanced with Specific Specialty Needs

• Increased Emphasis on Patient Safety and Quality Improvement

• Enhanced Effectuation of the “Continuum”

• Transparency of Standards and Processes

• Enhanced Institutional Accountability

Thomas J. Nasca, MD, MACP

Building Blocks or Components of The “Next” Accreditation System

Clinical Learning Environment Review CLER Visits

Continuous RRC and IRC Oversight and Accreditation

10 Year Self-Study Visit

prn Site Visits (Program or Institutional)

10 year Self-Study


Emphasis of CLERAssessment of Effectiveness of Sponsor in:

• integration of residents into Patient Safety programs of the institution, and demonstration of impact

• integration of residents into Quality Improvement programs of the institution, efforts to reduce Disparities in Health Care Delivery, and demonstration of impact

• establishment and implementation of Supervision policies

• oversight of transitions in care

• oversight of duty hours standards implementation

• Emphasis on Professionalism throughout


Implementation of CLER

• Senior Vice President and Administration

• Regional Vice Presidents (3)

• Physician Site Visitors (9)

• CLER Evaluation Committee• Co-Chairs:

• Kevin Weiss MD MPH

• James Bagain MD PE

• Alpha Phase 7-9/2012

• Beta Phase 9/2012-Present

• Single Site Sponsors• Details December 2013

• Tentatively not until July 2014


CLER in the context of NAS

• CLER evaluation based on expectations• CLER is designed as a formative learning

process for both the institutions and ACGME

• Collective knowledge from CLER will likely inform future institutional requirements (raising the floor)

Building Blocks or Components of The “Next” Accreditation System

Clinical Learning Environment Review CLER Visits

Continuous RRC and IRC Oversight and Accreditation

10 Year Self-Study Visit

prn Site Visits (Program or Institutional)

10 year Self-Study


The Conceptual ChangeFrom…

The Current Accreditation System

Rules

Corresponding Questions

“Correct or Incorrect” Answer

Citations and Accreditation Decision

Rules

Corresponding Questions

“Correct or Incorrect” Answer

Citation andAccreditation Decision


The Conceptual ChangeTo…

“Continuous”Observations

Assure that the Program Number of Potential Fixed the Problem Related “Rules” Problems

PromoteInnovation

Diagnose the Problem

If there is one!

The “Next Accreditation System”


The “Next Accreditation System” in a Nutshell

• Continuous Accreditation Model – annually updated• Based on annual data submitted, other data requested, and

program trends

• Scheduled Site Visits replaced by 10 year Self Study Visit

• Standards revised every 10 years• Standards Organized by

• Core/Detailed Structure• Core/Detailed Resources• Core Processes• Detailed Processes• Outcomes


Implementation Timeline forThe “Next” Accreditation System

• First “round” of CLER visits – underway• 9/2012-6/2014

• New Policies and Procedures take effect 7/1/2013• Phase 1 Specialties

• 1/2012 Ceased routine Site Visits• 7/2012 Entered “preparation year”• 7/2013 Begin Continuous Accreditation

• Phase 2 Specialties, Institutional, Transitional Year• 1/2013 Will cease routine Site Visits• 7/2013 Will enter “preparation year”• 7/2014 Will begin Continuous Accreditation


Milestones

Milestones

• Observable developmental steps moving from Novice to Expert/Master

• Organized under the rubric of the six domains of clinical competency• Describe a trajectory of progress from neophyte towards

independent practice• Articulate shared understanding of expectations• Set aspirational goals of excellence• Provide a framework and language for discussions across the

continuum

Not to you…

Not for you…

With you

Specialty SpecificTeams

BoardPD AssociationCollegeRRCResidents

Milestones&

Core Evaluation Requirements

ACGME

Specialty SpecificCompetency Evaluation Program Requirements

for reporting (Outcomes)

Increase the Accreditation Emphasis on Educational Outcomes

Thomas J. Nasca, MD, MACPModified by T. Brigham

Expectations

• Milestones• When and where possible, identification of

appropriate assessment “tools”/methods/systems

• Creation of a summary reporting document to be used by a clinical competence committee in each program to report to the ACGME and Specialty Board

