Version: November 14, 2015The authors of this eBook have no actual or potential conflict of interest in relation to this work.

Adapted from: Montpetit M, Hogue RJ, Geller C, MacDonald CJ, Johnston S. Essential teaching skills 3: Teaching professionalism. Ottawa, ON: Department of Family Medicine University of Ottawa, 2013. Available from: http://familymedicine.uottawa.ca/ETS3/

AuthorsDonna Johnston, MD, FRCPC, FAAP, Department of Pediatrics, University of Ottawa

Madeleine Montpetit, MSc, MD, CCFP, FCFP, Department of Family Medicine, University of Ottawa

Rebecca J. Hogue, PhD Candidate, Faculty of Education, University of Ottawa

Carol Geller, MD, CCFP, FCFP, Department of Family Medicine, University of Ottawa

Colla J. MacDonald, EdD, Faculty of Education, University of Ottawa

Sharon Johnston, MD, LLM, CCFP, Department of Family Medicine, University of Ottawa

Project LeadDerek Puddester, MD, MEd, FRCPC, ACC, Associate Professor, Department of Psychiatry and Special Project Lead, Innovation & Evaluation, Postgraduate Medical Education, Faculty of Medicine, University of Ottawa

Project ManagerColla J. MacDonald, EdD, Full Professor, Faculty of Education and Special Project Educator, Innovation & Evaluation, Postgraduate Medical Education, Faculty of Medicine, University of Ottawa

Editor and Educational Consultant Emma J. Stodel, PhD, Learning 4 Excellence

eBook ProducerRebecca J. Hogue, PhD Candidate, Faculty of Education, University of Ottawa

VideographerHugh Kellam, PhD Candidate, Faculty of Education, University of Ottawa

Graphic DesignShawn Phillips, Shift 180

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Credits

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FundingThe development of this eBook was supported by funds from the Postgraduate Medical Education Office at the Faculty of Medicine, University of Ottawa.

iBooks TutorialFor a series of short video tutorials on how to get the most out of this eBook, see http://ipad-fm.ca/using-ibooks.

How to reference this document:Johnston D, Montpetit M, Hogue R.J, Geller C, MacDonald C.J., Johnston S. uOttawa: Developing the CanMEDS Professional. Ottawa: University of Ottawa, 2015. Retrieved from http://www.med.uottawa.ca/Postgraduate/eng/pgme_ebooks.html

Postgraduate Medical Education Faculty of Medicine, University of OttawaRoom 2115, 451 Smyth Road Ottawa ON K1H 8M5Phone: (613) 562 5413 Fax: (613) 562 5420Website: http://www.med.uottawa.ca/postgraduateEmail: pgmesup@uottawa.ca

Copyright © 2015 by the University of Ottawa

All rights reserved. This material may be reproduced in full for educational, personal, or public non-commercial purposes only, with attribution to the source as noted below. Written permission from the University of Ottawa is required for all other uses, including commercial use.

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Defining the CanMEDS Professional

Video: Developing the CanMEDS Professional: Introducing the Role of Professional

Introducing the role of Professional

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What do you know about the Professional role?

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What do you know about the Professional role?

Check Answer

Question 1 of 10Physicians disciplined by a state medical-licensing board are three times more likely to have displayed unprofessional behaviour during medical school compared to physicians who have not been disciplined.

A. True

B. False

The term professionalism arose out of the desire to reaffirm humanistic qualities such as compassion and altruism back into the medical world.

Prior to the 1990s, professionalism as a subject was not ‘taught’ in the standard medical curriculum. This was not because professionalism wasn’t believed to be important, but because it was thought that the values and behaviours associated with professionalism would be acquired during the socialization of residents and medical students as they “acquired the complex ensemble of analytic thinking, skillful practices and wise judgment” (Sullivan, 2005).

Including professionalism in the curriculum became increasingly necessary in light of evolving challenges in the training environment, such as decreased time for role modelling, the increasing diversity of the medical student population, and evolving social attitudes towards medicine and health care in general.

The Physician Charter adopted in 2002 essentially forms the basis of our professionalism curriculum to ensure that future generations of medical professionals will uphold the tenets of the profession. For more information on the history of professionalism in medical education see The Emergence of

Professionalism on the University of Ottawa Faculty of Medicine Professionalism website.

The University of Ottawa recently instituted an Office of Professionalism within the Faculty of Medicine. The office’s policy has the purpose to reaffirm the Faculty of Medicine’s commitment to maintaining standards of professionalism in interactions among Faculty members and learners in the academic, research, and clinical care setting.

References1. The Emergence of Professionalism, Faculty of Medicine,

University of Ottawa: http://www.med.uottawa.ca/students/md/professionalism/eng/emergence_professionalism.html

2. Office of Professionalism, Faculty of Medicine, University of Ottawa: http://www.med.uottawa.ca/Organisation/ProfessionalAffairs/eng/offices.html

3. Principles of Medical Professionalism, Office of Professional Affairs, Faculty of Medicine, University of Ottawa: http://www.med.uottawa.ca/Organisation/ProfessionalAffairs/eng/policies_procedures_professionalism.html

4. About Professionalism, Faculty of Medicine, University of Ottawa: http://www.med.uottawa.ca/students/md/

A brief history of medical professionalism

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CanMEDS 2015

Copyright © 2015 The Royal College of Physicians and Surgeons of Canada. http://www.royalcollege.ca/portal/page/portal/rc/canmeds. Reproduced with permission.

