Advancing and Assessing Medical Professionalism · PDF fileMedical Professionalism ....
Transcript of Advancing and Assessing Medical Professionalism · PDF fileMedical Professionalism ....
M. BROWNELL ANDERSON
PETER J. KATSUFRAKIS, MD, MBA
A MERICA N UNIVERSITY OF BEIRUT
JA NUARY, 2 014
Advancing and Assessing Medical Professionalism
Disclosure
American University of Beirut January 2014
Peter Katsufrakis has no financial relationships and no conflicts of interest relevant to this presentation.
M. Brownell Anderson has no financial relationships and no conflicts of interest relevant to this presentation.
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Most important (in ABIM Charter)
What is different or overlap with AUB Charter
Behaviors that are most amenable to observation
Objectives
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1. Review the ―Professionalism Charter‖ created in March 2013 and the ABIM Physician Charter
2. Evaluate appreciative inquiry as an approach to consider promoting medical professionalism at AUB.
3. Identify potential approaches to assess professionalism that align with curricular goals and objectives
4. Enjoy!
A Definition of Professionalism
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Clinical Competence (Knowledge of Medicine)
Communication Skills
Ethical and Legal Understanding
EX
CE
LL
EN
CE
AL
TR
UIS
M
HU
MA
NIS
M
AC
CO
UN
TA
BIL
ITY
PROFESSIONALISM
Stern, et al. ―Measuring Medical Professionalism‖ 2006
American Board of Internal Medicine Physician Charter
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THREE WORDS THAT DESCRIBE CHANGE
Basics of Appreciative Inquiry
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Assumption:
Every system has something that works right
Methods
Asset, forward based qualitative method (semi-structured interview)
Focus on success; explore in depth key elements
Analysis Identification of: Themes
Strategies for overcoming barriers
Basics of Appreciative Inquiry Used with/for:
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Indiana U – 2004 JGIM - Professionalism Used an organizational change methodology known as appreciative
inquiry, which focuses attention on existing capabilities and successful experiences as a foundation for creating more of what is desired
Univ of Washington & UMKC - Professionalism UW – Strategy for enhancing an institutional culture of professionalism
(2007 Acad Med) UMKC – Narrative storytelling as variant of AI to identify principles
contained in definitions of professionalism to deepen understanding (2010 Acad Med)
Learning in Interprofessional Teams Med Teacher/ AMEE Guide #28 (2009)
Faculty Development at: Emory, Indiana, Rochester, Baylor, Minnesota Core Curriculum session to enhance reflective learning - – Acad Med
2009
Directions for Exercise One
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Step back… Think of recent experience (last 3-4 months) related to medical student curriculum Pick a time when you have felt most engaged, alive, absorbed,
excited, proud.
Everyone have an experience?
A learning experience with or between students and faculty
(Re) Affirmation of your role as a future physician, teacher, learner, educator, faculty member.
Occurred in any setting/context – in/out of class, as part of core/non-core pathway time, in a hallway/e-mail, in a clinic or the library, Simulation Center, Starbucks.
AI Success Worksheet Write it Down
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Worksheet (continued)
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Describe the experience in sufficient detail
What did it feel like?
How does it connect to something you value?
Who, What Where, When were you involved?
What did you and/or others do to contribute to this success?
What did you learn that might apply to other aspects of educational programs?
Is there an analogy, image, or metaphor that captures what you learned?
Worksheet #2- Directions
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Tell Your Story to Your Group Record – key words/phrases
Debrief Group & Record Common Features/Themes on success
Identify someone in the group to give a 1 minute report of KEY THEMES
STRATEGIES TO BUILD ON? OVERCOME OBSTACLES?
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Cross-Cutting Themes
DOES IT MATCH OUR THEMES?
EXPAND/ENRICH OUR UNDERSTANDING?
WHAT HAVE WE ADDED?
What does the Literature Tells Us?
What Does the Literature Tell Us?
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50% of all organizational changes fail Beer, M, & Nohria, N. (Eds.). (2000). Breaking the code of change. Cambridge, MA: Harvard Business School.
Failure can:
Happen early failure of buy in/leadership group
Happen late, when success is not sustained failure to live up to agreements
Peer pressure
Conflicting priorities
So, how can change succeed?
Works on Successful Change: Identifying Key Characteristics
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Herb Shepard: 8 Rules of Thumb for Change (1975)
John Kotter: 8 Steps of Change (1996)
Kerry Patterson, et al: Influencer (2008)
Six sources of influence
John D. Adams – review of various ―models:
8 + 4 themes for successful change
Herb Shephard‘s Rules of Thumb for Change Agents
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Rule I: Stay alive This rule is a double entendre—
Herb advised us both to avoid ―self-sacrifice‖ and to be ―fully alive‖ in our work.
