special article

15 Pages·2015·0.17 MB·English

SURVEY OFOPHTHALMOLOGY VOLUME52(cid:2)NUMBER3(cid:2)MAY–JUNE2007
SPECIAL ARTICLE
Teaching and Assessing Professionalism in
Ophthalmology Residency Training Programs
Andrew G. Lee, MD,1,2HilaryA.Beaver,MD,1H. Culver Boldt, MD,1Richard Olson, MD,1
Thomas A. Oetting, MS, MD,1,4 Michael Abramoff, MD, PhD,1 and Keith Carter, MD1,3
1Department of Ophthalmology; 2Neurology and Neurosurgery; 3Otolaryngology, at the University of Iowa Hospital and
Clinics, Iowa City, Iowa; and 4Veterans Affairs Medical Center, Iowa City, Iowa, USA
Abstract. TheAccreditation Council forGraduate MedicalEducation (ACGME)has mandatedthat
all residency training programs teach and assess new competencies including professionalism. This
article reviews the literature on medical professionalism, describes good practices gleaned from
publishedworks,andproposesanimplementationmatrixofspecifictoolsforteachingandassessing
professionalism in ophthalmology residency. Professionalism requirements have been defined by the
ACGME, subspecialty organizations, and other certifying and credentialing organizations. Teaching,
rolemodeling,andassessingthecompetencyofprofessionalismareimportanttasksinmanagingthe
ACGME mandate. Future work should focus on the field testing of tools for validity, reliability,
feasibility,andcost-effectiveness. (SurvOphthalmol52:300--314,2007. (cid:2)2007ElsevierInc.Allrights
reserved.)
Key words. ACGME (cid:2) competency (cid:2) professionalism (cid:2) residenttraining
The Accreditation Council for Graduate Medical professionalism.9 In this article we review the
Education(ACGME)hasmandatedthatallresidency literature on medical professionalism, update and
programs ‘‘teach and assess’’ six general competen- applytheresultsfromtheLynchreviewforresidency
cies. One of these competencies is professionalism training in ophthalmology, glean ‘‘good practices’’
(ACGME Outcome project. Available from www.acg- from published works, and propose an implementa-
me.org/outcome/comp/compFull.asp [accessed on tion matrix, including specific tools for teaching
13February2006]).59Theconceptofprofessionalism and assessing professionalism in ophthalmology
inmedicineisanancientandreveredoneandwecan residency.
all perhaps recall professing the ‘‘Hippocratic oath’’
(or some version of the oath) at our own medical
Methods
school graduation ceremonies. These professional
valueshaveasmuchimportanceandrelevanceinthe A PubMed literature search (limited to ‘‘English
modern era as they did for Hippocrates 2,500 years language’’ from 1966 to2005) was performed using
ago. In fact, it is by design that the competency of thesearchterms:professionalismandassessment.Titles
professionalismwasincorporateddirectlyandprom- were reviewed for topicality by a content expert
inentlyinto theoriginalACGMEmandate.Lynchet (AGL) and selected abstracts were then reviewed in
al in 2002 previously reviewed the assessment of more detail. Individualfull papers were obtained in
300
(cid:2)2007byElsevierInc. 0039-6257/07/$--seefrontmatter
Allrightsreserved. doi:10.1016/j.survophthal.2007.02.003
TEACHING MEDICAL PROFESSIONALISM 301
order to glean specific ‘‘good practices’’ from the org/outcome/implement/impHome.asp [accessed
literature and to make recommendations regarding on14December2005]).VandeCampetalreviewed
tools for teaching and assessing medical profession- the literature and proposed a multidimensional
alism in ophthalmology residency training. Addi- construct including interpersonal (e.g., altruism,
tional abstracts and presentations were obtained respect, integrity), public (e.g., accountability, self--
fromWebsitesonresidenteducation,includingthe regulation,justice),andintrapersonal(e.g.,lifelong
ACGME site. learning, maturity, morality, humility) professional-
Lynchet alhad previously reviewed the literature ism.104 The ACGME defines professionalism ‘‘as
on assessing professionalism.59 These authors manifested through a commitment to carrying out
searched five electronic databases from 1982--2002 professional responsibilities, adherence to ethical
using Medline, the Educational Resources Informa- principles, and sensitivity to a diverse patient
tion Center (ERIC), Topics in Medical Education population.’’ The ACGME definition of profession-
Literature (TIMELIT), Health and Psychosocial alism is intended to be broad and inclusive, which
Instruments (HAPI), and PsychINFO. In the search has both advantages and disadvantages. We include
by Lynch et al, 28 search items were included: differentdefinitionsfromvariousauthorsinorderto
professionalism, duty, ethics, and variations of these allow the reader some flexibility in their own
terms or in combination with assessment, evaluation, interpretation of the ACGME mandate for this
and measurement. The reference lists of the retained specific competency. Table 1 contains the sub-
articlesandtheliteraturereviewswerealsomanually competenciesthatcomposetheACGMEconceptof
searched by Lynch et al.59 The content expert professionalism (ACGME Outcome project. Avail-
(AGL) used the following criteria for selecting and able from www.acgme.org/outcome/comp/comp
including full articles in this review: topicality to Full.asp [accessed on 13 February 2006]). Table 2
ophthalmic resident education, inclusion of assess- includes a more representative list of selected
ment of professionalism, and empiric evidence of attributesthatmightcomposeprofessionalism.63
use and preferably outcome. Letters to editor, case Somemedicalspecialtiesandprofessionalsocieties
reports, opinion pieces, editorials, abstracts, and (e.g., anesthesiology, internal medicine, obstetrics
descriptive reports without outcome data were only and gynecology, orthopedics) have defined even
includedifthey addedsignificantnew orimportant more subsets of behavior that compose professional-
information. Papers related to teachingorassessing ism within their specific subspecialty area. The
professionalism in medical students, nurses, or AmericanBoardofInternalMedicine(ABIM)‘‘Char-
paraprofessionals were included only if they were ter on Professionalism’’ was one of the first national
directly applicable to resident assessment. initiatives to bring attention to the issue. The ABIM
Charterhasreceivedextensivemedical(e.g.,Annalsof
Internal Medicine and The Lancet) and lay press
Results exposure(e.g.,250USandinternationalnewspapers
and newsletter citations, 70 radio, television, and
Theliteraturesearchmethodologygenerated162
online interviews, and O60,000 reprint requests)
titles. Limiting the search to English language
(ABIMCharter.Availablefromwww.abimfoundation.
