Post on 30-Dec-2015
description
Objectives for this Session
List the key elements of professional behavior, as identified in the “Physician Charter.”
Describe three interactive methods for teaching professionalism to residents/fellows.
Use a tool to create learning cases. Identify useful online resources for
teaching and evaluating professionalism. Discuss evaluation strategies for a
professionalism curriculum in your home program.
My Educational Domain
1 2 3 4 5 6
47%
33%
13%
0%0%
7%
1. Institutional2. Program3. Undergraduate
Medical Education
4. Nursing Education
5. Faculty Development
6. Other
What is your discipline?
1 2 3 4 5 6 7 8 9 10
0%
20% 20%
0%
40%
7%7%7%
0%0%
1. Anesthesiology2. Family Medicine3. Internal Medicine4. Neurology5. OB-Gyn6. Ophthalmology7. Pediatrics8. Psychiatry9. Surgery10. Other
What is your best method for evaluating your
residents?
1 2 3 4 5 6 7
7%
36%
43%
7%7%
0%0%
1. Critical event documentation
2. Global evaluation forms
3. Multisource feedback4. OSCE5. Peer evaluation6. Professionalism mini-
evaluation exercise (P-MEX)
7. Small group faculty evaluation
What is the next best method for evaluating your
residents?
1 2 3 4 5 6 7
0%
42%
25%
8%8%
17%
0%
1. Critical event documentation
2. Global evaluation forms
3. Multisource feedback4. OSCE5. Peer evaluation6. Professionalism mini-
evaluation exercise (P-MEX)
7. Small group faculty evaluation
Have you previously attended a workshop on developing a
professionalism curriculum?
1 2 3 4
53%
13%13%
20%
1. No2. Yes, at my
institution3. Yes, with my
program director association
4. Yes, at another site
Small Groups
Brainstorm characteristics of unprofessional behavior
Establish the elements that define professionalism
Report out
Your Definition of Professionalism
Accountable Respectful Compassionate Humility Approachable Dress Punctual Adaptable Ethical
Integrity Responsible Ambassador Hardworking Emotional Intelligence Ownership of Pts Positive Attitude Responsive Lifelong Learner Interacting Well with
Staff, Patients, Families
Six Step Approach to Curriculum Development
Problem Identification and General Needs Assessment– Health Care Problem– Current v Ideal
Approach Targeted Needs
Assessment– Learners– Learning Environment
Goals and Objectives
Educational Strategies– Content– Method
Implementation– Resources– Barriers– Delivering Curriculum
Evaluation and Feedback– Learners– Program
Curriculum Development for Medical Education: A Six-Step ApproachEds. Kern, Thomas, Hughes. 2009
Step 1: Problem Identification
Residents must be educated in a humanistic educational environment that protects their safety, and nurtures professionalism and the effacement of self interest that is the core of the practice of medicine and the profession in the United States.
Nasca 2010, Open Letter
Step 2: Targeted Needs Assessment
Shared definition at an institutional level
Defining the local issues– Remediating unprofessional behavior– Advancing professionalism
Your Definition of Professionalism
Accountable Respectful Compassionate Humility Approachable Dress Punctual Adaptable Ethical
Integrity Responsible Ambassador Hardworking Emotional Intelligence Ownership of Pts Positive Attitude Responsive Lifelong Learner Interacting Well with
Staff, Patients, Families
Stern’s Definition of Professionalism
“Professionalism is demonstrated through a foundation of clinical competence, communication skills, and ethical understanding, upon which is built the aspiration to, and wise application of the principles of professionalism: excellence, humanism, accountability, and altruism.”
Stern DT (ed.), Measuring Medical Professionalism, Oxford University Press, 2006
Clinical Competence (Knowledge of Medicine)
Communication Skills
Ethical and Legal Understanding
Ex
celle
nc
e
Hu
man
ism
Ac
co
un
tab
ility
Altru
ism
Professionalism
Stern DT (ed.), Measuring Medical Professionalism, Oxford University Press, 2006
Step 3: Goals and Objectives
The Physician Charter ABIM: Project Professionalism ABP/APPD: Teaching and Assessing
Professionalism Royal College of Physicians ACGME
Physician Charter Three Fundamental Principles Ten Professional Responsibilities with
Commitment to:– Professional competence– Honesty with patients– Patient confidentiality– Maintaining appropriate relations– Improving quality of care– Improving access to care– Just distribution of finite resources– Scientific knowledge– Maintaining trust by managing conflicts of interest– Professional responsibilities
Medical Professionalism in the New Millennium: A Physician Charter. Ann Intern Med 2002;136:243-6.