The CanMEDS framework describes the competencies physicians need to effectively care for their patients within seven roles: Medical Expert, Communicator, Collaborator, Manager/Leader, Health Advocate, Scholar, and Professional. The framework is reviewed and updated at regular intervals. In

March, 2015 the Royal College of Physicians and Surgeons of Canada released a third iteration of the CanMEDS framework for discussion. This revised, working draft defines the role of Professional as follows:

As Professionals, physicians are committed to the health and well-being of individual patients and society through ethical practice, high personal standards of behaviour, accountability to the profession and society, profession-led regulation, and maintenance of personal health.Key Competencies:

Physicians are able to:

• Demonstrate a commitment to patients by applying best practices and adhering to high ethical standards.

• Demonstrate a commitment to society by recognizing and responding to societal expectations in health care.

• Demonstrate a commitment to the profession by adhering to standards and participating in physician-led regulation.

Defining Professionalism

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• Demonstrate a commitment to physician health and well-being to foster optimal patient care.

The CanMEDS 2015 framework breaks each of these 4 key competencies into a number of enabling competencies, which can be reviewed in the Draft CanMEDS 2015 Physician Competency Framework, along with further information about the proposed revisions to the Professional role.

CanMEDS-FM

Image adapted by the College of Family Physicians of Canada in 2011 from the CanMEDS Physician Competency Diagram with permission of the Royal College of Physicians and Surgeons of Canada. Copyright © 2009. Reproduced with permission of the CFPC.

In 2009, the College of Family Physicians of Canada adapted the Royal College of Physicians and Surgeons of Canada’s CanMEDS

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2005 framework to categorize physician competencies in family medicine. They created CanMEDS-Family Medicine (CanMEDS-FM), with the same, slightly adapted, seven roles: Family Medicine Expert, Communicator, Collaborator, Manager, Health Advocate, Scholar, and Professional.

The College of Family Physicians of Canada defined the role of Professional as follows:

As Professionals, family physicians are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour.Key Competencies:

Family Physicians are able to:

• Demonstrate a commitment to their patients, profession, and society through ethical practice.

• Demonstrate a commitment to their patients, profession, and society through participation in profession-led regulation.

• Demonstrate a commitment to physician health and sustainable practice.

• Demonstrate a commitment to reflective practice.

The CanMEDS-FM framework breaks each of these 4 key competencies into a number of enabling competencies, which can be reviewed in the document CanMEDS-Family Medicine.

Make sure you are familiar with the key and enabling competencies of the role presented on the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada websites.

For a list of observable behaviours of the twelve themes that define professionalism in family medicine go to: http://www.cfpc.ca/uploadedFiles/Education/Professionalism.pdf. This resource will help you find the necessary words to describe the concerning behaviours when providing feedback to learners or when documenting breaches in professionalism.

References1. Royal College of Physicians and Surgeons of Canada. The

CanMEDS framework. Ottawa, ON: Royal College of Physicians and Surgeons of Canada, 2005. Available from: http://www.royalcollege.ca/portal/page/portal/rc/canmeds/framework

2. Tannenbaum D et al. CanMEDS-Family Medicine. Mississauga, ON: College of Family Physicians of Canada, 2009. Available from: http://www.cfpc.ca/uploadedFiles/Education/CanMeds%20FM%20Eng.pdf

3. About Professionalism, Faculty of Medicine, University of Ottawa: http://www.med.uottawa.ca/students/md/professionalism/eng/about.html

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4. Principles of Medical Professionalism, Office of Professional Affairs, Faculty of Medicine, University of Ottawa: http://www.med.uottawa.ca/Organisation/ProfessionalAffairs/eng/policies_procedures_professionalism.html

5. Competencies in ethics and professionalism for Canadian Family Medicine Residency Programs (Appendix 1): Ogle K, Sullivan W, Yeo M. Ethics in family medicine: Faculty handbook. Mississauga, ON: College of Family Physicians of Canada, 2012. Available from: http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/Health_Professionals/Faculty%20Handbook_Edited_FINAL_05Nov12.pdf

6. Observable behaviours of the twelve themes that define professionalism in family medicine. Available from: http://www.cfpc.ca/uploadedFiles/Education/Professionalism.pdf

7. Canadian Medical Association. Code of ethics (update 2004). Available from: http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD04-06.pdf

8. College of Physicians and Surgeons of Ontario. Values of the profession: The practice guide. Available from: http://www.cpso.on.ca/uploadedFiles/policies/guides/PracticeGuideExtract_08.pdf

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Teaching the CanMEDS Professional

There are three types of curriculum:

• Formal curriculum: The formal curriculum is how the program explicitly addresses the development of competency. It is planned, has specific learning objectives, and uses teaching and assessment activities.

• Informal curriculum: The informal curriculum refers to the interpersonal, unplanned forms of teaching and learning that take place in a variety of clinical environments.

• Hidden curriculum: The hidden curriculum is the set of influences that function at the level of the organizational structure and culture. The influences may be unknown and disruptive.

