Teaching and Assessing Medical Professionalism at Mayo Clinic

Paul S. Mueller, MD, MPH

Associate Professor of Medicine

Objectives

• Define professionalism

• Describe the rationale for teaching and assessing professionalism

• Describe methods for teaching and assessing professionalism

• Describe Mayo Clinic experiences with teaching and assessing professionalism

What is professionalism?

Hallmarks of a profession

• Competence in a specialized body of knowledge

• Acknowledgment of specific duties and responsibilities

• Autonomy to train, admit, monitor, and discipline its members; a privilege granted by society through licensure

Physicians must be:

1. Altruistic

2. Knowledgeable

3. Skillful

4. Dutiful

AAMCMedical School Objectives

Accreditation Council for GMEGeneral competencieshttp://www.acgme.org/outcome/comp/compFull.asp#5

ABIM/ACPCharter on Medical ProfessionalismAnn Intern Med 2002;136:243-246 and Ann Intern Med 2003;138:839-841

Less than 15 months after its release, the

Charter was endorsed by more than 90

specialty societies.

8

Clinical competence (knowledge)

Communication skills

Sound ethics

Excellence

Humanism

Accountability

Altruism

Professionalism

From: Stern D., ed. Measuring Professionalism (New York: Oxford University Press, 2006).

Reflection CommunicationTeamwork

Professionalism at Mayo ClinicHistorical perspective

“The best interest of the patient is the only interest to be considered…

and in order that the sick may benefit from advancing knowledge

a Union of Forces is necessary”

William J. Mayo, MDJune 1910

3000083-3

Altruism Humanism Excellence

Mayo’s primary value“The needs of the patient come first.”

Mayo’s mission“Mayo will provide the best care to every patient every day through integrated clinical practice, education, and research.”

The Mayo Clinic Model of Care

What makes Mayo unique?• Not smart physicians or

breadth of science

• Rather:– Patient-centered care

– Multidisciplinary teamwork

– Allied health personnel

– Remarkable facilities

– Unique culture and ethos

Should professionalism be taught?

Patient expectionsIdeal physician behaviorsMayo Clin Proc. 2006;81:338-344.

192 patients in 14 specialty settings:• Confident: engenders trust• Empathetic: “Understands my feelings”• Humane: compassionate and kind• Personal: patient is a person, not a disease• Forthright: “Tells me what I need to know”• Respectful: “Takes my input seriously”• Thorough: conscientious and persistent

Mayo Clinic patient satisfaction

High correlation

High satisfaction

2006 PRC 3-Site Outpatient Satisfaction, n=36500

Reasons for concern

• Professionalism lapses

• Conflicts of interest among physicians common

• Declining trust in the medical profession

Reasons for concern

• Unprofessional behavior in training associated with later disciplinary action by licensing boards (NEJM 2005;353:2673-2682)

• Nearly all physician leaders and nurses have experienced disruptive physician behavior (Phys Exec 2004;Sept-Oct:6-14, Am J Nurs 2005;105:54-64, AORN J 2001;74:317-331)

Consequences of disruptive physician behaviorhttp://cme.medscape.com/viewarticle/590319

• Reduced employee satisfaction, morale and productivity and increased employee turnover

• Reduced communication, teamwork, and efficiency and increased costs

• Decreased learner satisfaction, burnout, depression and unprofessional behavior

Reasons for optimism

Professionalism is not simply innate.

Professionalism can be taught“Advancing Education in Medical Professionalism.” ACGME Outcome Project, 2004.

• Formal and informal curricula influence professional attitudes and beliefs, moral reasoning, and behaviors

• Role models influence attitudes and behavior; “hidden curriculum”

Professionalism is associated with important outcomes“Advancing Education in Medical Professionalism.” ACGME Outcome Project, 2004.

• Increased patient satisfaction and trust

• Increased patient treatment adherence

• Patients more likely to “stay with” and recommend physician

• Fewer patient complaints

• Less patient litigation

• Overall physician excellence

Should professionalism be taught? Yes.“Advancing Education in Medical Professionalism.” ACGME Outcome Project, 2004

• We are a profession • AAMC, ACGME,

ABIM, and JCAHO recommendations and requirements

• Expectations of patients and society

• Formal and informal curricula influence professional attitudes and beliefs, moral reasoning, and behaviors

• Associated with important outcomes

How do you teach professionalism?

25

Clinical competence (knowledge)

Communication skills

Sound ethics

Excellence

Humanism

Accountability

Altruism

Professionalism

From: Stern D., ed. Measuring Professionalism (New York: Oxford University Press, 2006).

Consider the elements of

professionalism.