The Charter as a Blueprint for Program Directors
Promoting Professionalism: A Definition
Professionalism in Patient Care– Professional competence– Honesty with patients– Patient confidentiality– Maintaining appropriate relations
Professionalism With Physician Colleagues and Other Health Professionals– Improving quality of care– Professional responsibilities– Teamwork
Stress and Its Impact on Professionalism– Professional responsibilities– Self-Awareness– Balancing Personal and Professional Commitments
Professionalism and Society– Improving access to care– Just distribution of finite resources– Scientific knowledge– Maintaining trust by managing conflicts of interest
Professionalism Beyond Residency– Professional competence
Step 4: Educational Strategies
Setting Expectations– Ceremonies, Policies, Orientation,
Charters Providing Experiences
– Formal, Informal, Hidden Curricula– Context– Developmental Process
Evaluating Outcomes– Assessments before residency– Multiple perspectives
Context
Does professionalism represent a set of stable traits of the individual?
Disconnect between how education approaches knowledge and skills versus behavior
Tied to role responsibilities
Ginsburg S, Regehr G, Hatala R, et al. Context, conflict, and resolution: A new conceptual framework for evaluating professionalism. Acad Med 2000;75:S6-11.
Developmental Achievement Levels
Professional Identity Among Cadets– Early: Professional values and standards
as rules to be followed– Transition: Internalize profession’s
values as internal qualities– Later: Own the values, can assess them,
and are able to reconcile conflicts
Forsythe GB, et al. Making Sense of Officership: Developing a Professional Identity for 21st Century Army Officers. In: The Future of the Army Profession. New York: McGraw-Hill, 2002.
Developmental Achievement Levels
Professional Identity Among Residents– Early: Explicit rules to be followed,
attendance, finishing dictations, sign outs
– Transition: Internalize profession’s values class rules, creed of accepted conduct
– Later: Own the values, can assess them, seniors assess internsForsythe GB, et al. Making Sense of Officership: Developing a Professional
Identity for 21st Century Army Officers. In: The Future of the Army Profession. New York: McGraw-Hill, 2002.
Case of JM
Jeopardy call rules – available on-site within three hours.
She is on jeopardy call and tests her luck by going two hours away on a workday.
This is a serious lapse in professional behavior
1 2 3 4 5 6 7
0%
38%
15%
8%
15%15%
8%
1. Strongly Agree2. Agree3. Somewhat
Agree4. Neutral5. Somewhat
Disagree6. Disagree7. Strongly
Disagree
Case of JM
Jeopardy call rules – available on-site within three hours.
She is on jeopardy call and tests her luck by going two hours away on a workday.
She is away because she is looking for a place to live for her fellowship, which begins in a month.
This is a serious lapse in professional behavior
1 2 3 4 5 6 7
8%
38%
8% 8%
15%15%
8%
1. Strongly Agree2. Agree3. Somewhat
Agree4. Neutral5. Somewhat
Disagree6. Disagree7. Strongly
Disagree
Case of JM
Jeopardy call rules – available on-site within three hours.
She is on jeopardy call and tests her luck by going two hours away on a workday.
She is away because she is looking for a place to live for her fellowship, which begins in a month.
Several classmates note a photo of her new apartment on her Facebook dated the day of her scheduled call.
This is a serious lapse in professional behavior
1 2 3 4 5 6 7
6%
24%
6% 6%
18%
24%
18%
1. Strongly Agree2. Agree3. Somewhat
Agree4. Neutral5. Somewhat
Disagree6. Disagree7. Strongly
Disagree
Thoughts about JM?
Is it a professionalism issue if she tests limits and is not called in?
What if she is scheduled to graduate in 4 weeks and needs to relocate for fellowship?
What if she had tried to trade call unsuccessfully?
What about stretching the rules and electronically documenting her behavior?– Unprofessional? – or just not so smart?
This is a serious lapse in professional behavior
1 2 3 4 5 6 7
94%
6%
0% 0%0%0%0%
1. Strongly Agree2. Agree3. Somewhat
Agree4. Neutral5. Somewhat
Disagree6. Disagree7. Strongly
Disagree
JM facts
She does get called in. When reached, she denies she knew
she was on call. She calls back and says she was
indeed aware but cannot return within 3 hours to take call. “Just call in the back-up jeopardy person.”
This is a serious lapse in professional behavior
1 2 3 4 5 6 7
87%
7% 7%
0%0%0%0%
1. Strongly Agree2. Agree3. Somewhat
Agree4. Neutral5. Somewhat
Disagree6. Disagree7. Strongly
Disagree
JM facts
She does get called in. When reached, she denies she knew
she was on call. She calls back and says she was
indeed aware but cannot return within 3 hours to take call. “Just call in the back-up jeopardy person.”
She had an appointment with the school district about her special needs son’s placement.