Be aware of the types of curriculum that exist. This way, you can optimize the positive outcomes of your teaching efforts by picking teaching strategies that best suit the topic and the skills required. Once you have determined what to teach, it becomes easier to tease out the best format in which to deliver the content, observe whether the knowledge has been incorporated, determine whether the learner can customize to the needs of the clinical situation, and evaluate for mastery of the competency in question.

Remember, the hidden curriculum is often unconsciously transmitted. Program-wide safeguards and teacher self-reflection need to be in place to avoid disruptive influences on training outcomes.

Definitions of curriculum

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A study in the New England Journal of Medicine by Papadakis and colleagues in 2005 examined the relationship between disciplinary action by medical boards against physicians and physicians’ prior behaviour in medical school. They found that disciplinary action by a medical board was strongly associated with prior unprofessional behaviour in medical school. The types of unprofessional behaviour most strongly linked with disciplinary action were severe irresponsibility (odds ration 8.5) and severely diminished capacity for self-improvement (odds ratio 3.1). Disciplinary action was also associated with low scores on the MCAT and poor grades in the first 2 years of medical school but the association was not as strong as that with unprofessional behaviour.

When dealing with unprofessional behaviour, it’s important to consider why a learner might have acted unprofessionally. They are often many reasons behind the behaviour and these must be considered. A learner may act unprofessionally because:

• They don’t know: They may have different cultural expectations and/or different definitions of professionalism. In this case, learners can learn what it means to be professional.

• They don’t care: They are sociopaths or psychopaths. In this case, modification of a learner’s behaviour is possible.

• They can’t care: They are overwhelmed and struggling to cope, and/or have mental health issues. Always “THINK ILL BEFORE EVIL” when considering issues of professionalism. (David McKnight, Associate Dean, Equity & Professionalism, Faculty of Medicine, University of Toronto)

Reasons to teach professionalism include:

• It is a fundamental part of being a competent physician.

• It allows us to share a common definition of expected behaviours within our profession.

• It allows us to maintain our status as a self-regulating profession.

• To help prevent future complaints from the College.

• To address and identify the hidden curriculum, which may undermine professional values.

• To prevent the impact of unprofessional behaviour, which is serious and far-reaching.

Why we teach professionalism

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• To prepare learners for a future autonomous medical career practising within our society and its expectations of physicians.

• It supports patients’ and societies’ confidence in our ability to self-regulate our profession.

• Unprofessional behaviour affects the reputation of healthcare providers and/or professional organizations.

Reference1. Papadakis MA et al. Disciplinary action by medical boards and

prior behaviour in medical school N Engl J Med. 2005 Dec 22;353(25):2673-2682.

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When should we teach professionalism?

ALWAYS!Professionalism is part of who we are as medical professionals from the time we begin the apprenticeship. It is a defining role and needs to be identified implicitly.

To negate the effect of the hidden curriculum, we must highlight the expectations for the role of Professional from all members of the team from first year students to seasoned faculty.

Developing competence in the role of Professional occurs in stages and teaching professionalism should be aligned with the appropriate stage at which the learner is at. Early stage learners are more focused on following the rules, whereas self reflection begins in earnest in the PGY2 stage. As the level of the learner increases (medical student to first year resident to upper year resident) their level of sophistication also increases, as does their level of responsibility. This allows the knowledge imparted to the learners to increase in complexity and improves their ability to self-reflect.

In postgraduate training programs, professionalism topics are woven into the curriculum in various areas and in diverse formats. Formal sessions occur in academic half-days and university postgraduate symposia. Informally, but even more

effectively, discussions around professionalism are actively encouraged during exposure to all clinical encounters. Active role modelling by faculty is incorporated throughout the whole experiential training/apprenticeship program.

Adapted from Steinert Y, Snell L. Teaching methods: Principles and practices. In Creuss R, Creuss S, Kearney R, Snell L, Steinert Y. The CanMEDS Train-the-Trainer (TTT) Program on Professionalism. Ottawa: The Royal College of Physicians and Surgeons of Canada, 2009. Reprinted with permission.

When to teach professionalism

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You are a role model to learners both in and outside the clinical environment. This is part of the informal curriculum where most of the learning around professionalism occurs. How you behave sets an example for what is acceptable within your organization. Be aware of your own behaviour at all times and immediately correct any lapses in your own professionalism. Be explicit about what is being modelled. Consider how the organizational structure and culture of your unit support or undermine the demonstration of professional behaviours by your learners.

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Where should we teach professionalism?

EVERYWHERE!All interactions that are witnessed by learners are role-modelling opportunities; for example, journal clubs, discussions with colleagues, and interactions with clinic or ward staff. Even a simple encounter, such as how you speak to the cafeteria attendant after standing in line for 15 minutes waiting to pay for your lunch, may influence how the learner perceives acceptable professional behaviour.