Milestones Group

• Convened by American Board of Internal Medicine and the ACGME

• Membership sought from ACP, APDIM, residents, as well as ABIM and RRC-IM

• Goal to translate the “general” competencies into Internal Medicine specific competencies to be met by all residents

• Goal to create “core” resident outcomes in the competencies, not “standardization” of all outcomes (or programs)

The Internal Medicine Milestones GroupEva M. Aagaard, MDJane H. Barnsteiner, PhD, FAANThomas A. Blackwell, MDKaren Hsu Blatman, MDDonald R. Bordley, MDKelly Caverzagie, MDDavoren A. Chick, MD, FACPCharles P. ClaytonThomas G. Cooney, MDRosemarie L. Fisher, MDMichael L. Green, MD, MScLuke Hansen, MDLinda A. Headrick, MDKevin T. Hinchey, MDEric S. Holmboe, MD, FACPHolly J. Humphrey, MD, FACPWilliam F. Iobst, MD

Gregory C. Kane, MDDavid Karlson, PhDCharles M. Kilo, MD, MPHLynne M. Kirk, MDCatherine R. Lucey, MD, FACPThomas J. Nasca, MD, MACPEileen E. Reynolds, MDEugene C. Rich, MD, FACPPaul H. Rockey, MD, MPHWilliam E. Rodak, PhDMichele Sanders, MDHenry J. Schultz, MD, MACPLawrence Smith, MDAbraham Verghese, MD, MACP, DScSteven E. Weinberger, MD, FACPBrent C. Williams, MD, MPH

The Internal Medicine Milestones Group Delivers Their First Report to the Profession

Journal of Graduate Medical Education. 1(1). 5-20. 2009.

Green, et.al. Journal of Graduate Medical Education. 1(1). 5-20. 2009.

Dimensions of Professionalism and MilestonesInternal Medicine

Professionalism - PhysicianshipDemonstrate compassion, integrity, and respect for others

Responsiveness to patient needs that supersedes self-interestAccountability to patients, society, and the profession

Elements of the Physicianshipin Internal Medicine

• Adheres to basic ethical principles• Demonstrates Compassion and

Respect to Patients• Provides timely, constructive

feedback to colleagues• Maintains accessibility• Recognizes conflicts of interest• Demonstrates personal

accountability• Practices individual patient

advocacy

Milestones of Trainingo Demonstrates empathy and

compassion to all patients (3rd month)

o Demonstrates a commitment to relieve pain and suffering (3rd month)

o Provides support (physical, psychological, social, and spiritual) for dying patient and their families (24th month)

o Provides leadership for a team that respects patient dignity and autonomy (24th month)

Green, et.al. Journal of Graduate Medical Education. 1(1). 5-20. 2009.

“M” and “M”(meaningful) (manageable)

Milestone “Framework”

Competency

Sub-competency (approximately 6)

Developmental Milestones Narratives(approximately 5 narrative on a Dreyfus or equivalent trajectory)

The “Envelope of Expectations”Professionalism


1 2 3 4 5

Per

form

ance

Abi

lity

This resident does not respond collegially and promptly to requests for consultation nor promptly notify supervisors of the request. The resident does not make his role clear to the patient..

This resident responds collegially and promptly to a request for consultation and promptly notifies supervisors of therequest. The resident makes his/her roleclear to the patient.

This resident, when consulted,acknowledges the request with thereferring team and notifies the seniorresident and attending surgeon promptly of the results of the consultation..

This resident, when consulted, communicates an initial diagnosis and plan to the referring team and notifies the attending surgeon promptly of the results of the consultation.

This resident provides prompt and definitive consultation and assures complete communication with the referring team, patient's family, andother involved persons.

Expert Panel Assembled for:

• Systems-based Practice• Practice-based Learning and Improvement• Communication Skills• Professionalism• Assessment

All residents at all levels to be evaluated every 6 months

Clinical Competence Committee



End of Rotation

Evaluations

Peer Evaluations

SelfEvaluations Case

Logs

Student Evaluations

Patient / Family

Evaluations

Operative Performance

Rating Scales

Nursing and Ancillary

Personnel Evaluations

Assessment of Milestones

Clinic Work Place

Evaluations

Mock Orals

OSCE

ITE SimLab

© 2013 Accreditation Council for Graduate Medical Education (ACGME)John Potts, MD, modified by T. Brigham

Professionalism

Unprofessional

Resident seeks out opportunities to demonstrate compassion and

empathy in the care of all patients; and demonstrates respect and is

sensitive to the needs and concerns of all patients, family members, and members of the

health care team.