yielded 152 articles. The content expert (AGL)
org/mpp2003/charter_prof.htm).1,90 In addition to
reviewed the articles as noted above and selected
thehumanisticandpersonaldevelopmentaspectsof
113finalreferences(includingseveralWebsitesand
articles from prior published reviews) for inclusion
in this article (ABIM Project Professionalism, avail-
TABLE 1
able at www.abimfoundation.org/mpp2003/biblio_
ACGME Professionalism Subcompetencies
prof.htm).1--113Usingtheliteraturereview,wedefine
professionalism, describe means to teach and assess Residents areexpectedto:
professionalism,andprovideexamplesthatmightbe a. Demonstrate respect, compassion, andintegrity;
aresponsiveness to theneedsof patients andsociety
applicabletoophthalmologyresidencytraining.
thatsupersedes self-interest, accountability to patients,
society,andtheprofession.
b. Demonstrate a commitmentto ethical principles
What is Professionalism? pertaining toprovision or withholding of clinical care,
confidentiality of patient information, informed
Many authors4,21--25,63,96--98 have attempted to consent, andbusiness practices.
defineprofessionalisminmedicinebutitisunlikely c. Demonstrate sensitivity andresponsiveness to
that any one definition is suitable for every patients’;culture, age, genderanddisabilities.
circumstance (ACGME. Advancing education in Table derived from information at www.acgme.org/
medical professionalism, available at www.acgme. outcome/project/proHome.asp.
302 Surv Ophthalmol52 (3)May--June 2007 LEEETAL
TABLE 2 probably drift in and out of full compliance with
alloftheelementsofprofessionalcompetency.This
Professionalism and the Three Social Values
drift may occur due to external factors that impact
I. Respect forthe well-beinganddignity of every professional performance (e.g., time of day, clinic
individual
census or time pressures, hunger, anger, illness,
A.First ‘‘do noharm’’
psychosocial stressors, or other environmental fac-
B.Reducehuman pain andsuffering
C.Preserve andpromotehuman lifeand function tors). Although many of our colleagues believe that
D.Seekknowledgeandunderstandingofselfandothers doctors are either professional or are not pro-
E.Observe ethicalreasoning in selfand others fessional, we do not believe that it is an all or none
II. Commitment tocivil societyandcommunity
concept. For example, at 5:00 PM on a holiday
engagement
weekendafterabusypatientclinicdayoneclinician
A.Tell thetruth
B.Promotejustice may or may not spend as much professional time
C.Protect humanrights andstrengthen socialbonds with a patient as on a Monday at 8:00 AM of a light
D.Care forthose in need clinic day. In addition, there clearly is a hidden
E.Promote individualandcollective accountability for
curriculum from which good and bad professional
the well-beingof all
behaviors are role modeled for our learners. One
III. Dedication to theobligations of theprofessions in
society example is when a patient is presented at grand
A.Masterknowledge andskills essentialto the rounds and implicitly or explicitly the care of the
responsible practiceof medicine outside hospital or the outside doctor is called into
B.Strive continuously for competenceandexpertise
question or even ridiculed. This would not be
C.Cultivatecollegial professional andinterpersonal
considered professional behavior to an outside
relations
D.Promote researchandadvancesin medicine and observer. Likewise, many of the behaviors and
public health medical derogatory slang used in the clinics and
E.Strengthen the professionof medicine onthewardstodescribepatients(e.g.,‘‘gomers,old
Tablemodified from O’Donnell.63 vet, squirrel, dirtbag’’) might also be considered to
be unprofessional behavior.