While professionalism weaves itself through all aspects of the learner’s professional development and is constantly modelled by physicians, there are many other methods of teaching and learning professionalism. You can teach professionalism in many settings and situations including:

• Teaching rounds (e.g., Postgraduate Academic Symposia Series has mandatory sessions on professionalism issues: http://www.med.uottawa.ca/Postgraduate/eng/symposia_forums.html)

• Academic half-days

• Journal clubs

• Conferences (e.g., International Conference on Residency Education: http://www.royalcollege.ca/portal/page/portal/rc/events/icre)

• Informal discussions

• Bedside

• All clinically relevant environments

Where to teach professionalism

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One way to change the culture in medicine towards valuing professionalism is to integrate it into everyday teaching. Take time to pause during interactions with learners to point out examples of professionalism (or unprofessionalism) to highlight this role to learner—make the implicit explicit. For example, if a resident asks you about a patient whilst you are in a public place, respond that you will answer the question once you are back in your office in a more private setting. When a resident acts in a professional manner, stop to point this out and provide positive feedback, even though it should be the norm. For example, when the resident asks for help because they feel the situation is beyond their limit of clinical competence or when they show a commitment to their own personal health and work-life balance.

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Who teaches professionalism?

EVERYONE!Staff are involved in a significant proportion of informal professional teaching experiences. Senior residents and allied health professionals also provide a large volume of professionalism teaching. One element of the informal curriculum is the messages staff, residents, and allied health professionals convey to students and junior residents about behaviours that are counter to the objectives of the formal curriculum (i.e., unprofessional behaviours). On the other hand, the informal curriculum also has the potential to model highly desirable behaviours.

REMEMBER!You are a role model for many things, including professionalism!

Who teaches professionalism

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There are a number of strategies for developing competency within the role of Professional. These can be implemented at the program, learning team, or learner level.

Program • Interactive lecture (e.g., academic half-day on

professionalism where learners view examples of unprofessional behaviour and plan feedback as a group)

• Discussion groups (e.g., give groups of learners examples of unprofessional behaviour to discuss and come up with suggestions for how to address the issues, discuss professionalism issues within the program and ask learners for suggestions on how to address them)

• Workshops (e.g., formal review of professionalism with hands-on practice of different scenarios, such as identifying lapses in professional behaviour, discussing how to deal with these lapses, etc)

• Formal role playing (e.g., role play a situation demonstrating an unprofessional and then professional approach, do a role play demonstrating how to provide feedback on unprofessional behaviours)

• Simulated Office Oral (SOO)/Simulations (e.g., ask a standardized patient or colleague to act out unprofessional behaviours and ask learners to address them)

• Case-based vignette with guided reflection (e.g., provide learners with written cases describing unprofessional behaviours and a series of questions requiring the learner to identify the behaviour, how to address it, and how the situation could have been handled more professionally)

Learning Team • Direct observation (e.g., provide the learner with

feedback on their behaviour—both professional and unprofessional)

• Guided reflection (e.g., use examples from your program of unprofessional behaviour and discuss how to approach it as a group)

• Role modelling (This should be ongoing throughout the training environment; e.g., taking time to explicitly point out examples of both professional and unprofessional behaviour to residents as they occur in practice)

How we teach professionalism

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Learner • ePortfolio (e.g., include entries that reflect on professional

and unprofessional behaviour, either learner’s own behaviour or behaviour they have witnessed by others)

• Journalling (e.g., reflect on own and others’ professional and unprofessional behaviour)

• Online modules (e.g., Collaborative Curriculum module on the role of Professional)

This eBook will focus on strategies at the team level.

Direct observationDirect observation refers to observing and giving feedback to a learner on his/her performance. It is a commonly used teaching strategy for the development of clinical skills. However, it can also be used to develop competence in the role of Professional.

Written feedback can be a powerful tool. There are a number of tools that can be used to document direct observation:

• Mini-Clinical Evaluation Exercise (Mini-CEX): http://www.foundationprogramme.nhs.uk/download.asp?file=GUIDANCE_-_Mini-CEX_guidance_for_assessors_100616FINALv2.pdf

• Professionalism Mini-Evaluation Exercise (P-MEX): http://familymedicine.uottawa.ca/ETS3/Resources/FullPage-P-MEX.pdf Cruess RL, Herold-McIlroy J, Cruess SR, Ginsberg S, Steinert Y. The P-MEX (Professionalism Mini Evaluation Exercise): A preliminary investigation. Acad Med. 2006:81:S74-S78.

To improve direct observation:

• Observe the learner in clinical and non-clinical encounters.

• Be focused; direct observation requires concentration.

• Ask the learner for his/her insight on the event before providing feedback.

• Reinforce positive behaviour and discuss opportunities for improvement.

• Have the learner observe you and give you feedback. Remember the hallmarks of a good physician. For example, when seeing a patient with a resident, ask the resident how they think you did during the encounter and if there was anything they would have done differently.

References1. Russell G, Ng A. Taking time to watch: Observation and learning

in family practice. Can Fam Physician. Sep 2009;55(9):948-950. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2743595/

2. Mini-Clinical Evaluation Exercise (Mini-CEX): http://www.foundationprogramme.nhs.uk/download.asp?file=GUIDANCE_-_Mini-CEX_guidance_for_assessors_100616FINALv2.pdf

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3. Professionalism Mini-Evaluation Exercise (P-MEX): http://familymedicine.uottawa.ca/ETS3/Resources/FullPage-P-MEX.pdf Cruess RL, Herold-McIlroy J, Cruess SR, Ginsberg S, Steinert Y. The P-MEX (Professionalism Mini Evaluation Exercise): A preliminary investigation. Acad Med. 2006:81:S74-S78.