Teaching professionalismMethods“Advancing Education in Medical Professionalism.” ACGME Outcome Project, 2004

• Lectures

• Discussion groups

• Role plays, simulation

• Experiential (eg, clinical setting)

• Team learning

• Role modeling

• Independent learning

Teaching professionalismStrategiesJAMA 2001;286:1067-1074

• Establish a climate of humanism

• Be practical and relevant

• Recognize and use seminal events

• Role model

• Encourage self-reflection

• Address the “hidden” curriculum

Should professionalism be assessed? Yes.• Professionalism can be assessed (Stern

DT. Measuring Professionalism; Oxford, 2006)

• Formative and summative feedback– “They don’t respect what you expect; they

respect what you inspect.” (Cohen JJ. Forward. In Measuring Professionalism; Oxford, 2006)

• Evaluate education programs

Failure to assess sends conflicting messages to learners, physicians, and patients.

How do you assess professionalism?

Assessing professionalism Stern D, ed. Measuring Professionalism; Oxford, 2006

“Most practicing physicians observe each others’ behaviors only in the

hallways and conference rooms--rarely with patients. The solution to this problem is to expand the number of

observers and the settings in which they observe.

Effective assessment of professionalism Stern D, ed. Measuring Professionalism; Oxford, 2006JAMA 2008;300:1326-1333

• Multiple observers and instruments

• Variety of settings• Realistic context• Situations that

involve conflict• Not overly stringent

• Transparency; learners know purpose of assessment

• Symmetry; all levels of the hierarchy are assessed

What do you do with the information?• Formative feedback

• Summative feedback

• Reward exemplars

• Evaluate professionalism education programs and generate research hypotheses

Using a “professionalism portfolio”

Teaching and assessing professionalism at MayoAll levels:• Allied health staff• Administrators• Medical students• Resident physicians

and fellows• Faculty

Mayo Medical SchoolRequired (school year) professionalism elements• Bioethics core

curriculum(1,3)• Anatomy (1):

cadaver as first patient, peer review

• Professionalism reflections (2)

• “Safe Harbor” professionalism program (3)

• Assessment (1-4)– Peer and vertical

• Result: portfolio on professionalism incorporated into the Dean’s letter

Mayo Medical SchoolElective

• Journal club

• MD Connect (new student publication)

• 1-month “selective”

Mayo School of Graduate Medical EducationResidency and fellowship training

Required for all:• ACGME core

competency for all programs

• Orientation module on professionalism

• Web-based curriculum in development

DOM additional requirements:

• Core curriculum• M+M ethics and

professionalism sessions

• Professionalism OSCEs

• Assessment

Assessing internal medicine resident professionalism at Mayo• Tests of knowledge

• OSCEs

• Mentor review of “lapses”

• Patient complaint review

• Electronic 360-degree assessments by peers, senior residents, faculty, others

• Result: professionalism portfolio

Electronic assessment

Electronic assessment

These 2 questions have the highest inter-rater reliability.

Electronic assessment of professionalism at MayoJAMA 2008;300:1326-1333

• The mean score for top 20% (“highly professional”) IM residents was 4.40, and for the remainder was 4.02 (P<.001)

• High professionalism scores were associated with greater knowledge, skills, and conscientious behaviors

Mayo facultyRequired

• Periodic web-based and interactive modules

• CALD program– Professionalism module– Communication module

• Note ABIM maintenance of certification• Assessment: attendance, learner

evaluations,360-degree reviews

CALD professionalism module

• Reflective listening

• Attributes of professionalism

• Review data supporting professionalism

• Recognizing and responding to professional and unprofessional behavior

• Collaborate with a psychologist

• Feedback: outstanding

CALD professionalism module

CALD communication module

• Communication a core competency • Reflective listening re-emphasized• 3-function model:

– Relationship building– Information gathering– Patient education (eg, new diagnosis)

• Didactic, video vignettes, and role play• Feedback: outstanding

CALD communication module

Mayo facultyElective

• Professionalism conferences

• Annual ethics conference

• Medical grand rounds

Mayo allied health staffMinnesota Medicine. 2007;90:47-49.

• Nearly 3000 DOM allied health staff

• Didactic lectures, video vignettes, and role plays

• >95% reported benefit• Increased patient

satisfaction in all divisions

Teamwork is REAL

• The nexus of professionalism and quality is teamwork

• Enterprise-wide program

• Common language• Outcomes

measured

• Relationship building

• Effective communications

• Assertion

• Leading with mutual respect

Teamwork

Relationship BuildingWork in partnership with all colleagues for the genuine

concern and well being of our patients

and othersEffectiveCommunications

Listen for understanding

to the diverse opinionsof others

Assertion

Empowered to voicemy opinion and trust

thatit will be heard

Leading withMutual Respect

Treat one another with respect and courtesy

Acknowledge and value the contributionsof others

Tools

Reflective

Listening

PEARLS

SBARPositiv

eAsserti

on

Conclusions

• Medical professionalism is a core competency

• Professionalism is associated with important clinical outcomes

• Professionalism should be taught and assessed

• Professionalism can be taught, learned and assessed

Thank youmueller.pauls@mayo.edu

“The best interest of the patient is the only interest to be considered…

and in order that the sick may benefit from advancing knowledge

a Union of Forces is necessary”