Resident demonstrates compassion and empathy in care

of some patients, but lacks the skills to apply them in more

complex clinical situations or settings. Occasionally requires

guidance in how to show respect for patients, family members, or

other members of the health care team.

Resident frequently fails to recognize or actively avoids opportunities for compassion

or empathy. On occasion demonstrates lack of

respect, or overt disrespect for patients, family members,

or other members of the health care team

Narrative Summative Report

ACGME Goal for Milestones - Permits fruition of the promise of “Outcomes Based Accreditation”

• Specialty specific normative data and common expectations for progress of individual residents

• Less prescriptive ACGME program requirements, lengthened program site visit cycles, less frequent standards revision• Promote curricular innovation

• Enhance curricular and rotation design flexibility

• Opportunity for communication and improvement across the continuum of medical education

• Development of specialty specific evaluation tools and techniques


ACGME Goal for Milestones - Permits fruition of the promise of “Outcomes Based Accreditation”

• Tracks what is important - Outcomes• Begins using existing tools and observations of

the faculty• Clinical Competency Committee triangulates

progress of each resident• ACGME and ABMS are able to provide

accountability for effectiveness of educational program in producing outcomes, and achieved outcomes of individual trainees

Thomas J. Nasca, MD, MACP, 2012

Webpage

Professionalism

Moral Foundation of Medical Practiceand the Basis of the

Social Contract between Medicine and SocietyUnilateral Pledge to:• respect those who mentored you• teach those who follow• place the needs of the patient over those of the physician• provide care to those who need it, and only the care they need• do no harm• expand medical knowledge for the good of our patients• maintain confidentialityThe expectation of return from society:• “If I keep this oath faithfully, may I enjoy my life and practice my art,

respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.”1

• This is a hopeful request, not a bilateral agreement1 from: “The Hippocratic Oath.” Translated by Michael North,

National Institutes of Health. National Library of Medicine. http://www.nlm.nih.gov/hmd/greek/greek_oath.html.

“Whatever we measure, we tend to improve.”

D. Leach

We’re facilitating the setting of expectations…

You’re working on the ground to innovate, motivate, and transform:

1. The faculty2. The journey of the learner3. The learning environment

Evolving Concept Professionalism

• Personal• Interpersonal• System

The Resident’s Journey of Transformation

http://www.doctordisruption.com/wp-content/uploads/2011/03/heros-journey-large.jpg

Personal

Charge to the Panel: Develop milestones in Professionalism, Interpersonal and Communications Skills, Practice-Based Learning and Improvement, and Systems-Based Practice for adoption and/or adaptation by specialty milestone groups.

Milestones were created to reflect the following expected levels of performance: Level 1 – Typical graduating medical student; Levels 2 and 3: Resident during the program; Level 4: Graduating resident; Level 5: Advanced, specialist resident or practicing physician

ACGME EXPERT PANEL ON MILESTONES

DRAFT VERSION 9-11-11

PROFESSIONALISMINTERPERSONAL AND COMMUNICATION SKILLS

PRACTICE-BASED LEARNING AND IMPROVEMENTSYSTEMS-BASED PRACTICE

This document is for ACGME milestone use only. Do not disseminate.

PROF-1: Compassion, integrity, and respect for others as well as sensitivity and responsiveness to diverse patient populations including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation

Level 1 Level 2 Level 3 Level 4 Level 5

1. Consistently demonstrates behavior that conveys caring, honesty, and genuine interest in patients and families when interacting or discussing with others

2. Seeks out, learns from and models the attitudes and behaviors of physicians who exemplify appropriate professional attitudes, values and behaviors.