Guided reflectionGuided reflection involves giving learners a series of prompts to help them develop reflective thinking skills. It has been found to be an effective educational tool to help learners explore professionalism (Aronson, 2011; Stark et al., 2006). Reflection allows learners to reflect on what they do and do not know, as well as become aware of how their beliefs constrain the way they see the world.

(from www.academicsupportplan.com)

Aronson (2011) provides 12 tips for designing, implementing, and evaluating reflective exercises in medical education:

1. Define reflection

2. Decide on learning goals for the reflective exercise

3. Choose an appropriate instructional method for the reflection

4. Decide whether you will use a structured or unstructured approach and create a prompt

5. Make a plan for dealing with ethical and emotional concerns

6. Create a mechanism to follow up on learner’s plan

7. Create a conducive learning environment

8. Teach learners about reflection before asking them to do it

9. Provide feedback and follow-up

10.Assess the reflection

11.Make this exercise part of a larger curriculum to encourage reflection

12.Reflect on the process of teaching reflection

References1. Aronson L. Twelve tips for teaching reflection at all levels of

medical education. Med Teach. 2011;33(3):200-205.

2. Stark P, Roberts C, Newble D, Bax N. Discovering professionalism through guided reflection. Med Teach, 2006;28(1):e25-31. Available from: http://informahealthcare.com/doi/pdf/10.1080/01421590600568520.

3. A guide to reflective practice: http://www.ucl.ac.uk/medicalschool/staff-students/course-information/portfolio/year3/docs/a-guide-to-reflective-practice-2010-11.pdf

4. How to teach reflective practice: http://www.walesdeanery.org/images/stories/Files/Documents/Medical_Education/how_to/howtoreflective.pdf

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5. Reflection in medicine: Models and application (Canadian Family Physician: Teaching Moment, 2013): http://www.cfp.ca/content/59/1/105.full.pdf

6. Reflection and physicianship: A primer for Osler fellows: http://www.medicine.mcgill.ca/physicianship/Reports/Reflectionandphysicianshipaprimerforoslerfellows.doc

Role modellingRole modelling is one of the main methods of teaching professionalism. Role modelling can be defined as “teaching by example”. It assumes the supervisor is demonstrating the required skills and desirable behaviours and involves conscious and unconscious teaching. The challenge for preceptors is recognizing that you are being observed whenever you are with learners and your behaviour could be emulated.

Physicians should always model professional behaviour and make the implicit explicit when it comes to providing positive feedback to learners. It is often challenging to identify and point out examples of professional behaviour to learners as this should be the norm.

Lapses in one’s own professional behaviour DO occur. It should be communicated to learners that these were lapses and guidance should be given on how to avoid similar lapses in the future. Specific examples of unprofessional behaviour should be pointed out to learners. A simple example of an unprofessional behaviour is the breach of confidentiality that occurs when discussions regarding a patient occur in public places, such as in the elevator. Another common example is texting or responding to non-urgent personal calls on one’s cell phone while consulting with a colleague or resident.

Three core characteristics of a good role model are:

• Clinical competence

• Teaching skills

• Personal qualities

Learners recognize excellent role models as those who, in addition to providing good clinical care, take the time to provide feedback and make a conscious effort to articulate what they are modelling.

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ActivityAs you watch this video of an interaction between a staff physician and resident, reflect on the staff physician’s behaviour. Have you acted similarly in your own work at any time? How did you address the situation?

1. How would you react if you had a similar lapse in your own professional behaviour?

2. What might be a barrier to correcting your own unprofessional behaviour?

Video: Developing the CanMEDS Professional: Teaching the Role of Professional

• You are a role model for learners and must be aware of your own behaviour at all times.

• Be explicit about what is being modelled.

• Seek opportunities to highlight and discuss examples of professional behaviour when done well to help learners understand how it is done well. Professionalism should not always be seen as a negative issue.

• Reflect on how you as a teacher and the institution model professionalism.

• Be aware of subtle unprofessional behaviours.

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Without context, behaviour is often linked to character. The underlying assumption is that observing behaviours enables judgement of whether a person is “professional” or “unprofessional”. However, it must be kept in mind that behaviours may not always reflect underlying motivations. Try to frame the concerning behaviour as a learning opportunity and a basis for dialogue. Rather than ignoring unprofessional behaviour, which is a common response, have a conversation about the behaviour. There are many dangers in not addressing the behaviour. For example, the learner may not recognize that the behaviour is unprofessional and thus not make an effort to change the behaviour. Or, the learner may think that the behaviour is acceptable; that is, you may be unintentionally reinforcing the behaviour by not addressing it.

There are some identified barriers to addressing professionalism issues, including:

• Lack of personal comfort in addressing unprofessional behaviour.

• Belief that the behaviour or attitude is not changeable.

• Fear of being seen negatively.

• Belief that medically oriented issues take precedence over professionalism issues.

• Lack of experience or confidence in dealing with these issues.

• Feeling sorry for the learner.

• The perception that corrective feedback would be ineffective.

• Lack of professional reward for giving negative feedback.

Follow these six steps when addressing professionalism issues with a learner (adapted from Dr Monica Branigan, Collegial Conversations):

1. Create a safe environment in which to discuss the issue:

• Use judgement about the timing of the conversation.

