Project Professionalism - ABIM Foundation

46 Pages·2001·0.19 MB·English

Project Professionalism
Project Professionalism
American Board of Internal Medicine
Promoting
Excellence in
Health Care
Project Professionalism is dedicated to promoting integrity within the specialty of internal medicine and the
educational environment and among all internists and subspecialists. Its principles are committed to the
enhancement of professionalism by the medical profession as a whole.
Project Professionalism is available online at <www.abim.org>;also learn more about medical professionalism
and a new activity of the ABIM Foundation by visiting <www.professionalism.org>.
Project Professionalism was sponsored by the ABIMCommittee on Evaluation of Clinical Competence in conjunction with the ABIM Clinical
Competence and Communications Programs. For additional copies please call 215-446-3630 or fax [phone].
First printing 1995, second printing 1996, third printing 1997, fourth printing 1998, fifth printing 1999, sixth printing 2000, seventh printing 2001.
© American Board ofInternal Medicine,510 Walnut Street,Suite 1700,Philadelphia,Pennsylvania,19106-3699
Table of Contents
Acknowledgements - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - i
Project Professionalism:Staying Ahead ofthe Wave - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1
Professionalism in Medicine: Issues and Opportunities in the Educational Environment- - - - - - - - - - - - 5
Professionalism Vignettes - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 11
Strategies for Evaluating Professionalism - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 21
Selected Readings on Professionalism: Annotated and General Bibliographies - - - - - - - - - - - - - - - - - - 31
Acknowledgements
Members ofABIM Project Professionalism,1992-1994
John D.Stobo,MD,Project Chair Michael A.LaCombe,MD
President,University ofTexas Medical Branch at Practicing Internist
Galveston South Paris,Maine
Chair,ABIM Board ofDirectors,1996-1997 Member,ABIM Board ofDirectors
Jordan J.Cohen,MD Geraldine P.Schechter,MD
President,Association ofAmerican Medical College Chief,Hematology Section
Washington Veteran Affairs Medical Center,Washington,DC
Chair,ABIM Board ofDirectors 1993-1994 Member,ABIM Board ofDirectors
Harry R.Kimball,MD Linda L.Blank,Staff
President,American Board ofInternal Medicine Vice President,Clinical Competence and Communications
Philadelphia American Board ofInternal Medicine,Philadelphia
The following people have contributed to the successful outcome ofthis project and their efforts are gratefully
acknowledged:
Melissa E.Abraham Robert M.Glickman,MD Arthur H.Rubenstein,MD
Erin L.Arnold,MD Nancy L.Grant Barbara S.Schneidman,MD
William J.Arnold,MD David B.Hellmann,MD Barbara L.Schuster,MD
J.Claude Bennett,MD Holly J.Humphrey,MD David R.Scrace,MD
John A.Benson,Jr.,MD Tod Ibrahim John F.Sherman,PhD
Janet Bickel Edgar B.Jackson,Jr.,MD Neil J.Smelser,PhD
Evelyn B.Biney Jerome P.Kassirer,MD Daniel Soloman,MD
Jamie L.Bishoff,JD Mark A.Kelley,MD Salley E.Steffen,JD
Robert McL.Boote,JD John I.Kennedy,MD St.Peter’s Medical Center,
Martin Brotman,MD Juha P.Koko,MD New Brunswick,New Jersey,
Alexander M.Capron Richard I.Kopelman,MD Department ofMedicine Residents
Christine K.Cassel,MD Julius R.Krevans,MD Emma J.Stokes,PhD
David D.Clarke,MD Leonard A.Laster,MD Henry F.Strozeski
Sidney Cohen,MD Linda S.Leffler Myles A.Tanenbaum,Esq.