3. Displays a consistent attitude and behavior that conveys tolerance and acceptance of diverse individuals and groups

1. Demonstrates an understanding of the importance of compassion, integrity, respect, sensitivity and responsiveness and able to exhibit these attitudes consistently in common and uncomplicated situations

2. Aware of personal beliefs and values that impact interactions with others and may influence provision of medical care; able to manage these values and beliefs so that they have minimal impact on patient care

3. Developed and exhibits an interest in and strategies to learn about issues of diverse population that potentially may impact patient care

1. Able to exhibit these attitudes consistently in complex and complicated situations

2. Recognizes how own personal beliefs and values impact medical care; consistently manages own values and beliefs to optimize relationships and medical care

3. Knowledgeable about the beliefs, values and practices of diverse patient populations and the potential impact on patient care; consistently demonstrates an interest in these issues and the necessary skills to obtain and effectively use this type of information to provide good patient care

1. Able to exhibit these attitudes consistently in all relationships and situations

2. Developed and uses an integrated and coherent approach to understanding and effectively working with others to provide good medical care that integrates personal standards with standards of medicine

3. Able to consistently provide good medical care even in the context of disagreeing with patient beliefs/ choices; aware of types of medical care that cannot provide due to personal beliefs and has a plan to maintain quality patient care in those situations.

1. Consistently practices medicine and specialty in a manner that upholds values and beliefs of self and medicine;

2. Demonstrates leadership and mentoring regarding these principles

3. Develops organizational policies and education to support the application of these principles in the practice of medicine.

Professionalism - Residents must demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles. Residents must develop and acquire a professional identity consistent with values of self, specialty and the practice of medicine.

PROF-2: Knowledge about, respect for and adherence to the ethical principles relevant to the practice of medicine, remembering in particular that responsiveness to patients that supersedes self-interest is an essential aspect of medical practiceLevel 1 Level 2 Level 3 Level 4 Level 5

1. Recognizes the importance and priority of patient care, with an emphasis on the care that the patient wants an needs; demonstrates a commitment to this value

2. Aware of basic bioethical principles; able to identify ethical issues in clinical situations

1. Consistently able to recognize and identify own beliefs and values and their impact on practice of medicine; recognizes internal and external barriers that interfere with patient care

2. Consistently recognizes ethical issues in practice; able to discuss, analyze and manage in common and frequent clinical situations

1. Demonstrates awareness of own values and beliefs and how they impact perspective on ethical issues; able to effectively manage personal beliefs to avoid any negative impact on patient care

2. Able to effectively analyze and manage ethical issues in complicated and challenging clinical situations

1. Develops and applies a consistent and appropriate approach to evaluating appropriate care, possible barriers and strategies to intervene that consistently prioritizes the patient’s best interest in all relationships and situations

2. Consistently considers and manages ethical issues in practice; develops and applies consistently a systematic and appropriate approach to analyzing and managing ethical

1. Knowledgeable about, consistently uses and effectively manages ethical principles of medicine in general and as related to specialty care

2. Demonstrates leadership and mentorship on understanding and applying bioethical principles clinically, particularly responsiveness to patients above self-interest and self monitoring

3. Develop institutional and organizational strategies to protect and maintain these principles

PROF-3: Accountability to patients, society and the profession


1. Consistently behaves in a responsible, reliable manner that demonstrates a commitment to patient care, working effectively with others and upholding the core values of medicine

2. Demonstrates professional accountability, including timely and adequate completion of professional responsibilities, being dressed and groomed appropriately as well as being ready and able to perform expected duties

3. Recognizes when needs assistance and is able and willing to ask for help

1. Able to define and understand physician accountability to patients, society, and the profession

2. Consistently demonstrates an understanding of the importance of compassion, integrity, respect and accountability in common and basic clinical situations

3. Consistently recognizes limits of knowledge in common and frequent clinical situations and asks for assistance

1. Develops an understanding of own beliefs and values and how impact attitude and behavior; able to understand and balance needs of self and others to prioritize and provide appropriate medical care

2. Consistently demonstrates an understanding of the importance of compassion, integrity, respect and accountability in complicated and challenging clinical situations

3. Consistently recognizes limits of knowledge in uncommon and complicated clinical situations; develops and implements plans for the best possible patient care

1. Develops and employs a coherent and systematic approach to making decisions about patient care that considers and integrates the values and beliefs of self, patient, society and the core values of medicine

2. Consistently demonstrates an understanding of the importance of compassion, integrity, respect and accountability in all clinical situations

3. Consistently demonstrates the ability to identify limits of own knowledge and to develop and implement a plan for the best possible patient care

1. Knowledgeable about and consistently able to consider and balance the needs, values and available resources of patient, society, profession, and self while providing good medical care generally and in specialty

2. Demonstrates leadership and mentorship regarding these principles

3. Develops organizational policies and education to support the application of these principles in the practice of medicine.