• Consider privacy issues.

• Respect confidentiality concerns.

• Consider personal biases.

2. Seek out the learner’s perspective to help determine the contextual issues that may be playing into the perceived unprofessional behaviour. Use leading questions:

How we address professionalism concerns

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• How did you decide to . . .

• What were you hoping to achieve when you . . .

• What do you see as your responsibilities here?

• Why did you . . .

• What was your intent when you . . .

3. Ascertain whether the learner appreciates the impact of his/her unprofessional behaviour. Ask:

• What do you think the consequences of your behaviour were?

• Was there a positive outcome?

• Were there any negative impacts?

• Have you considered the impact of your behaviour on professional relationships?

4. Once you have identified with the learner what the issue is and the context in which the issue occurred, the learner needs to appreciate that a more appropriate behaviour is required in future similar situations. Ask:

• If you had to do this again, would you change anything?

• What are you taking away from this encounter?

• Is there another/more effective/more skillful way to accomplish your intention?

• What support would you need to do this?

• Can you identify any systems issues?

5. Take action where appropriate:

• Praise and acknowledgement of good behaviour is powerful.

• Support change management with empathy.

• Communicate clearly when behaviour is unacceptable.

• Define expectations clearly.

• Outline consequences if improvement is not demonstrated.

• Discuss how this impacts the system.

6. Document unprofessional behaviour and your interventions to remediate. This is especially important when behaviour is recurrent. Documentation can often be done by summarizing discussions and agreed upon actions and having the learner comment and sign off on the summary.

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ActivityAs you watch this video of a resident-patient interaction, reflect on the feedback that you would provide to this resident if you were supervising her. Then, watch the supervisor provide feedback. What does she do well? What would you do differently?

1. What do you think about the feedback given and the manner in which it was given?

2. Think about similar instances where you have had to give feedback to a resident about unprofessional behaviour. What worked well and what would you do differently in the future?

Video: Developing the CanMEDS Professional: Addressing Professionalism Concerns I

When providing feedback:

• Facilitate reflection with the resident and encourage dialogue.

• Ask the resident for his/her thoughts prior to giving your feedback. This will give you more insight in the situation for your evaluation and a sense of whether the resident has insight and is willing to change their behaviour or not.

• Protect time to provide feedback. If you know the feedback might be challenging ensure you have enough time to adequately address the issue.

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ActivityAs you watch this video of an interaction between a supervisor and resident, reflect on how the supervisor provides feedback to the resident. What does she do well? What would you do differently?

1. What do you think about the feedback given and the manner in which it was given?

2. Think about similar instances where you have had to give feedback to a resident about unprofessional behaviour. What worked well and what would you do differently in the future?

Video: Developing the CanMEDS Professional: Addressing Professionalism Concerns II

Always consider the reasons for a resident’s unprofessional behaviour before reacting: Think ill before evil.

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Evaluating the CanMEDS Professional

As a teacher, you must be able to demonstrate how you document and evaluate resident progress in the development of professionalism competencies in order to be accountable to the learner, your Department/Division, the Faculty of Medicine, and the College. You need to be explicit in the expectations and evaluation of the learners’ behaviours that reflect professional attributes. It is also important you provide learners with feedback so they can begin to self regulate.

Importance of evaluation

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1. Establish a baseline for what is expected from learners. Once you have established a baseline, show learners where they are compared to baseline.

2. Learner’s performance in terms of professionalism can be assessed in a number of ways. Pick the most appropriate evaluation tool. These may be context specific, learner stage specific, structured, or free form:

• Informal observation (e.g., observe learners’ interactions during rounds and with other members of the team)

• Formal observation (e.g., observe the learner doing a full history and physical examination and his/her interaction with the patient)

• ITERs: The next page shows some examples from University of Ottawa programs

• OSCEs (e.g., develop an OSCE that assesses professionalism. For example, the scenario is that the resident is post-call and has performed only two lumbar punctures up until this point in his/her training. The resident is asked by the parent of a child needing a lumbar puncture if he/she is able to perform this procedure and whether he/she has done it before. The parent specifically states that she does not want her child to be a guinea pig and serve as a teaching tool for residents. The resident is to have a discussion with the

parent about doing the lumbar puncture and is marked based on truthfulness, amongst other things (e.g., clarity, empathy, relatability, insight into parental concerns)

• Multisource feedback (360˚ review) (e.g., Pulse 360 Survey: http://www.pulseprogram.com)

• Mini-Clinical Evaluation Exercise (Mini-CEX): http://www.foundationprogramme.nhs.uk/download.asp?file=GUIDANCE_-_Mini-CEX_guidance_for_assessors_100616FINALv2.pdf

• Professionalism Mini-Evaluation Exercise (P-MEX): This is a validated, well-accepted tool: http://familymedicine.uottawa.ca/ETS3/Resources/FullPage-P-MEX.pdf Cruess RL, Herold-McIlroy J, Cruess SR, Ginsberg S, Steinert Y. The P-MEX (Professionalism Mini Evaluation Exercise): A preliminary investigation. Acad Med. 2006:81:S74-S78.