Barbara J.Culliton Hollice L.Lespoir James G.Terwilliger
Dema C.Daley James E.Lewis,PhD Patricia Thomas
Paul J.Davis,MD M.Jane Luistro-Daly Phillip P.Toskes,MD
Susan C.Day,MD Joan S.Marks Marie C.Trontell,MD
Haile T.Debas,MD Robert J.Mayer,MD Marvin Turck,MD
William E.Dismukes,MD Rosalie Moseley University ofAlabama at
F.Daniel Duffy,MD Karen J.Mullian Birmingham,Department of
Adrian L.Edwards,MD John J.Norcini,PhD Medicine Residents and Fellows
Linda Emanuel,MD,PhD Maxine Papadakis,MD and UAB Nurses’Ethics Group
Bernard A.Feigenbaum,MD Joseph G.Perpich,MD,JD Eleanor Z.Wallace,MD
Donald I.Feinstein,MD Robert G.Petersdorf,MD Stephen I.Wasserman,MD
Jaquelyn Fleckenstein,MD Joan Racklin Wallace Waterfall
Anne Flipse,MD Paul G.Ramsey,MD George D.Webster,MD
Charles K.Francis,MD Brian H.Rank,MD Michael E.Whitcomb,MD
Marvin Garrell,MD P.Preston Reynolds,MD,PhD David I.Zolet,MD
Richard J.Glassock,MD Pulcheria D.Ricks-Poole
i
Project Professionalism: Staying Ahead of the Wave
F
UNDAMENTAL to the art and science of " Define professionalism
medicine,professionalism has been an
intrinsic part ofcertification since the " Raise the concept ofprofessionalism in the
inception ofthe American Board ofInternal consciousness ofall within internal medicine
Medicine (ABIM) in 1936.The fundamental principle
ofcertification reflects a set ofstandards for physician " Provide a means for program directors to
competence in regard to knowledge,skills,attitudes, inculcate the concepts ofprofessionalism within
and behavior in the care ofpatients.It is that set of their training programs
attitudes and values that constitutes the essence of
professionalism.Since ABIM’s mission is “to enhance " Develop strategies for assessing the profes-
the quality ofhealth care available to the American sionalism ofresidents and subspecialty fellows
public by continuously improving the process and during training.
maintaining high standards for certifying internists
and subspecialists who possess the knowledge,skills, The project took form in 1992 with the appointment
and attitudes essential for the provision ofexcellent ofa subcommittee that reviewed the literature,
care,”the board has been increasingly concerned that developed an issues list,asked questions,prepared a
recent changes in the health care delivery system have comprehensive syllabus,and organized workshops and
resulted in “stress surges”that can have a negative symposia to explore those aspects ofprofessionalism
impact on the professional behavior ofphysicians.This upon which the project would focus.Chaired by John
concern is sharpened as physician reimbursement Stobo,MD;the subcommittee included Jordan Cohen,
changes and health care is provided in a competitive MD;Harry Kimball,MD;Michael LaCombe,MD;and
environment ofmanaged and prepaid care,threatening Geraldine Schechter,MD;and was staffed by Linda
to reduce the status ofpatients to commodities rather Blank.
than people with an affliction.
These efforts led to the consideration ofmany issues
During the 1980s,ABIM recognized “humanistic including the profession’s accountability to the public
qualities”as a defined and formal component of and itself,professional ethics (illustrated by dilemmas
clinical competence and as a requirement for posed by pharmaceutical industry influences),fraud in
certification.Former ABIM President John Benson, research and the Medicare program,fraudulent board
MD,and Julius Krevans,MD,former Chancellor, certificates and misrepresentation,conflicts ofinterest
University ofCalifornia,San Francisco,along with (such as self-referral),moral and ethical behavior in
members ofthe ABIM Subcommittee on Humanistic the clinical setting,greed,and lack ofconscien-
Qualities,spearheaded efforts to develop a simple, tiousness.