Rule II: Start where the system is
Rule III: Never work uphill Corollary 1: Don‘t build hills as
you go Corollary 2: Work in the most
promising area Corollary 3: Build resources Corollary 4: Don‘t over-organize Corollary 5: Don‘t argue if you
can‘t win
Rule IV: Innovation requires a good idea, initiative, and a few friends
Rule V: Load experiments for success
Rule VI: Light many fires
Rule VII: Keep an optimistic bias
Shepard, H. A. (1975). Rules of thumb for change agents. OD Practitioner 7(3), 1-5.
Kotter, J. P. (1996). Leading change. Cambridge, MA: Harvard Business School Press.
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1. Establishing a sense of urgency
2. Creating a guiding coalition
3. Developing a vision and strategy
4. Communicating the change vision
5. Empowering employees for broad-based action
6. Generating short term wins
7. Consolidating gains and producing more change
8. Anchoring new approaches in the culture
Kerry Patterson, et al. The Influencer 6 Sources of Influence
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Motivation Ability
Personal Make the Undesirable
Desirable
Surpass Your Limits
Social Harness Peer Pressure
Find Strength in Numbers
Structural Design Rewards and Demand
Accountability
Change the Environment
John Adams: 8 Themes for Successful Change
Understand and accept the need for change
Believe change is desirable and possible
Sufficient passionate commitment:
Changing habits (25% of people)
Specific deliverable goal and a few first steps
Structures/mechanisms that require repetitions of the new pattern
Feeling supported and safe
Versatility of mental models
Patience and perseverance
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John Adams: 4 Additional Success Factors
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Clear accountability
Explicit boundary management
Critical mass in alignment
Rewarding the new behavior and withdrawal of rewards for the old behavior
Theme Yes or N0
Theme
Yes or N0
Understand and accept the need for change
Versatility of mental models
Believe change is desirable and possible
Patience and perseverance
Sufficient passionate
commitment
Clear accountability – visible, vocal, persistent
sponsors and stakeholders
Specific deliverable/goal and a few first steps
Explicit boundary management
Structures/mechanisms that require repetition of new pattern
Critical mass in alignment
Feeling supported and safe Reward new and withdraw rewards for old behaviors.
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ASSESSING PROFESSIONALISM:
IMPLEMENTATION
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Advancing and Assessing Medical Professionalism-
Day Two
What Does Assessment Do?
Different types of assessments can measure:
Attitudes
Knowledge
Ability
Performance
Ensures minimum competency
Defines aspirational goals
Communicates values
What is important, or not important
Hierarchy of Abilities
Knowledge (knows)
Competence (knows how)
Performance (can do)
Practice (does)
Assessment Methods
Knowledge MCQ, short answer
Competence essay, oral, PMP
Performance simulations, bedside/lab exam
Practice audit, observation
Value Proposition for Assessment
Able to enhance products and services
Communicates values to stakeholders
Provides actionable information
Aligns activities to achieve outcomes
Objective: Improve Clinical Skills
of Students
Pre-1971: Year 3-4 =
discipline-based classes
Year 6 = didactic teaching
Evaluation = clinical bedside exam + multiple choice question (MCQ) exam
Post-1971: Year 3-4 =
organ-system-based
Year 6 = internship
Evaluation = ward assessments + MCQ; clinical bedside exam if unsatisfactory ward assessments
Newble DI, Jaeger K. The effect of assessments and examinations on the learning of medical students. Med Educ. 1983;17(3):165-71.
Few unsatisfactory ward ratings (3/480)
Academic success depended on MCQ exam
Students moved away from wards and into library to prepare
Clinical skills became less important as perceived by students
Newble DI, Jaeger K. The effect of assessments and examinations on the learning of medical students. Med Educ. 1983;17(3):165-71.
Outcomes of Curricular Change
Attempt to Remedy the Problem
Added 90 minute Objective Structured Clinical Exam (OSCE) to final examinations
Added 90 minute essay exam on clinical management
Retained ward ratings and MCQ exam
Surveyed students to assess impact of changes
Newble DI, Jaeger K. The effect of assessments and examinations on the learning of medical students. Med Educ. 1983;17(3):165-71.
Objective: Improve Clinical Skills of Students via USMLE Step 2 CS exam
Step 2 CS Exam introduced in 2004
Previously, basic skills were never or rarely observed throughout a student‘s medical school career
Approximately 2/3 US medical schools had a high-stakes clinical skills exam
Clerkship directors were surveyed at 109 US medical schools in 2005 about changes in teaching
Objective: Improve Clinical Skills of Students
Educational method
Use of method
increased (%)
Use of method
introduced (%)
Standardized patients 31 14
Direct observation of real patients 24 6
Simulators or synthetic mannequins 16 13
Faculty development programs 11 8
Percentage Change in the Introduction or
Use of Various Educational Methods
(n=88/109 respondents)
Gilliland WR et al. Changes in clinical skills education resulting from the introduction of the USMLE step 2 clinical skills examination. Medical Teacher. 2008;30:325-27.