PROF-4 : personal responsibility to maintain emotional, physical, and mental health


1. Exhibits basic professional responsibilities such as timely reporting for duty, rested and ready to work, able to deliver patient care as a functional physician.

2. Dresses in appropriate professional attire and grooming.

3. Aware of the basic principles and aspects of the general maintenance of emotional, physical, and mental health

1. Aware of the issues related to fatigue and sleep deprivation

1. Identifies basic principles of physician wellness, including rest, diet, exercise, personal health, and balance in life.

2. Demonstrates adequate management of personal emotional, physical and mental health

3. Knowledgeable about and effectively manages the issues related to fatigue and sleep deprivation

1. Assesses application of principles of physician wellness, alertness, delegation, teamwork, and optimization of personal performance to the practice of medicine.

2. Able to identify and manage situations in which maintaining personal emotional, physical and mental health is challenged by common and typical clinical care situations

1. Optimizes professional responsibilities through the application of principles of physician wellness to the practice of medicine.

2. Able to identify and manage situations in which maintaining personal emotional, physical and mental health is challenged by complicated and less frequent clinical care situations

3. Recognizes signs of physician impairment and demonstrates appropriate steps to address impairment in colleagues

1. Demonstrates leadership abilities in professional responsibilities.

1. Develops institutional and organizational strategies to improve physician insight into and management of professional responsibilities, train physicians and educators regarding responsibility, wellness, fatigue and physician impairment.

Interpersonal

We tend to be very poor at Self - Assessment

Com

pete

nce

Tragic

Dangerous

Confidence

It is imperative that you be there to mentor, challenge and

guide them

You may have to go on YOURown journey

Institute on Medicine as a Profession (IMAP) Survey on Medical Professionalism

D. Blumenthal, et al • 1,662 physicians from six specialties (3 primary care, 3

non-primary care)• Found most physicians agreed with the principles of the

ACP/ABIM/EFIM Physician Charter (primacy of patient welfare, patient autonomy, social justice)• Incongruities were found between beliefs and

behaviors

Campbell EG, Regan S, Gruen Rh, Ferris TG, Rao Sr, Cleary PO,Blumenthal D (2007) “Professionalism in Medicine: Results of a NationalSurvey of Physicians.” Annals of Internal Medicine, 147 (11), 795-802

Eric Holmboe, 2013Modified by T. Brigham

Fulfilling Professional Responsibilities Including Self-Regulation

0%10%20%30%40%50%60%70%80%90%

100%

Physicians should report all instances ofsignificantly impaired or incompetent

colleagues to hospital, clinic, or other relevantauthorities

In the last 3 years, have you had a directpersonal knowledge of a physician who was

impaired or incompetent in your hospital,group, or practice and have NOT reported

that physician?

96%

67%


Improving Quality Care

0%10%20%30%40%50%60%70%80%90%

100%

Physicians should participate in peerevaluations of the quality of care provided by

colleagues

In the last 3 years, have you reviewedanother physician's medical records for

quality improvement?

56%


93%

This Framework Compels us as Individual Medical Educators:

• To model these values and virtues in our own everyday activities (the informal curriculum)

• To have the courage to advocate for the needs of all our patients

• To have the courage to advocate for the needs of our residents

The System

Evaluating Residency Programs Using Patient Outcomes n= 4,906,169 deliveries in Florida and New York, 1992-2007

4124 physician program graduates of 107 residency programs

0

2

4

6

8

10

12

14

Q5 Q4 Q3 Q2 Q1 Q1-Q5

Residency Program of Origin, Ranked (Quintile) by Program Complication Rate

Rate of Major Obstetric Complications by Graduates (%)

10.1-10.5

11.3-11.411.9-12.0

12.3-12.5

13.6-14.0

2.8 – 3.8

∆

Difference remainsafter correction for

USMLE performance

Excess Risk ∆ 33%Q1 vs Q5

JAMA 2009;302(12):1277-1283. Asch, DA, et.al., Table 4

Hidden Curriculum

Miller’s Pyramid

Formal didactic & formal

presentations

Simulation & experiential learning (case presentations, clinical scenarios, etc.