Thereareincreasingthreatstoprofessionalismin
professionalism, Kearney et al reported ‘‘meta-
the modern medical era, including generational-
competencies’’ among anesthesiologists in profes-
based attitude differences among physicians and
sionalism, including vigilance, responsiveness, team
physicians-in-training, increasing patient loads with
worker, advocacy, flexibility, decisiveness, manner,
declining reimbursements, the malpractice and
confidence, communicativeness, expert pattern rec-
litigation crisis, evolving and expensive biotechnol-
ognition,resourcefulness,assertiveness,conflictreso-
ogy and information technology, the corporate
lution,fluency,managementskills,andleadership.55
transformationandcommercializationofthehealth
Obstetrics and gynecology program directors rated
care market place, potentially conflicting financial
‘‘honesty,accountability,respect,integrity,andexcel-
relationships with industry, and the politics and
lence’’ as important41 whereas orthopedic surgeons economics of managed care.64
rated ‘‘respect/relationships, altruism, accountabili-
Although some in academic medicine might
ty/reliability,integrityandexcellence’’asimportant.80
question the need for teaching and assessing
Table3includessomespecificrealworldexamplesof
professionalism, there is evidence that unprofes-
professionalism.97 To our knowledge, there is no
sionalbehavior(oftenunrecognizedorinadvertent)
ophthalmology-specificdefinitionforprofessionalism
occurscommonlyonanindividualandinstitutional
in the literature. It is likely that our specialty will be
basis. Feudtner et al reported that 98% of medical
able to define professionalism for ophthalmology
students at six medical schools reported hearing
using the existing definitions set forth by our
physicians speak in a derogatory manner about
colleaguesinothermedicalspecialties.
patients and 61% reported seeing examples of
unethical behavior by team members.38 Residents
in one survey reported (n 5 571) seeing unprofes-
Why is Professionalism Important
sional behavior, such as ‘‘falsification of patient
to Academic Medicine?
records’’; ‘‘others taking credit for their work’’
‘‘Professionalism is the basis of medicine’s con- (almost 50%); ‘‘mistreatment of patients or col-
tractwithsociety.’’90Webelievethatthecompetency leaguesworkingwhileimpaired’’(75%);and‘‘being
of professionalism is a dynamic one that occurs requiredtodosomethingtheyconsideredimmoral,
during each and every patient encounter. We also unethical, or otherwise personally unacceptable’’
believe that clinicians, including academic attend- (25%).8 The lack of professionalism as a medical
ing physicians as well as residents and fellows, student or resident can be predictive of future
TEACHING MEDICAL PROFESSIONALISM 303
TABLE 3
Listing of Some Examples of Professionalism
Recognize theprimacy of patient welfare(‘‘firstdonoharm’’)
Respect patient dignity,autonomy,andconfidentiality
Treatpatients, staffmembers, faculty members,andtrainees with respectand politeness
Practice social justice (e.g.,just distribution offinite resources)
Employ complete, accurate,and compassionate communication andinterpersonal skills
Useempathy and compassion forpatient asa whole
Be sensitiveto patient’sculture, language, age,genderand disability
Maintainhonesty,trust,andintegrityinallphysicianrelationships(e.g.,avoid,manage,ordiscloseappropriatelyanyreal
orpotential conflicts ofinterest)
Practice altruism andsubordination of self-interests in favor ofothers*
Commit to thevalues of publicservice, scientificknowledge,excellence in clinical care, andlife-long learning
Be accountableandaccept responsibility for actionsorinactions
Complywithhealth‘‘citizenship’’andprofessionalorganizationobligations(e.g.,Federalandstageregulatoryagencies
orlaws,local healthregulations, statelicensing boardrequirements, hospital, institutional,or departmental policies
andprocedures)
Demonstrate work ethic,be reliable, responsible,anddependable, anda teamplayer
Recognize andrespectslimits andboundaries (e.g., asksforhelpwhen needed)
Meetrelationship-centeredexpectationsrequiredtopracticemedicinecompetently(e.g.,patient-physicianrelationship;
community-physician relationship;healthcare system-physician relationship;physician-physician relationship;
self-physician relationship)
Tablederivedfrom Swick andcolleagues.96,97
*Author’s note: Obviously there are limits to the practice of altruism. This component of professionalism has to be
balanced againstthe equally important professional responsibility to one’s ownpsychological and physicalhealth. This
wouldincludestressreduction,timemanagement,keepingfit,andmakingtimeforone’sselfandfamily.Inonesense,
thisisalsoaformof‘‘rolemodeling’’forone’sresidentsandpatients(e.g.,eatingright,exercising,reducingstress,and
maintaining balance forhealthy living).
professionalstatemedicalboarddisciplinaryaction. withproblems.Ithasbeenourexperiencethatmost
Papadakisetalperformedacase-controlstudyof68 problem residents are problematic not because of
cases of Medical Board of California disciplinary lack of intellect but because of lack of profession-
action(1990--2000)againstUniversityofCalifornia-- alism. In the traditional model, only extreme
San Francisco Medical School graduates. Of these outliersinprofessionalbehaviorcouldbeidentified.
actions, 95% were for deficiencies in professional- Fortheseindividuals,attemptsatremediationwould
ism rather than clinical incompetence. Logistic follow, but often once the disciplinary path was
regression analysis showed that disciplined physi- started either the end result was suspension, pro-
ciansweremorelikelytohavehadpriordisciplinary bation, and dismissal, or the situation was recog-
problems in medical school (P 5 0.02).65 Teherani nized too late in the training process to allow due
et al reported in a retrospective case-control study process and the problem resident was simply
that there were three domains of unprofessional graduated despite marginal evaluations. Fear of
behavior related to future disciplinary outcome by litigation often was a powerful (real or perceived)
a state medical board: 1) poor reliability and barrier to formal dismissal from a program. Poor
responsibility, 2) lack of self-improvement and documentation of progress or failure in remedia-
adaptability, and 3) poor initiative and motiva- tion efforts islikelyacontributing factor to the lack
tion.103 Conversely Rowley et al reported that of enthusiasm or motivation for pursuing formal
residents who had higher levels of professionalism dismissal of a problem resident.