This is a serious lapse in professional behavior
1 2 3 4 5 6 7
50%
21%
14%
0%0%0%
14%
1. Strongly Agree2. Agree3. Somewhat
Agree4. Neutral5. Somewhat
Disagree6. Disagree7. Strongly
Disagree
Dénouement
Back up called She had to pay back call to back up Professionalism sign off deferred until
six months into fellowship Precedent set
Designing Professionalism Cases
Select a case Prepare for discussion Decide how to reveal the case and
the conflicts Prepare a short discussion
Designing Professionalism Cases
Select a case– Tell a story– Ok to merge cases– Identify context and key conflicts
Prepare for discussion Decide how to reveal the case and
the conflicts Prepare a short discussion
Designing Professionalism Cases
Select a case Prepare for discussion
– Adapt to levels of learners– Anticipate issues that may arise– Generational issues– Re-evaluate case
Decide how to reveal the case and the conflicts
Prepare a short discussion
Designing Professionalism Cases
Select a case Prepare for discussion Decide how to reveal the case and
the conflicts– Create tension!– Highlight competing conflicts in the case
Prepare a short discussion
Designing Professionalism Cases
Select a case Prepare for discussion Decide how to reveal the case and
the conflicts Prepare a short discussion
– Review learning objectives– Tie back to Physician Charter– Summarize discussion
Step 5: Implementation
Political Support/buy-in Resources
– Faculty– Time
Implementing, Sustaining, and Improving the Curriculum
Teaching Strategies
Setting expectations Appreciative inquiry Cultural norm setting
– Retreats, Play of the Week– P.A.D.S.
Lectures/Curriculum Reflective exercises Professionalism series
St. Christopher’s Hospital for Children
Target audience –clinical fellows Three, small group didactic –
followed by case-based reflection (90 minute sessions)
Curriculum – 1/3 of ABP/APPD Guide per session
Evaluation – Retrospective pre-test and post-test
University of Wisconsin
Noon conference facilitated discussions, focusing on each of the sections of the APPD-ABP book:– Content discussion (5 min)– Vignettes– Longer cases
Newer strategies
Peer review system (Bonder J, Elwood D, Heckman J, et al. PM&R 2010;2(2):117-24)
Reader’s Theatre – scripted faculty development (Bell SK, Wideroff M, Gaufberg L. Pt Ed & Couns 2010;80(3):354-7.)
Wikis - (Varga-Atkins T, Dangerfield P, Brigden D. Med Teach 2010;32(10):824-9.)
Step 6: Evaluation and Feedback
The Learners– Evaluations can also help set
professionalism expectations– Role of reflection
The Program
Evaluating Learners 360 or multi-source evaluations Nursing evaluations Peer evaluations Small groups* Professionalism mini-evaluation
exercise (P-MEX)**
*Haidet et al. The Role of the Student-Teacher Relationship in the Formation of Physicians The Hidden Curriculum as Process. J Gen Intern Med 2006; 21:S16–20.
**Cruess R, McIlroy JH, Cruess S, Ginsburg S, Steinert Y. The professionalism mini-evaluation exercise: A preliminary investigation. Acad Med 2006;81:S74-8.
Evaluating Learners (cont)
Critical events & reflection Professionalism Series Conscientiousness index*
*McLachlan JCP, et al. The conscientiousness index: A novel tool to explore students’ professionalism. 2009 Acad Med 84:559-565
Importance of Reflection
Faculty and residents need to gain additional experience in observing and reflecting on their own and others’ behavior
Learners should be encouraged to share their stories during all teaching sessions
Evaluating the Curriculum
Satisfaction Examine trends on global, peer, 360
evaluations over time Changes in behaviors (need
mechanism to monitor) Reflections
Six Step Approach to Curriculum Development
Problem Identification and General Needs Assessment– Health Care Problem– Current v Ideal
Approach Targeted Needs
Assessment– Learners– Learning Environment
Goals and Objectives
Educational Strategies– Content– Method
Implementation– Resources– Barriers– Delivering Curriculum
Evaluation and Feedback– Learners– Program
Curriculum Development for Medical Education: A Six-Step ApproachEds. Kern, Thomas, Hughes. 2009
Thanks!!
John Frohna– frohna@wisc.edu
Rob McGregor– Robert.McGregor@DrexelMed.edu
Curriculum
233 program directors surveyed – 1/3 no curriculum or formal
professionalism experience– ~1/3 combined with ethics– ~1/3 independent curriculum
Barriers – – Faculty expertise / Need for faculty
development– Curricular crowding
Lang CW et al. Ethics and Professionalism in the Pediatric Curriculum: A Survey of Pediatric Program Directors Pediatrics 2009.
Philadelphia Professionalism Series
Children's Hospital of Philadelphia (CHOP) Residents
St. Christopher’s Hospital for Children (SCHC) Fellowships
CHOP Model
Ten, monthly sessions at 7:30-8:30 AM
20-24 house staff and 3-4 preceptors Ten major themes (6 from the
ABP/APPD Guide)
CHOP Series
All sessions rated “very helpful, helpful” by at least 50%
Attendance mean – 5.0 (range 1-9) Numbers per group – 9.43 (range5-10) Qualitative outcomes – global –societal topics not
as well received Best received
– Fatigue and Burnout and Their Impact on Clinical Care**– Coping with Medical Errors*
Small group important
** Designed internal module