straightforward definition ofthese qualities —
integrity,respect,and compassion — in regard to ACTIONS
patient care.1In addition,ABIM proved that these
From 1992 to 1994 the subcommittee developed a
qualities could be evaluated and documented in the
working definition ofprofessionalism as well as a
training environment with the support ofeach resi-
document for program directors and faculty to use in
dency and subspecialty program director and use ofan
promoting the teaching and evaluation ofprofes-
effective evaluation system.2
sionalism in physicians during training.A series of
GOALS AND OBJECTIVES workshops and symposia were also developed for
national meetings ofmedical and subspecialty
In 1990,ABIM established a project to enhance the organizations to provide a broader framework for the
evaluation ofprofessionalism as a component of project,promote a better understanding ofthe
clinical competence and to promote the integrity of complexities and conflicts surrounding the concept of
internal medicine.In large part,the project was professionalism,and assure a diverse infusion ofideas.
motivated by changes,inside and outside the
educational environment,eroding professional
standards.The board wanted this effort to accomplish
the following objectives:
1
Many individuals and groups outside ABIM were asked Although this project focuses on the patient,one addi-
to review the products ofProject Professionalism, tional goal is to recognize the unique importance of
including members ofthe ABIM Board ofAdvisors; professionalism within the context ofrelationships
participants at formal presentations to the Association between physicians and other health professionals,
ofProfessors ofMedicine (APM);the Association of between specialties,and between professional
Program Directors in Internal Medicine (APDIM);the organizations.
Association ofAmerican Medical Colleges (AAMC);
RECOMMENDATIONS
the Society ofGeneral Internal Medicine (SGIM);the
American College ofPhysicians (ACP)-American
Finally,the project resulted in a series ofrecommenda-
Society ofInternal Medicine (ASIM);the Clinical
tions for ABIM to pursue during the year ahead:
Practice Section ofthe American Gastroenterological
Association (AGA);the organization for Public (1) Publish the ABIM resource document on profes-
Responsibility in Medicine and Research (PRIM&R); sionalism and distribute it to program directors;
the Association for Behavioral Sciences and Medical clerkship directors;key faculty members,including
Education (ABSAME);internal medicine residents, nurses;residents and subspecialty fellows;deans of
subspecialty fellows,and nurses at the University of medical schools;and medical organizations.The
Alabama at Birmingham;and internal medicine purposes ofthis document are to promote profes-
residents at St.Peter’s Medical Center in New sionalism within the educational environment and
Brunswick,New Jersey.Moreover,the ABIM describe ABIM standards.
Committee on Evaluation ofClinical Competence
provided an extensive critique ofthe work in progress, (2) Continue efforts to emphasize the significance of
and in June 1994,the ABIM Board ofDirectors professionalism by sponsoring workshops and
approved the project report and recommendations. symposia at national meetings ofmedical
organizations and subspecialty societies.
Project Professionalism has resulted in several publica-
tions (including this paper) advocating the role of
(3) Develop multiple-choice questions on profes-
certification in promoting the profession’s integrity.
sionalism for board certification and recertification
Other contributions include a resource document
examinations (including the latter’s self-evaluation
aimed at program directors,clerkship directors,faculty,
process);identify professionalism as a separate
and housestaff,to promote professionalism within the
category on the cross-content portion ofthe
educational environment.This document places special
examination blueprint;and promote similar efforts
emphasis on signs and symptoms that erode profes-
within the national in-training examination for
sionalism,such as abuse ofpower and sexual
second-year internal medicine residents developed
harassment,conflicts ofinterest,professional arrogance,
by the ACP,APM,and APDIM.
physician impairment,and fraud in research.Aids to
professionalism are also described,including the
(4) Remind program directors oftheir responsibility
importance ofrole models and mentoring.
to ensure adequate verification ofthe backgrounds
Complementary to the resource document is a series of
ofprospective trainees (including relevant creden-
vignettes designed to illustrate quandaries ofprofes-
tials),explanation ofdiscrepancies in training or
sionalism,specific assessment strategies for use in
employment gaps,and explanation ofpast legal or
evaluating the professionalism ofresidency and
criminal involvement.Professionalism requires
subspecialty trainees,and a listing ofsuggested
rigorous adherence to established institutional pro-
readings.In addition,the project reviewed ABIM,as
cedures in order to verify that all candidates for
well as other American Board ofMedical Specialties
residency and subspecialty fellowship positions are
(ABMS) member boards’experiences with fraudulent
qualified and deserve appointment.
certificates and a spectrum ofmisrepresentation
incidents.