were also more likely to be deemed clinically We believe that a formalized professionalism
competent.79Finally,medicalstudentsandresidents curriculum that outlines explicit expectations for
themselves in surveys have indicated their need for professionalbehaviorandisdistributedattheonset
more ethics and professionalism teaching.74 of the residency is a crucial first step. Multiple
formal assessments and samples of professional
behavior should occur early in training and should
Dealing with the Problem Resident
continue in a routine, scheduled, and standardized
One important consequence of teaching and manner throughout the residency. Identifiable
assessing professionalism will be a paradigm shift behavior-specific deficiencies should be addressed,
from simply remediating or dismissing the problem remediated,anddocumentedwithvalidandreliable
resident to preventing and managing the resident tools, using multiple tools and multiple observers.
304 Surv Ophthalmol52 (3)May--June 2007 LEEETAL
Non-resident-related factors that produce unprofes- How to Teach and Assess Professionalism
sional behavior should be addressed (e.g., an
Althoughsomewouldarguethatethicalcharacter
unsupportive or hostile learning environment,
and professionalism are personal and that person-
negative role models, or an institutional culture or
ality traits cannot be taught per se, we believe that
hidden curriculum that de-professionalizes young
both professional and ethical behavior can be
physicians). For example, Shanafelt et al reviewed
taught and assessed. Eckles et al reviewed the
resident burnout using the Maslach Burnout In-
medical literature on ethics (1978--2004) and
ventory (MBI) based on depersonalization, emo-
concluded that deficits existed in the areas of 1)
tional exhaustion, or decreased personal
theoretical work on the goals of medical ethics
accomplishment. Of the 115 participating internal
education; 2) empirical studies that attempt to
medicine residents, an astounding 76% met MBI
examine outcomes; 3) studies examining teaching
criteria for burnout and 53% reported suboptimal
methods;and4)studiesevaluatingtheeffectiveness
patient care practices (e.g., poor professional
of various teaching methods.31 Despite these limita-
attitudes or unethical behavior). Predisposing fac-
tions, there has been significant work on teaching
torsintheworkenvironmentorinstitutionalculture
and assessing professionalism for residents and an
may contribute to unprofessional behavior later in
emerging body of literature on new and innovative
the problem resident. Early recognition of these
tools for the job.
environmental factors might allow programmatic
improvements that would benefit all residents.82
Daughertyetalreportedthat93%of1,277residents
When and How Should We Teach and
reportedmistreatmentduringtrainingbyattending
Assess Professionalism
(81%), senior residents (77%), patients (63%), or
nurses (62%). Unprofessional behaviors that were The process of teaching and assessing profession-
identified included mistreatment of patients (40%) alism begins in medical school but continues
and falsification of medical records (45%).26 Cyni- throughout residency training and beyond. Hilton
cal, hypercritical, or demeaning comments about and Slotnick51 suggested six domains of profession-
the medical field by attending physicians (e.g., alism: ethical practice, reflection/self-awareness,
regarding decreased autonomy, government regula- responsibility for actions, teamwork, respect for
tions,financialpressures,medicalliability,academic patients, and social responsibility. They proposed
pressures for research and productivity) are also that the term phronesis (Greek: ‘‘practical wisdom’’)
contributing factors to the erosion of resident captured the essence of the professionalism compe-
physician satisfaction and probably impacts pro- tency and that this characteristic was acquired only
fessional behavior of residents. It is easy to un- after a prolonged period of experience and re-
derstand how this informal or hidden curriculum flectiononexperienceoccurringinconcertwiththe
may run counter to the formal concepts taught to professional’s evolving knowledge and skills base.
residents on professionalism in the structured They termed the prior period of pre-professional
curriculum(i.e.,‘‘Doaswesay,notaswedo.’’).60,112 development as proto-professionalism and they recom-
mended stage-appropriate learning experiences.
These authors suggest that medical educators
should maximize opportunities for attainment of
What is not Professional?
professionalism (e.g., positive role models, encour-
Although it may be difficult to define profession- agement and support) and minimize inappropriate
alism, we all seem to agree with the famous 1964 attrition (e.g., negative role models, unsupportive
Justice Potter Stewart’s definition of ‘‘obscene’’ work conditions, and pressure of overwork).51 It is
(i.e., ‘‘I know it when I see it’’) as a field definition likely that during this proto-professionalism stage,
for unprofessional behavior. The ABIM identifies teaching professionalism can affect the learner the
seven general areas for lack of professionalism: most. Modification and formation of attitudes,
abuse of power, arrogance, greed, misrepresenta- ethics, and professionalism is likely actively taking
tion, impairment, lack of conscientiousness, and place outside of the formal curriculum in learners
conflict of interest. Duff gave some specific exam- during this proto-professionalism stage. As men-
ples of unprofessional conduct in academic medi- tioned previously, much of this learning occurs
cine (Table 4).30 Critical or sentinel event markers withinthisinformalorhiddencurriculum(e.g.,role
based upon these types of unprofessional conduct models,learningenvironment,institutionalculture,
should be included in the learner’s record. Appen- policies and procedures). Obviously, the hidden
dix1listssomesamplesofprofessionalconductthat curriculum may help or in some cases hinder (e.g.,
were developed for anesthesiology. mixed messages) professional development. We
TEACHING MEDICAL PROFESSIONALISM 305
TABLE 4
Duffs ‘‘Top Ten’’ List of Unprofessional Conduct in Academic Medicine
1.Intellectualorpersonaldishonesty(e.g.,falsifyingclinicalrecordsorfabricatingresearchresultsorlaboratoryvalues,
failureto follow through onassignments, plagiarism,cheating onexaminations).