Lessons About Assessment
Change in assessment method has greater effect than change in curriculum
Assessment methods influence study methods chosen by students
Assessment methods influence faculty behavior
Assessment method measurement characteristics are important
Assessments must have consequences to be effective
Assessing Professionalism Exercise #1 – Focus and Methods
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Using Miller‘s Pyramid, what areas might we target when assessing professionalism?
What assessment methods could we use to measure each of these?
(e.g. test of knowledge of ethical principles; reflective writing exercise; observed performance in a clinical setting, etc.)
Assessing Professionalism Exercise #2 – Challenges
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In small groups, discuss challenges to assessing professionalism generally and challenges of specific methods previously discussed
Wherever possible, suggest strategies to mitigate or remove the challenges
What must be done?
Who needs to be involved?
What are most likely approaches that will be successful in the context of the institution?
Assessing Professionalism Exercise #3 – Ideas to Action
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Individually, identify one particular component of professionalism that is meaningful to you. How might you assess it?
In one sentence, describe the professionalism component
Identify 1-3 methods you might use to assess this aspect of professionalism
Pick one method, outline the tasks necessary that you might accomplish within the next month to implement this assessment
In pairs, describe and discuss your approach(es)
Prepare to report to the larger group
TAKING THE LITERATURE AND THEMES TOGETHER–
HOW DO WE ADVANCE AND ASSESS
PROFESSIONALISM?
Translating ―Themes‖ Into
Action Plans
ACTION PLANS
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Identify a current change effort (implementing professionalism charter at AUB)
List the key features of your change strategy that connect to the success themes
What is the ONE thing – based on themes for success – that you can do to transform ―half empty‖ responses to change to positive/forward ―half full‖ perspective:
- 1st day you return to work
- Within one week of return
Brief Reports of Selected Action Plans
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Final Comments, Summary & References
• AI ENGAGING METHOD
• Application to change anxiety
• Opportunity to talk about success
• LITERATURE ON “CHANGE”
• APPLICATION TO HOME SETTING?
Using Success to Manage Anxiety→ Moving
forward in same direction
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http://executiveeducation.wharton.upenn.edu/wharton-at-work/0810/images/cartoon2b_lg-0810.gif
References & Additional Info (1)
Adams JD. Transforming Leadership. 2nd Edition. Ed. Alexandria, VA: Miles River Press, 1998.
Branch WT, Frankel R, Gracey CF, et al. A Good Clinician and a Caring Person: Longitudinal Faculty Development & the Enhancement of the Human Dimensions of Care. Acad Med 2009;84(1):117-125.
Cooperrider DL, Whitney D. Appreciative Inquiry: A Positive Revolution in Change. San Francisco, CA: Berrett-Koehler Publishers, 2005.
Cottingham AH, Suchman AL, Litzelman DK, et al. Enhancing the informal curriculum of a medical school: a case study in organization culture change. J Gen Intern Med 2008;23(6):715-22.
Fryer-Edwards K, Van Eaton E, Goldstein EA, et al. Overcoming Institutional Challenges through Continuous Professionalism Improvement. Acad Med 2007;82(11):1073-1078
Hammiick M, Olckers L, Campion-Smith C. Learning in interprofessional teams: AMEE Guide #38. Medical Teacher 2009;31(1):1-12.
Kotter,JP. Leading change. Cambridge, MA: Harvard Business School Press 1996.
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References & Additional Info (2)
Kouzes JM, Posner BZ. The Leadership Challenge, 4th Edition. San Francisco: Jossey-Bass; 2007.
Kumar LR, Chacko TV. Using appreciative inquiry on learning styles to facilitate student learning. Med Educ 2010; 44(11):1121-22.
Patterson K, et al. The Influencer: The power to change anything. McGraw Hill. New York. 2008.
Quaintance JL, Arnold L, et al. What students learn about professionalism from faculty stories: An ‗appreciative inquiry‘ approach. Acad Med 2010;85(1):118-23.
Shepard, H. A. (1975). Rules of thumb for change agents. OD Practitioner 7(3), 1-5
Simpson D, Lal A, Redlich PR. Sentinel Events as Surgeons – Appreciative Inquiry & Identify Formation. Focus on Surgical Education 2009;26(1):17-20.
Suchman AL, Williamson PR, Litzelman DK, Frankel RM, Mossbarger DL, Inui TS. Relationship-Centered Care Initiative Discovery Team. Toward an informal curriculum that teaches professionalism: Transforming the social environment of a medical school. J Gen Intern Med. 2004;19(5 Pt 2):501-4.
Whitney D, Trosten-Bloom, A. The Power of Appreciative Inquiry: A Practical Guide to Positive Change – 2nd Edition. Berrett-Koehler Publishers, Ind. 2010.
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•FINAL COMMENTS
•“PEARLS” FROM PARTICIPANTS
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SUMMARY
M A R G A R E T M E A D
A N T H R O P O L O G I S T ( 1 9 0 1 – 1 9 7 8 )
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Never doubt that a small group of thoughtful, committed citizens can
change the world. Indeed, it is the only thing that ever has.
SHUKRAN