(5) Highlight the expansion ofboard policy on revoca-
The subcommittee has defined the core ofprofessional- tion ofcertificates in conjunction with material
ism as constituting those attitudes and behavior that misstatements or omissions offact concerning an
serve to maintain patient interest above physician self- individual’s certification or board eligibility status.
interest.Accordingly,professionalism,as the Board has
defined it within the project’s framework,aspires to (6) Publish ABIM’s increasing experience with misrep-
altruism,accountability,excellence,duty,service,honor, resentation and use offraudulent certificates and
integrity,and respect for others. results ofrelated ABMS surveys.
2
(7) Encourage the community ofcertifying boards REFERENCES
(ABMS members) to develop a standardized
1. Guide to Awareness and Evaluation ofHumanistic
approach to address issues,policies,and physicians
Qualities,Second Edition 1992-1995,American
involved in misrepresentation and use of
Board ofInternal Medicine,Philadelphia.
fraudulent certificates.
2. Blank LL.Assessment ofCandidates’Ethics and
(8) Monitor the impact on program accreditation of
Humanistic Values.In:Mancall E,Bashook P.,
the Program Requirements for Residency Education
Dockery,JL,eds.Establishing Standards for Board
in Internal Medicine and the Subspecialties,sections
Certification.Evanston,IL:American Board of
on professional ethical behavior and profes-
Medical Specialties;1994:27-38.
sionalism (see appendix);and offer revisions as
appropriate.
(9) Work with other professional medical Reprinted with permission from the American Journal ofMedicine,
organizations to promote standards for profes- December 1994.97(6):i-iii
sionalism that will serve the public and the
profession.
The medical profession has long enjoyed a special posi-
tion in society.In the last few decades,however,
accelerating advances in medical knowledge and
technology have placed greater pressures on physicians
to absorb and communicate information to patients
and other health professionals.In the wake ofthese
changes,demands and expectations ofthe public and
the medical community have altered the perception of
what being a physician really means.Unprofessional
behavior and attitudes on the part ofsome physicians
have eroded medicine’s historically respected position.
Today,the medical profession stands at a crossroads.
The direction it takes depends largely on its collective
willingness to abide by a standard ofexcellence and
behavior that requires a commitment to self-improve-
ment and peer review.The fundamental principle of
certification (and recertification) reflects such a
standard and provides one channel for the medical
profession to stay ahead ofnew waves ofuncertainty.
John D.Stobo,M.D.
Chair,Project Professionalism
Linda L.Blank,Project Staff
Vice President,Clinical Competence and
Communications
American Board ofInternal Medicine
3
Appendix
Excerpt from the PROGRAM REQUIREMENTS FOR RESIDENCY EDUCATION IN INTERNAL
MEDICINE AND THE SUBSPECIALTIES
PROFESSIONAL ETHICAL BEHAVIOR
1. Physician Accountability 4. Professional Ethics
The training program must have mentors,role model The training program must foster a commitment to
clinicians,and a resident culture that demonstrates the professional ethics in residents that is demonstrated by
values ofprofessionalism,such as placing the needs of a spirit ofcollegiality and a high standard ofmoral and
patients first,maintaining a commitment to ethical behavior within the clinical setting in the care of
scholarship,helping colleagues meet their responsi- patients,in the education ofresidents,in conducting
bilities,a commitment to continued improvement and research and in interactions with pharmaceutical
being responsive to society’s health care needs. companies and funding organizations.
Residents should be given the opportunity to
participate in community service,professional
organizations and institutional committee activities.