While the preceptor might be the first person to appreciate unprofessional behaviour in a learner, often other team members will recognize signs of professionalism breaches. When giving feedback to learner it is important to provide the learner with concrete examples of the issues that have been identified. Multi-source survey tools are useful for compiling information regarding breaches, for giving context to concerns,

Framework for evaluation

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and for ultimately speaking to the impact of the problematic behaviour.

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Activity1. Take a minute to review the P-MEX tool.

2. View the video below and use the P-MEX to evaluate the learner’s professionalism.

Video: Developing the CanMEDS Professional: Evaluating the Role of Professional

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Remediating the CanMEDS Professional

You know there is an issue, you have named the issue, you have collateral information, you have had a conversation so that everyone is on the same page and knows expectations and understands concepts . . . and yet the unprofessional behaviour persists. Now what?

Remediating unprofessional behaviour is a challenge.

Unprofessional behaviour needs to be:

• Recognized as a problematic issue.

• Addressed early.

• Managed by a community (i.e., don’t try to address it on your own).

• Monitored for improvement and/or ongoing issues that may necessitate further support for the preceptor and/or learner.

When maladaptive patterns of behaviour persist, a more formal remediation plan or contract is required. The learner must be made aware that his/her performance will now be monitored formally by the program.

Remediating unprofessional behaviour

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A consistent approach to learners who require formal remediation is essential. In situations where formal remediation is required, certain basic steps need to be followed:

Reinforce the shared goal

• We all want the learner to emerge as a healthy competent practitioner after their training.

Think ill before evil

• Consider referral to the Faculty Wellness Program for evaluation:

• http://www.med.uottawa.ca/wellness/eng/• wellness@uottawa.ca • 613-562-5800 ext. 8507

• PARO 24 hour helpline 1-866-HELP-DOC

• OMA Physician Health Program 1-800-851-6606

Put together a support team

• Working with a learner in difficulty can be trying for all. Professionalism concerns make it even more demanding both emotionally and physically for the preceptor and learner. It is important to get support from others. Bounce ideas off them, tap into their expertise, share the load, or just debrief with them.

Create a learning plan, targeting the specific issues identified for the learner

1. Formally identify the professionalism issue that requires remediation.

2. Determine the context and case specific objectives and outcomes for the remediation plan.

3. Select appropriate teaching strategies and evaluation tools.

4. Build a learning plan that clearly outlines to both the learner and teacher the expectations, strategies, and expected outcomes. The Academic Support Process website provides guidance and support in the development of individualized learning plans. Have both the learner and preceptor sign the agreed upon remediation plan.

5. Set a time limit for remediation in which progress is expected. Clearly state the consequences if objectives are not met within the designated time frame.

6. Document, document, document!

Formal remediation

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Initiate the formal remediation process

• For cases that cannot be resolved at the program level or that have egregious concerns, consider referral to the Postgraduate Medical Education Sub-Committee on Professionalism.

• PGME Sub-Committee on Professionalism• Referral to the Professionalism Committee (Word

Doc)

ReferencesUniversity of Ottawa resources:

1. Policy on Professionalism: http://www.med.uottawa.ca/Organisation/ProfessionalAffairs/eng/policies_procedures_professionalism.html

2. PGME Sub-Committee on Professionalism: http://www.med.uottawa.ca/Postgraduate/assets/documents/Committees/TOR%20PGME%20Committee%20on%20Professionalism.pdf

3. Referral to the Professionalism Committee Form: http://www.med.uottawa.ca/Postgraduate/eng/evaluation_policy_forms.html

4. Remediation Recommendation and Plan, Faculty of Medicine, University of Ottawa: http://www.med.uottawa.ca/Postgraduate/assets/documents/evaluation_policy_forms/Remediation%20recommendation%20and%20plan%20version%20Jan%2029%202014%20(1).pdf

5. Remediation Outcome, Faculty of Medicine, University of Ottawa: http://www.med.uottawa.ca/Postgraduate/assets/documents/evaluation_policy_forms/Remediation%20Outcome%20version%20Feb%204%202014.pdf

Other resources:

6. The Practice Guide: Medical Professionalism and College Policies (CPSO): http://www.cpso.on.ca/Policies-Publications/The-Practice-Guide-Medical-Professionalism-and-Col

7. Guidebook for Management of Disruptive Physician Behaviour (CPSO): http://www.cpso.on.ca/CPSO/media/uploadedfiles/policies/policies/Disruptive_Behaviour_Guidebook.pdf

8. Physician Workplace Support Program (OMA): http://php.oma.org/pwsp.html

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Strategies for remediating issues of professionalism can be the same as those used for teaching and evaluation professionalism. In addition, the following ideas emerging from a 1-day think tank hosted by the American College of Surgeons and Southern Illinois University Department of Surgery (Sanfey et al., 2012), as well as other sources, may be useful:

• Reflection: Encourage the learner to gain insight into his/her behaviour by writing a reflective paper or maintaining a journal to track thoughts and emotions throughout the day.

• Increase self-awareness through external and internal feedback: Solicit feedback from nurses and other members of healthcare team to get insight into how the learner is viewed by others.

• Identify features of work environment that may trigger unprofessional behaviour: Talk to others in the residency program to see if there are triggers in the environment that may contribute to problem behaviours.

• Structured mentoring: Assign a senior resident as a mentor with a clear “job description” or a faculty member who meets regularly with the learner.

