S. DAWSON THEOGARAJ 30TH ANNUAL LECTURE

Mary H. McGrath, MD MPH

Professor of Surgery

University of California San Francisco

May 7, 2015

S. Dawson Theogaraj, MD FACS

1976 First successful hand replant in Virginia

Wyndell

Merritt

Charlie McDowell

DawsonTheogaraj

S. DAWSON THEOGARAJ 30TH ANNUAL LECTURE

HOW CAN WE TEACH ACCOUNTABILITY AND PROFESSIONALISM?

Mary H. McGrath, MD MPH

Professor of Surgery

University of California San Francisco

May 7, 2015

Disclosure

Dr. McGrath and collaborators have funding from The Josiah Macy Foundation IMAP professionalism grant to study faculty development in a professionalism learning community.

This presentation at a glance -

• Definition of the term • Why are we being told we must teach accountability?

• Review past teaching successes and failures

• Potential blueprint for the future

 

Four dimensions of Accountability

1. Responsibility – “a duty that binds to the course of action”

2. Answerability – “being called to account”3. Trustworthiness – “a trait of being

worthy of trust and confidence”4. Liability – “being legally bound to a debt

or obligation”

Source of definitions: Webster’s Dictionary

Question for Attendings

Were you taught professionalism and accountability during your surgical training?

a) Yesb) No

Question for Attendings

How did you learn accountability in your training?a) Lectures / Grand Roundsb) Seminars / discussions / roundsc) M & M Conferenced) Observing other surgeon(s) / role modee) I had it before I started trainingf) None of the above

Question

Do you think professionalism and accountability need to be part of the formal curriculum for surgery residents today?

a) Yesb) No

Question

Are surgical trainees today less committed to professional values?

a)No, they are the same as in the pastb)Yes, they are faced with more challenges

to professional values

Question

Which of the following are primary challenges to the professional development of surgical trainees?

a) The social and ethical fabric nationallyb) Resident work hour restrictionsc) The health care delivery system including

employment optionsd) Student indebtednesse) Absence of training in accountability and

professionalism

To summarize . . .

International Social Survey Programme survey (ISSP)March 2011 through April 2013 (InternationalSocial Survey Programme Research Group.Supported by RWJ Foundation, and NIMH

Public Trust in Physicians — U.S. Medicine in International PerspectiveRobert J. Blendon, Sc.D., John M. Benson, M.A., Joachim O. Hero, M.P.H.

• project supported by Robert Wood Johnson Foundation & National Institute of Mental Health

• polling data on public trust in U.S.physicians and medical leaders 1966-2014• public trust in the leaders of the U.S.medical profession has declined sharply

over the past half century. • In 1966, 73% of Americans said they had great confidence in the leaders of

the medical profession. • In 2012, 34% expressed this view

• only 23% express “a great deal” or “quite a lot” of confidence in the system (Gallup 2014).

“We believe that the medical profession and its leaders are a contributing factor.”

“The US is unique among the countries in that it ranks near the bottom in the public’s trust in the country’s physicians but near the top in patients’ satisfaction with their own medical treatment.”

n engl j med 371;17 nejm.org october 23, 2014

Public lack of trust in medical

institutions and delivery systems

Organized medicine’s response

• Evidence based medicine• Patient safety• Quality of care• Team based care• Physician workforce• Disclosure of errors• Physicians need to

rediscover professionalism• Teach and assess physician

professionalism

Accountability for what?

Evolution of the curriculum in professionalismPast Present

Methods• Group discussion• Written reflections• Case based narratives

Topics• Communication, cultural

diversity, substance abuse, privacy, disclosing error, disparities, health delivery systems, team training

• Altruism, integrity, compassion, respect, accountability, responsibility.

Methods• Clinical setting with real

patients, real illness• Exposure to role-model MDs• Guidance of faculty mentors• “teachable moment”

Topics• same

What’s Missing?

JAMA. 2010;304(24):2732-2737

A Behavioral and Systems View of ProfessionalismLesser, CS, Lucey, CR, Egener B, et al.JAMA. 2010;304(24):2732-2737

A Behavioral and Systems View of ProfessionalismLesser, CS, Lucey, CR, Egener B, et al.JAMA. 2010;304(24):2732-2737

Individual Physician Behaviors

A Behavioral and Systems View of ProfessionalismLesser, CS, Lucey, CR, Egener B, et al.JAMA. 2010;304(24):2732-2737

A Behavioral and Systems View of ProfessionalismLesser, CS, Lucey, CR, Egener B, et al.JAMA. 2010;304(24):2732-2737

Organizational Behaviors (practice settings, professional organizations, physician advocacy

We do not act rightly because we have virtue or excellence but rather we have those because we have acted rightly. We are what we repeatedly do. —Aristotle

. . . an art won by training and habituation

Accountability - not a laudable attribute, but a behavioral

competency

Virtue Behavior Teachable skill

Trustworthiness

Conscientious performance of tasks

Time management skills

Responsibility

Responding to pages constructively

Communication skills Emotional intelligence

Creating a Professionalism Learning Community (PLC) to Promote Skills Development of Faculty

through Case-Based Workshops 

Tess Lang, MD; Maria A.Wamsley, MD; Arianne Teherani, PhD; Mary H. McGrath, MD MPH; Louise Aronson, MD MFA; Rachael Lucatorto, MD; Sandrijn van Schaik, MD PhD; Christine Burke; Maxine Papadakis, MD; Patricia O’Sullivan, MS EdD; Catherine Lucey, MD

Funded by The Josiah Macy/IMAP professionalism grant

Discussion after the moment

Peer coaching

De-escalation

Mental models and triggers

Conflict resolution

Crisis communication

Candid conversations about unprofessional behavior

Preventing Risks Of Professionalism Slips (PROPS)Anticipating unprofessional behavior before it happensPlace yourself in their situation Recommend alternative strategies Orient them towards sustainable behavior Provide encouragement Structure resources into their work * Regulating Professionalism in the Moment Disrupting unprofessional behavior when it happensRecognize and call out the emotionRelate to the individual in questionRecalibrate towards correct behaviorRedirect the conversation

 

Summary: Framework for teaching professionalism

• Clarify domains of a physician’s commitment• Individual physician’s personal competency• Social contract with institutions and society (disparity, access, costs,

systems improvement)

• Articulate ideals and values as observable behaviors• Identify sets of teachable skills that enable the behavior • Develop faculty trained to teach the skills• Provide for practice of the skills with guidance, ie feedback

and reflection• Appreciate the “hidden curriculum” of attending role

modelling and importance of same standards of behavior

Thank you!