2. Humanistic Qualities Developed by the Residency Review Committee for Internal
Medicine and approved by the Accreditation Council for
Physicians must have the welfare oftheir patients as Graduate Medical Education;effective July 1,2000.
their primary professional concern.Thus the resident, Graduate Medical Education Directory 2000-2001American
faculty members and Program must demonstrate Medical Association,Chicago.
humanistic qualities that foster the formation of
patient/physician relationships.These qualities include
integrity,respect,compassion,professional respon-
sibility,courtesy,sensitivity to patient needs for comfort
and encouragement,and professional attitude and
behavior toward colleagues.The written curriculum
must emphasize the importance ofhumanistic qualities
throughout the residency.
3. Physician Impairment
The residency program must instruct residents and
faculty members in physician impairment,to include
the recognition of,intervention in,and management of
impairment such as alcohol and other substance abuse;
depression;dementia;and other mental,emotional and
physical disorders in their peers as well as the principles
and methods ofactive intervention.
4
Professionalism in Medicine: Issues and Opportunities in
the Educational Environment
INTRODUCTION
T
HE American Board ofInternal Medicine is and principles ofprofessionalism,developed questions
the organization responsible for certifying designed to assess aspects ofprofessionalism on
physicians committed to careers in internal certification and recertification examinations,and in
medicine or the medical subspecialties.This the educational context ofconferences and small group
mandate requires that the Board define,promote and discussions.The subcommittee also presented
assess all ofthe components within the domain of workshops and symposia at national meetings of
competence.Competence as an internist comprises not professional medical societies to discuss profes-
only medical knowledge,clinical judgment,and clinical sionalism.
skills including proficiency in performing certain
The materials developed thus far are intended to
procedures,but also the professional attitudes and
provide a framework for standards for professionalism
behavior which are the foundation for success as a
that one can hang a hat on.ABIM presents guidelines
physician.While knowledge and technical skills are
for ideal behavior while recognizing that the ideal is
important,how they are used is more important.In
something we endeavor to achieve but do not always
recognition ofthis fact,the Board in 1980,turned its
reach.
focus toward the importance and assessment of
humanistic qualities (integrity,respect and com-
I. DEFINITION AND OBJECTIVES
passion) in the training ofphysicians.This culminated
in the inclusion ofhumanistic qualities as an essential Professionalism in medicine requires the physician to
component ofclinical competence and in the require- serve the interests ofthe patient above his or her self-
ment for program directors to evaluate and document interest.Professionalism aspires to altruism,
the demonstration ofthese qualities during training in accountability,excellence,duty,service,honor,integrity
order for candidates to be eligible for certification. and respect for others.The elements ofprofessionalism
required ofcandidates seeking certification and recer-
A decade later,the Board embarked on a similar pro-
tification from the ABIM encompass:
cess to address professionalism.For several years,the
Board has been concerned that changes in the health A commitment to the highest standards of
care environment produce stress that can negatively excellence in the practice ofmedicine and in the
affect the professional behavior ofphysicians.This generation and dissemination ofknowledge.
concern is sharpened as physician reimbursement is A commitment to sustain the interests and wel-
changing and health care is provided in a competitive fare ofpatients.
environment ofmanaged and prepaid care,threatening
A commitment to be responsive to the health
to reduce the status ofpatients to commodities rather needs ofsociety.
than people with an affliction.Responding to these
concerns,in 1990 the Board began a process to define
These elements are further defined as:
professionalism;to raise the concept ofprofes-
sionalism in the consciousness ofall in internal Altruismis the essence ofprofessionalism.The best
medicine;and to provide a means for program interest ofpatients,not self-interest,is the rule.
directors to inculcate the concepts ofprofessionalism in
Accountabilityis required at many levels — individual
their training programs and assess professionalism in
patients,society and the profession.Physicians are
their trainees.
accountable to their patients for fulfilling the implied
This process evolved under the guidance ofProject contract governing the patient/physician relationship.