The stories we tell

Role modeling“Being” The hidden curriculum

Knows

Knows how

Shows how

Does

http://www.jrheum.org/content/36/6/1101/f1.large.jpg

Miller, GE. The Assessment of Clinical Skills & Performance Academic Medicine (supplement) 1990 05 19); 63-67

“Good souls tell good stories.”William F. Kraft

Ways of the Desert: Becoming Holy Through Difficult Times

4 Room Apartment

Claes Janssen 1982

Contentment Renewal

DenialConfusion/chaos

What to do in each room

Weisbord, 1987, p. 220

Contentment Renewal

Denial Confusion/chaos

“I like it just as it is”

Leave people alone (unless the building’s on fire)

What, me worry?”

Ask questions, give support, raise awareness

“What a mess!! Help!!”

Focus on the future, structure tasks, get people together

“We have too many good ideas”

Offer help for implementation

Educational Program Faculty,

Structure, and

Function


Structure, and

Function


Structure, and

Function

The Essential Elements of Excellence in Clinical Education

Quality of Clinical Care

Excellence in Clinical Care in

Independent Practice

Tomorrow

Intelligence

Motivation and Attitude

Physical Abilities

ResidentAptitude

Patient Safety in

our Teaching Hospitals

Today

Humanistic Educational Environment

Effacement of Self Interest

Parting Thoughts…

Overcoming Inertia

Never be afraid to try something new. Remember that amateurs built the ark,

and professionals built the Titanic.

Anonymous

“If you think you’re too small to be effective, you have never been in bed with

a mosquito.”

Betty Reese (American officer and pilot)

The Next Phase

“Somebody has to do something,

Jerry Garcia The Grateful Dead

and it’s just incredibly patheticthat it has to be us.”

Grace Note

(LaSalle Leffall, Jr., MD)

StayTuned

Thank you

Questions?

Expert Panel Members

ACGME Committee Director

Susan Swing, PhD Vice President, Outcome Assessment

Professionalism

Arden Dingle, MDAssociate Professor, Psychiatry & Behavioral Sciences Training Director, Child , & Adolescent ResidencyEmory Medical School

Catherine A. Marco, MD, FACEPProfessor, Emergency MedicineProgram Director, Emergency Medicine ResidencyUniversity of Toledo College of Medicine

Interpersonal and Communication Skills

Karen Brasel, MD, MPHProfessor, Trauma & Critical CareDivision of Cardiothoracic Surgery Medical College of Wisconsin

Rich Frankel, PhDResearch Scientist Regenstrief Institute, Inc.Indiana University Center for Health Services and Outcomes Research

Joanne Schwartzberg, MDDirector, Aging & Community HealthAmerican Medical Association

Expert Panel Members

Practice-Based Learning and Improvement

Tina Foster, MD, MPH, MS**Preventive Medicine Residency Program DirectorDartmouth-Hitchcock Medical Center

Gary Loyd, MD, MMMProfessor and Director of Faculty DevelopmentDepartment of Anesthesiology and Preoperative MedicineUniversity of Louisville School of Medicine

Prathibha Varkey, MBBS, MHP, MHEP**Associate Chair, Department of Medicine, Faculty Development and Satisfaction Associate Professor of Medicine, Preventive Medicine and Medical Education Mayo Clinic, Rochester

**Also Systems-Based Practice

Systems-Based Practice

Robin Hemphill, MD, MPHChief Patient Safety OfficerVA National Center for Patient Safety

Douglas Paull, MD, FACS, FCCPDirector, Patient Safety CurriculumVA National Center for Patient Safety

Linda Williams RN, MSICo-Director Patient Safety Fellowship ProgramVA National Center for Patient Safety•

Copyright © 2012 American Medical Association. All rights reserved.

From: Evaluating Obstetrical Residency Programs Using Patient OutcomesAsch, DA, et.al.,

JAMA. 2009;302(12):1277-1283. doi:10.1001/jama.2009.1356

professionalism and the education of masterful physicians ... · of masterful physicians: the next...

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