2. Arroganceand disrespectfulness (e.g.,inappropriate sense of entitlement, breachingconfidentiality).
3. Prejudice(e.g., gender,ethnicity,age,or sexualorientation, threats orhatecrimes).
4. Abrasiveinteractions withpatients andco-workers (e.g.,exaggerated sense ofself-importance; noone else’stimeor
scheduleis asdemanding orasimportant).
5.Lackofaccountability(e.g.,medicalerrorsoradministrativeoversights;failuretodemonstratepersonalinvestmentin
patient’soutcome).
6. Fiscalirresponsibility (e.g., orderingexpensive and clinicallyunnecessary laboratorytests,accepting ‘‘kick-backs’’, or
inequitablydistributing benefits andincome withinapartnership, participating in a conflictof interest).
7. Lackofsustained commitmentto self-learning.
8.Lackofduediligence(e.g.,carelessness,laziness,inattentiontodetail,andfailuretofollowthroughonmanagement
plans).
9. Personal excess (e.g.,stealing medications, illicitsubstance useduringpatient care ordrugoralcohol abuse,high-
stakesgamblingleading to financialruin, andreckless high-riskbehavior).
10. Sexual misconduct(e.g., inappropriate sexualadvancesor relationships withpatients, coworkers, andstudents).
Tablederivedfrom Duff.30
believe that residents can find guidance for pro- andcharacterdevelopment.85Itisunlikely,however,
fessionalism through traditional and innovative that lectures alone will be able to teach and assess
teaching tools during this proto-professionalism professionalism in the new ACGME competency
period. model. Sulmasy et al reported the results of
Many institutions already have a formal medical a randomized trial to assess the impact of an ethics
ethics curriculum in place. Modification and en- curriculum on the knowledge and confidence of
hancement of these existing teaching tools is an university hospital residents. Of the 85 participants,
important first step in the evaluation and teaching 25% received a lecture series (i.e., limited interven-
of professionalism. Siegler (Table 5) described the tion [LI]), 25% received lectures and case confer-
UniversityofChicagoprinciplesforteachingclinical ences with an ethicist in attendance (i.e., extensive
medical ethics using the ‘‘Six C’s’’85 (i.e., clinically intervention[EI]),and50% werecontrols.Post-test
based, cases [real], continuous, coordinated [in- knowledge scores did not differ among the groups
tegrated], clean [simple], and clinicians as instruc- but confidence was significantly greater in the
tors). Teaching professionalism likely will require intervention groups compared to control group.93
the use of the six C’s in order to be time and cost Based upon our review of the literature we propose
effective for busy clinicians. Surdyk reported that that new teaching and assessment tools will be
certainknowledge-basedcomponentsofprofession- required to assess professionalism in residents.
alism can be taught and assessed (e.g., ethical
principles, advance directives, informed consent,
and business ethics); whereas other components
How to Assess Professionalism
(e.g., altruism, respect, integrity) are less amenable
to objective measurement.94,95 The first step in any teaching and assessment
Siegler described three dimensions of medical process is to define the goals for learners and
ethics that we believe also apply to teaching teachers. Specific, written and explicit expectations
professionalism: cognitive skills, behavioral skills, ofprofessionalismshouldbedefinedinthecurricu-
lum and provided to the residents at the start of
training.Cleardefinitionsoutliningtheexpectations
TABLE 5 for professional behavior, personal accountability,
The University of Chicago ‘‘Six C’s’’ in Teaching and the specific consequences for noncompliance
Clinical Ethics should be included in the orientation program for
residents. Trainees who fall below expectations
1. Clinicallybased
should enter voluntarily into a step-wise and pre-
2. Cases (real)
3. Continuous defined intervention and remediation program. We
4. Coordinated(integrated) believe that continuous behavior-specific formative
5. Clean(simple) feedback can change professional attitudes and
6. Cliniciansasinstructors
beliefs,reasoning,andbehavior.Table6listsspecific
Tablederivedfrom Siegler.85 examplesforteachingandassessingprofessionalism
306 Surv Ophthalmol52 (3)May--June 2007 LEEETAL
TABLE 6
Methods for Teaching and Assessing Professionalism
1. Cognitiveaspects of professionalism
Teaching
Independent learning(e.g., reading assignments, portfolio)
Interactive learning (e.g.,seminars, small group discussions)
Traditional lecture
Annualretreat orsymposium onprofessionalism
Journalclub articleson professionalism
Morbidityandmortalityconferenceonprofessionalismorincorporationofprofessionalismconceptsintoongoing
conferences
Assessment
Pre-andpost-testing of knowledge
Self-reported confidence survey in specificareas
Standardized written ororalexams
Attendancerecordsand portfolio documentation ofdiscussion
Facultyledchart stimulatedrecall exercise
Residentself-reflection withchart audit
Residentportfolio
II. Professionalism inclinical context
Teaching
Rolemodeling
Facultymentor
Formative feedbacksession