Professionalism,a subcommittee ofthe ABIM They are also accountable to society for addressing the
Committee on Evaluation ofClinical Competence.To health needs ofthe public and to their profession for
achieve its goals,the subcommittee has defined the adhering to medicine’s time-honored ethical precepts.
components ofprofessionalism (including what
constitutes unprofessional behavior),explored various
approaches to portray vignettes emphasizing elements
5
Excellenceentails a conscientious effort to exceed ordi- A. Abuse ofPower
nary expectations and to make a commitment to
life-long learning.Commitment to excellence is an Traditionally,the medical profession has enjoyed a high
acknowledged goal for all physicians. level ofrespect.Yearly polls consistently indicate that
the medical profession is second only to the clergy in
Dutyis the free acceptance ofa commitment to service.
the esteem afforded it by society.This respect offers
This commitment entails being available and responsive
tremendous power to physicians.When used appropri-
when “on call,”accepting inconvenience to meet the
ately,this power can accomplish enormous good and
needs ofone’s patients,enduring unavoidable risks to
can establish a norm for behavior that is in society’s
oneselfwhen a patient’s welfare is at stake,advocating
best interest.Patients,colleagues and society in general
the best possible care regardless ofability to pay,seek-
abide by what the profession does and says.When
ing active roles in professional organizations,and
abused,this power can establish a norm for deviant
volunteering one’s skills and expertise for the welfare of
behavior.These abuses can be insidious and may occur
the community.
at several different levels:
Honor and integrityare the consistent regard for the
" Interactions with patients and colleagues - The
highest standards ofbehavior and the refusal to violate
respect and trust placed in physicians by their
one’s personal and professional codes.Honor and
patients and professional colleagues are something
integrity imply being fair,being truthful,keeping one’s
to be cherished and promoted and not abused.Not
word,meeting commitments,and being straight-
allowing patients to voice their wishes or con-
forward.They also require recognition ofthe possibility
tribute to decision-making is an abuse ofpower.
ofconflict ofinterest and avoidance ofrelationships
Allowing financial and academic competitiveness
that allow personal gain to supersede the best interest
to affect honest evaluation ofone’s peers and
ofthe patient.
trainees is an abuse ofpower.Using junior col-
Respect for others(patients and their families,other leagues to enhance one’s own bibliography and
physicians and professional colleagues such as nurses, advance one’s own academic career is an abuse of
medical students,residents,and subspecialty fellows) is power,and so are actions that deliberately retard
the essence ofhumanism,and humanism is both the academic development ofjunior colleagues in
central to professionalism,and fundamental to order to co-opt their work.The gratuitous denigra-
enhancing collegiality among physicians. tion ofjunior colleagues also represents an abuse
ofpower.There are many other examples.
A major responsibility ofthose training internal
medicine residents and subspecialty fellows is to
" Bias and sexual harassment - The profession has a
emphasize the importance ofprofessionalism in the
responsibility to ensure an environment in which
patient/physician relationship and to illustrate this by
all colleagues enjoy respect for their contributions
example.
and where they can advance to their full potential,
The ability to affect attitudes,behavior patterns and irrespective ofdisability,ethnicity,gender,race,or
ethical conduct in patient care must be recognized and religion.This responsibility involves eliminating
used during residency and fellowship training — a time both the large and small inequities that bias against
ofunique clinical,educational and social experiences the professional and personal development of
for physicians.It must also continue after training and individuals.
throughout one’s professional career.
" Breach ofconfidentiality - Patients trust that
II. SIGNS AND SYMPTOMS comments which are made as part ofthe
patient/physician relationship will be held in
Seven issues that challenge or diminish the previously
strictest confidence.This trust is not to be abused.
identified elements ofprofessionalism are described
Casual comments or discussion ofdetails of
below and include abuse ofpower,arrogance,greed,
patients' situations in public (e.g.,a crowded
misrepresentation,impairment,lack ofconscientious-
elevator or a cocktail party) represents an abuse of
ness,and conflict ofinterest.
confidentiality.The physician must maintain the
confidences ofthe patient and make disclosures
only in the patient’s interest or when disclosure is a
legal requirement.
6