Professionalism: New Thinking about an Old IssueImplications for Maintenance of Certification •...
Transcript of Professionalism: New Thinking about an Old IssueImplications for Maintenance of Certification •...
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Professionalism:
New Thinking about an Old Issue
Catherine R Lucey MD
Professor of Medicine
Vice Dean for Education
UCSF School of Medicine
ABMS Spring 2015
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We have
a problem
with
Professionalism
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Highly Publicized Illegalities
Involving Physicians
Disruptive Physicians
Daily Incivilities
Conflicts of Interest
Disregard of EBSP
Collective Tolerance
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The Gap between Real and Ideal
• Intention- Behavior gap exists in practicing physicians
(Campbell 2007)
• The majority of nurses and physicians in ORs, EDs, L&D
units have witnessed unprofessional behavior in their
departments. (Rosenstein and Naylor 2012, Saxton 2012).
• 25-50% of Residents report witnessing >4 episodes of
disrespect in the health care environment. (Billings 2011)
• Almost all surveyed students report witnessing
unprofessional behavior in residents and faculty. (Wiggleton
2010)
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Consequences of that Gap
• 75% of personnel in a 100 hospital survey believed that
disruptive behavior (passive or overt) contributed to poor
quality of care; 18% had personally witnessed such an
event. (Rosenstein 2008)
• Intimidation of a nurse or pharmacist by a physician caused
7% of medication errors in one hospital. (Smetzer 2005)
• Two-thirds of nurses subjected to verbal abuse reported a
transient decrease in critical thinking. (Saxton 2012.)
• Residents exposed to an environment of verbal abuse
have higher rates of burnout and cynicism (Billings 2011)
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The Shifting Sands of
Professionalism
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JAMA. 2010;304(24):2732-2737 Lesser C, Lucey C et
al
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Professionalism Lapses, Like Medical Errors
Prevalence is common and inevitable Severity and impact vary widely Negligence is uncommon Caused by good people with transient deficiencies in knowledge, judgment or skills Systems may set people up to fail
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Professionalism Challenges:
Dueling Conflicts
Values, Patients, and Maslow Conflicts
Ginsberg S et al. Acad Med 2002; 77(6):516
Bryan CS. The Pharos 2005; 68(2): 4
Ginsberg S et al. JGIM 2003; 18(12):1015-22
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Managing a Professionalism Challenge
Requires Judgment and Skill
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Assess Situation
Identify Options
Analyze Options
Take Action
Know
Professionalism
Values
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Situational Analysis
Self Awareness and Self Control
Alternate Strategy Development
Diplomacy and Crisis
Communication
Peer Coaching and Intervention
Expand Professionalism Teaching to Include
Competencies that Support Optimal Performance
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Professionalism as a
Complex, Developmental Competency
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http://www.12manage.com/forum.asp? B=tuckman_stages_team_development&S=13
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Implications for Maintenance of Certification
• Professionalism, as an individual competency, can
either advance or decay based on how it is managed
across a career.
• Professionalism is influenced by advances in
biomedical science, care delivery and teamwork, and
patient expectations.
• Thus, professionalism must be a focus of both
continuing medical education as well as maintenance
of licensure and maintenance of certification
programs.
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Current MOC Professionalism Assessment
Valid License
Participa-tion in
CME/MOC
Patient Satisf
Surveys
OK Profes-sionalism
No Egregious Behavior
Commitment to Excellence
and Improvement
Effective Communicator
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Patient Centeredness
Personal Effectiveness in
Practice
Team Leader and Member
Participation in Organizational
Quality and Safety
Stewardship of Resources
Ethical Decision Making
Educating the Next Generation
Collaborating to advance science
Resiliency
Expanded
Professionalism
Competency
Domains to
Assess
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Modifying Existing MOC Tools and Strategies to
Assess Professionalism
• MCQ Exams: content related to ethics and
professionalism challenges
• Requires a different type of MCQ than single best answer
• MCQ Exams: stewardship concepts imbedded in clinical
decision making.
• Performance Improvement Modules: Increased
requirements for demonstrating system improvement
• Performance Improvement Modules: Reflection on a
professionalism challenge
• Performance Improvement Modules: Personal
performance data (procedures, patient satisfaction)
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New Tools and Strategies to Evaluate Expanded
Professionalism Competencies
Multisource Feedback:
• Physician Achievement Review (PAR) {Alberta, Canada}
(Violato et al 2008)
• Multisource feedback from patients, peers, coworkers and self
• Evaluated as valid, reliable, feasible and helpful
• Effectiveness and Respect Questionnaires for physicians
who teach (Papadakis et al)
• Structured Letters of Recommendation: Relative
Percentile Methods (McCarthy J. 2001)
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Tools Useful in Other Circumstances* not likely
to be used in the MOC environment
• Standardized Patients and Observed Structured
Clinical Exams (OSCEs)
• Critical Incident Reports
• Professionalism Mini Evaluation Exercise
• Professionalism Encounter Cards
* UGME and GME environments
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Additional Roles For Specialty Boards
Incorporating professionalism issues
into continuing education programs
and specialty meetings
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Billings ME et al. The effect of the hidden curriculm on resident burnout and cynicism. J Grad Med Educ.
2011 Dec;3(4):503-510.
Cambell EG et al. Professionalism in medicine: results of a national survey of physicians. Ann Intern Med.
2007 Dec 4;147(11):795-802.
Levinson W et al. Understanding Medical Professionalism. 2014 McGraw Hill
Lesser C et al. A behavioral and systems view of professionalism. JAMA. 2010;304(24):2732-2737
Rosenstein AH and O’Daniel M. A survey fo the impact of disruptive behaviors and communication defects
on patient safety. Jt Comm J Qual Patient Saf. 2008 Aug;34(8):464-471.
Rosenstein AH and Naylor B. Incidence and impact of physician and nurse disruptive behaviors in the
emergency department. J Emerg Med. 2012 Jul;43(1):139-148
Saxton R. Communication skills trainingto address disruptive physician behavior. AORNJ 2012
May;95(5):602-6011
Smetzer JL and Cohen MR. Intimidation: practitioners speak up about this unresolved problem. Jt Comm J
Qual Patient Saf. 2005 Oct;31(10):594-599.
Violato C et al. Changes in performance: a 5-year longitudinal study of participants in a multisource
feedback programme. Med Educ. 2008 Oct;42(10):1007-1013.
Wiggleton C et al. Medical students’ experiences of moral distress: development of a web based survey.
Acad Med 2010Jan;85(1):111-117