Chartstimulated recall
Grand rounds
Residentasteacher programs
Assessment
Simulated orstandardized encounter withobjective structured clinical exam(OSCE)20,71, 87,105
Facultymentorship androle-modelingwithself reflection onprofessionalism7
Chartreview (e.g., reviewof clinicalcases withaone-on-one facultycounseling session)
Chartaudit (e.g., self-reportedreview,randomor consecutivesample)
Innovativechartstimulated recalldiscussion formats (e.g., clinical reasoningin situations thatinvolve clinical
uncertainty,teamworkexercises,standardizedvignetteslikeBarryChallengestoProfessionalismQuestionnaire)9
Roleplayingandreview ofsimulated clinical casesorpanel discussion
IV.Assessment ofspecific professionalism behaviors
Globalevaluation form (e.g., Musick360 degreeevaluation from patients,62coworkers, peers, instructors, and
self assessment)
Patient satisfactionsurveysorquestionnaires (e.g., Wake ForestPhysician TrustScale)47
Learnersurveysof educationalenvironment (American Boardof Internal MedicineScale to MeasureProfessional
Attitudes andBehaviors inMedical Education)
Directobservation(real orsimulatedor standardized patient, videotaped orliveencounter).
Structuredprofessionalismchecklist(e.g.,punctuality,greeting,handwashing,politeness,demeanor,dress,personal
hygiene, communication andinterpersonal skills, empathy,compassion, altruism)
Criticalincidenttechniquesorsentineleventmarkers(e.g.,documentationofspecificpatientorothercomplaints
withfollow upreview ofremediation overtime)
Portfolio (e.g., self assessmenttool andimprovement project,prior patient orstaffcitations for excellence or
deficiencyinprofessionalism,videoportfolio,documentedremediationbaseduponalearningplan,self-reflection
diary)7,13, 44
‘‘Residentasteacher’’programs42
Longitudinaltracking ofresidents for criticalevents in thefuture (e.g., State Board of Medicinedisciplinary
actions)66,67
and Table 7 lists some of the attributes for pro- mance, there are significant disadvantages to using
fessionalismthattheemergingtoolscouldassess.We this tool in isolation for assessing professionalism.
provide these additional guidelines for assessing for First, the global evaluation form is subject to grade
evidence of professionalism. We suggest that the inflation(i.e.,scoresof7acrossalldomainsonthe9
readerselectfromthislistorsimilarlistsinorderto scale); the halo or horns effect (i.e., judging
determine the most appropriate attributes for their aresident aspoor orexcellent inall domains based
individualprogrammaticneeds. upon performance in one domain); a restricted
Althoughtheglobalevaluationformhasbeenthe grading scale (i.e., all of the grades are between 6
mainstay of faculty evaluation of resident perfor- to 9 on the 9 scale); inter-rater and intra-rater
TEACHING MEDICAL PROFESSIONALISM 307
TABLE 7 we encourage the reader to review the tools and
select the best practices for their program needs.
Evidence of Professional Commitment
Veloski et al performed an update of the Lynch
To professional competency
study as well as a review of studies on professional-
To honestywithpatients
ismfrom1982to2002(n5134studies).Reliability
To patient confidentiality
To maintainingappropriate relationships withpatients wasreportedinonly62studies.Contentvaliditywas
To improving qualityof care reportedin86studies,butonly34studieshadstrong
To improving accessto care evidenceforvalidity.Concurrentvaliditywasseenin
To ajust distribution of finiteresources
43studies,andpredictivevaliditywaspresentinonly
To scientificknowledge
16ofthestudies.106Baseduponourexperienceand
To maintainingtrustby managingconflicts of interest
To professional responsibilities reviewoftheliterature,webelievethatthefollowing
five tools are good practices: 1) role modeling, 2)
Tablederivedfrom Sox.90
formal mentoring programs, 3) peer and patient
components of a 360-degree global evaluation, 4)
routine integration of professionalism into the
reliabilityproblems(i.e.,easyandhardgraders)and curriculum including grand rounds and confer-
lack of standardized norm-referenced criteria for ences, and 5) a portfolio-based self reflection
the scoring rubric. project on professionalism achievement. We believe
Werecommendthatascoringrubricwithspecific that portfolio might be a particularly powerful tool
and explicit behavior-driven narrative anchors be for assessing professionalism because it is learner-
used in the global evaluation form to improve the driven and learner-maintained, it encourages self-
reliability and validity of the scoring. Larkin has reflectionandinstillsasenseoflife-longcommitment
reported on specific categories of performance for totheprocess,itprovidesarepositoryforevidenceof
professional attributes. These categories could be excellenceinprofessionalism(e.g.,patientorstaff,or
incorporated into a scoring rubric for the various facultycompliments,specialawardsorcitations),and
global assessment tools (Table 8). The use of an it can incorporate less tangible components of
explicitwrittenscoringrubricwithnarrativeanchors professionalism (e.g., self improvement, self reflec-
and criterion based descriptors might improve the tion,andselfstudy).