• Simulation activities: Have the learner role play as a patient to heighten sensitivity and awareness, then debrief.

• Role plays: Videotape the learner dealing with simulated scenarios, then debrief.

• Consider specific approaches to remediate specific concerns:

• To promote empathy: Have the learner practise the BATHE technique: http://www.gponline.com/Education/article/876833/consultation-skills-using-bathe-technique/

• To improve insight: Guidelines to help learners effectively reflect on their learning, experiences, and professional development: UCSF LEaP (Learning from your Experiences as a Professional): Guidelines for Critical Reflection: https://www.mededportal.org/publication/9073

References1. Sanfey H, et al. Pursuing Professional Accountability: An

Evidence-Based Approach to Addressing Residents With Behavioural Problems. Arch Surg. 2012;147(7):642-647. Available from: http://archsurg.jamanetwork.com/article.aspx?articleid=1217293

2. Papadakis MA, Paauw DS, Hafferty FW, Shapiro J, Byyny RL. The education community must develop best practices informed by evidence-based research to remediate lapses of professionalism. Acad Med. 2012 Dec;87(12):1-5.

Remediation strategies

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3. BATHE technique: http://www.gponline.com/Education/article/876833/consultation-skills-using-bathe-technique/

4. UCSF LEaP (Learning from your Experiences as a Professional): Guidelines for Critical Reflection: https://www.mededportal.org/publication/9073

5. Professionalism remediation process and tool, University of Toronto: http://www.pgme.utoronto.ca/sites/default/files/public/EdResearch/BoardOfExaminers/PoliciesGuidelines/5.1.3.4%20pgme_professionalism_Remediation_TB_v1_20Dec2011.pdf

ActivityReview the following cases and reflect on how you would respond in each situation.

Case 1

Dr Norman Noshow is a second year resident. Staff describe him as a strong resident and have no concerns with his performance. However, for the last few blocks he has been showing up late for his weekend call and on two occasions did not come in at all. Dr Noshow called the chief resident at the time his call was supposed to start to tell him he was sick and unable to come in. The chief resident had a hard time finding someone to cover with such short notice. Dr Noshow was asked to give several hours notice if he was not going to be able to work. Again, this past weekend he did not arrive on time for call and was paged. He answered the page saying he was too sick to come to work.

How would you address these concerns with Dr Noshow?

Case 2

Dr Kathy Kool is a first year resident. She is very bright and seems to have knowledge above her level of training. There are concerns

though because when she is on rounds with the team she questions how other residents manage their patients and quotes medical literature about every topic that comes up. She often interrupts the other residents to demonstrate her knowledge. Lately, you have been getting complaints from staff as she is interrupting them and quoting the literature to them as well. When managing patients, she is failing to consider the patient’s situation and is basing her treatment plans solely on the literature. It has gotten to the point that other residents are complaining and don’t want to work with her. The staff have given feedback that they too do not want to be on service with her as she is too disruptive to the team.

How would you address these concerns with Dr Kool?

Case 3

Dr Frank Fatigue is a third year resident and is currently on remediation for poor overall performance on his last two rotations. He was diagnosed with depression and was off work for three months. He has been medically cleared to return to work by his psychiatrist and the Wellness Program. He is on call with you.

He calls you about a patient with febrile neutropenia who is now hypotensive, febrile, and tachycardic. He does not make sense when telling you his management plan as he only discusses the patient’s chemotherapy. You direct him to treat the current symptoms. You are concerned, so you call the nurse. She tells you that when she spoke to Dr Fatigue earlier he was not making sense and was about to page you to discuss this patient’s management. You treat the patient with a fluid bolus and antibiotics. When you call back an hour later you are told the patient has stabilized.

The following morning you approach Dr Fatigue regarding his management of the patient overnight. He states he has no recollection of speaking to you or to the nurse. You give feedback on what he said to you. He then reveals that he took sleeping pills

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last night when he was on call, even though he is not supposed to take them when he is on duty. He realized this but did not inform you as the attending; he figured they would not affect his performance on call.

How would you address this situation with Dr Fatigue?

DebriefCase 1: In this case, Dr Noshow was not presenting for call. You may want to consider a remediation plan designed to increase awareness by asking the resident to reflect on the repercussions this has on his colleagues and patients.

Case 2: In this case, Dr Kool is showing disruptive behaviour and being disrespectful to her colleagues. You may want to talk to others in the program to see if there are things in the environment that trigger Dr Kool’s unprofessional behaviour, provide structured mentoring, and/or use a role play to heighten Dr Kool’s sensitivity of the situation and how it is affecting her colleagues.

Case 3: In this case, there is a concern for patient safety as Dr Fatigue is taking sleeping pills while on duty. Think ill before evil—is this remediable?

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PROFESSIONALISM ISSUES ARE CHALLENGING FOR ALL INVOLVED.

1. Integrate the teaching of professionalism into your regular clinical teaching.

2. Ensure expectations are clear from the start and learners understand what is expected of them. Remember that you are a powerful role model.

3. Use appropriate teaching and evaluation strategies to integrate the development of competency in the role of Professional into your clinical teaching.

4. Learn to recognize the signs of unprofessional behaviour.

5. Address any issues related to professionalism early.

6. Monitor closely.

7. Document, document, document!