reliability and validity of the assessment. Arnold has proposed three general areas of
Lynch et al summarized existing assessments in assessment of professionalism: 1) measurement of
four major areas: professionalism when evaluating clinical perfor-
mance, 2) measurement of professionalism as
1. Ethics (e.g., morality, ethical principles, honor
a comprehensive assessment, and 3) measure of
codes, social norms, deception, abuse or mis-
specific elements of professionalism.3 Based upon
treatment, cheating, disclosures, and sexual
our literature review, we believe that teaching
misconduct)
encounters can be divided into these same three
2. Personal characteristics (e.g., emotional intelli-
categories as proposed by Arnold:
gence, personal values, empathy, trustworthi-
ness, cynicism, and dogmatism) 1. Teaching about comprehensive principles of
3. Comprehensive professionalism (i.e., assess- professionalism (e.g. cognitive components).
mentsthataddressedtwoormorecomponents 2. Teaching during clinical performance (e.g.,
of professionalism) teaching at the bedside).
4. Diversity (e.g., cultural issues, socioeconomic 3. Teaching specific elements of professional
status, gender, age, or disability’’).59 behavior.
Table 9 lists the assessments identified by Lynch Teachingthecognitivecomponentsofprofession-
etal.Weprovidethelistinordertobeinclusivebut alism includes traditional lectures, case-based learn-
ing(perhapswithanethicistinattendance),special
grandrounds,smallgrouporseminardiscussion,or
TABLE 8
an annual retreat to review professionalism. Assess-
Larkin’s Classification of Professionalism ments of the effectiveness for these didactic teach-
ing tools might include lecture attendance records,
Ideal(e.g.,consistentlyaboveandbeyondthecallofduty)
Expected (e.g., meets allexpectations) portfolio documentation of discussion, faculty-led
Unacceptable (e.g.,single episodeof unprofessional chart-stimulated recall exercises, or resident self-
behavior) reflection projects with self- or externally assessed
Egregious (e.g.,persistent, recurrent pattern of
chart audit. There should also be time for in-
unprofessional behavior)
dependent learning (e.g., directed reading assign-
308 Surv Ophthalmol52 (3)May--June 2007 LEEETAL
TABLE 9
Example of Tools for Assessing Professionalism in Four Major Content Areas
I. Ethics
ChristieEthical Decisionmaking Questionnaire19
DefiningIssuesTest39
Professional Decisions Values Test72
SavulescuEthics Competence Tool81
Siegler Assessment86
SulmasyQuestionnaire for HouseOfficers92
WengerOrthopaedic Surgeon’s Knowledgeof Medical EthicsQuestionnaire109
TheEthicsobjective Structured ClinicalExam (OSCE)87
MoralBehavior Analysis (Sheehan TJ,ThaiSE,Krause KC,et al:Improving physician skills in managingmorally
problematiccases. (Presentedat theannualmeeting of theAmericanEducational ResearchAssociation,
Washington DC, April24, 1987)
Levitt EthicalIssues Questionnaire57
II. Personal characteristics
Trustin Physician Scale2
Humanismscale49
Wake Forest Physician TrustScale47
SchwartzValues Scale35
Jefferson Scaleof Physician Empathy52
LinnHumanistic attitudes58
Basictraitsand non-cognitive professional behaviors69
III. Comprehensive professionalism
NurseEvaluation ofMedical Housestaff Form18
Amsterdam Attitudes andCommunications Scale27
HumanismScale49
Scaleto Measure Professional Attitudes andBehaviors in Medical Eduction3
RochesterPeer Assessment form36
RochesterCommunications RatingScale36
AmericanAcademyof Pediatrics evaluation ofprofessionalism list56
EducationalCommissionforForeignMedicalGraduates(ECFMG)clinicalskillsassessment(CSA)usingstandardized
patients105
Universityof Michigan Department ofSurgery Professionalism AssessmentInstrument42
IV.Diversity
Culturalcompetence inMedicine Questionnaire43
Sociocultural Attitudes in MedicineInventory101
Robins HealthBeliefs Communication OSCE75, 76
ElamDiversity in MedicalSchool Questionnaire34
Tablederive from Lynchet al.59 Thefull reviewis availableat www.medicalteacher.rog/Lynch%20Table1a.pdf.
ments, textbooks, journals, handouts, audio-video, participation, self-reflection exercise on the impact
internet media) and provision of interactive learn- of specific journal articles on self-confidence in
ing environments (e.g., formal ethics and profes- specific domains of professionalism, or a portfolio
sionalism topics) within core curriculum (e.g., project linked to one or more articles from the
seminars, small group discussions). Assessments of journal club. Likewise morbidity and mortality
independent learning could include pre- and post- conference (e.g., giving bad news, dealing with
testing of knowledge, and self-reported confidence medical error) could be a springboard for directed
in specific areas of professionalism. Standardized discussions on professional behaviors. Innovative
written or oral examinations of cognitive compo- teaching formats could also be employed (e.g.,
nents of professionalism already exist for many clinical reasoning in situations that involve clinical
specialties (e.g., in-service training examinations, uncertainty, teamwork exercises, standardized vi-
qualifying examinations, specific focused testing of gnettes, role playing, review of simulated clinical
ethical or professionalism concepts). It may also be cases or panel discussion, or resident as teacher
useful to modify existing teaching encounters to programs48).
promote discussions on professionalism. For exam- Teaching professionalism in the clinical setting
ple, a journal club could be arranged with specific mightincludesimulatedorstandardizedencounters
professionalism-related articles and focused discus- with an objective structured clinical examination
sion. Assessment of this journal club tool might (OSCE) or checklist that can provide valuable
includeportfoliodocumentationofattendanceand formative feedback to residents.20,71,87,105 Faculty
TEACHING MEDICAL PROFESSIONALISM 309
mentorshipandrole-modelingintheclinicalsetting demeanor, dress, personal hygiene, communication
withperiodicresidentselfreflectionmaybeapower- and interpersonal skills, empathy, compassion,
ful teaching tool for professionalism.7 Residents altruism) might improve some of the problems
(93% in one survey) reported that contact with inherent in the global evaluation form. Critical
positiverolemodelswasthemostimportantmethod incident or sentinel event markers (e.g., documen-
of learning professionalism. Not unexpectedly, tation of specific patient or other complaints with
however, contact with negative role models was an follow up review of remediation over time) can
important learning encounter as well.15 The assess- identifyoutliersinprofessionalbehavior.Woffordet
ment of professionalism during clinical perfor- al identified several categories of unprofessional
mance could include chart reviews (e.g., review of behavior based on reviews of patient complaints
clinical cases with a one-on-one faculty counseling at one institution, including disrespect (36%),
session), periodic chart audit (e.g., self-reported disagreement about expectations of care (23%),
review, random or consecutive samples of behavior, inadequate information (20%), distrust (18%),
or checklist for critical or sentinel events), or perceived unavailability (15%), interdisciplinary
a global evaluation form (e.g., Musick 360-degree miscommunication (4%), and misinformation
evaluation from patients,62 co-workers, peers, in- (4%).They concluded that these seven complaint
structors, and self assessment). Peer (i.e., anony- categories could be useful in developing curricula
mousresidentonresident)assessmentsmayprovide related to professionalism.110 Longitudinal assess-
unique and particularly valuable insights into pro- ment programs of professionalism have been
fessionalism and specific behaviors that might not utilizedinsomemedicalschools.66,67Finally,aport-
be observable by faculty or be measured other- folio can serve as both a repository for self
wise.5,6,40,84,89 Patient satisfaction surveys or ques- assessment, for prior patient or staff citations for
tionnaires(Appendix2:WakeForestPhysicianTrust excellence or deficiency in professionalism, and for
Scale)47 and learner surveys of educationalenviron- a documented remediation based upon a learning
ment (American Board of Internal Medicine Scale plan and a self-reflection diary).7,13,44
to Measure Professional Attitudes and Behaviors in
Medical Education) can also provide formative
information about professionalism in the clinical
Summary
environment. Direct observation (e.g., either a real
orsimulatedorstandardizedpatient,oralternatively Professionalism is an important and critical
a videotaped or live encounter) may be an essential competency. Without professionalism first, profi-
element of professionalism assessment, and the use ciency in the other ACGME competencies (e.g.,
of a structured professionalism checklist (e.g., medical knowledge, patient care, communication
punctuality, greeting, hand washing, politeness, skills, practice based learning, or systems based
TABLE 10
Recommendations for Teaching and Assessing Professionalism
Defineexpectations forbehavior atthe start ofresidency witha written explicitcurriculum for professionalism.
Perform longitudinal, formal,performance-based, behaviorspecific assessment.
Teach andassessearly inthe residency trainingprocess.
Useassessment to improvethe educationalprocess aswellasimprove individuals.
Provide formative andsummative feedback to thelearners.
Reduce financial(e.g., debt),work environment (e.g.,duty hours), hierarchical (e.g.,‘‘pimping’’ residents),and
psychological stress tofoster andpromotea cultureof resident professionalism.60
Conductfrequentassessmentsovertimeusingmultipleobserves(e.g.,globalratingformsfrompatients,peers,faculty,
andancillarystaff),differenttools,andmultipleobservationsindifferentsettingstodefinereliabilityandvalidity.We
recommend againstover-reliance upona singletool(e.g., global evaluation) andencourage largersample sizesof
recorded observations and numbersof observers to improve reliabilityandvalidity.
Provide feedbackto learnersin a timelymanner andwithsufficient opportunity forimprovement.
Consider aformalfaculty--resident orsenior--juniorresident role-modelingandmentoring program to create
amechanism forproviding aninformallearning environment (role modeling)for professionalism andaformal
mechanismforone-to-oneformativefeedback.Thiswillrequirethatfacultybeexpectedtoupholdthesamestandards
of professionalism astheresidents who wearementoring.
Document teaching andassessment encounters.
Encouragelearnerself-reflection,self-designedlearningplan,andself-assessmentorprofessionaldevelopmentovertime,
andpromotelife-longlearningandcommitmenttoprofessionalself-improvement(e.g.,managingconflictofinterest,
continuingmedial education,avoiding physician impairment.