A Practical Approach to Developing a Professionalism Curriculum

1. A Practical Approach to Developing a Professionalism Curriculum MAME Workshop May 23, 2012

2. Disclosure • Drs. Frohna and McGregor have no conflicts of interest to report

3. 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.

4. My favorite Great Lake is • Huron • Ontario • Michigan • Erie • Superior

5. My Educational Domain • Institutional • Program • Undergraduate Medical Education • Nursing Education • Faculty Development • Other

6. What is your discipline? • Anesthesiology • Family Medicine • Internal Medicine • Neurology • OB-Gyn • Ophthalmology • Pediatrics • Psychiatry • Surgery • Other

7. Does your program have a formal professionalism curriculum? • Yes • No

8. Does your institution have a centralized professionalism curriculum? • Yes • No

9. Do you evaluate your curriculum? • Yes • No

10. What is your best method for evaluating your residents? • Critical event documentation • Global evaluation forms • Multisource feedback • OSCE • Peer evaluation • Professionalism mini-evaluation exercise (P-MEX) • Small group faculty evaluation

11. What is the next best method for evaluating your residents? • Critical event documentation • Global evaluation forms • Multisource feedback • OSCE • Peer evaluation • Professionalism mini-evaluation exercise (P-MEX) • Small group faculty evaluation

12. Have you previously attended a workshop on developing a professionalism curriculum? • No • Yes, at my institution • Yes, with my program director association • Yes, at another site

13. Getting to your definition of professionalism

14. Small Groups • Brainstorm characteristics of unprofessional behavior • Establish the elements that define professionalism • Report out

15. 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

16. 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 Approach Eds. Kern, Thomas, Hughes. 2009

17. 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

18. Step 2: Targeted Needs Assessment • Shared definition at an institutional level • Defining the local issues • Remediating unprofessional behavior • Advancing professionalism

19. 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

20. 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

21. Professionalism Excellence Humanism Accountability Altruism Ethical and Legal Understanding Communication Skills Clinical Competence (Knowledge of Medicine) Stern DT (ed.), Measuring Medical Professionalism, Oxford University Press, 2006

23. Step 3: Goals and Objectives • The Physician Charter • ABIM: Project Professionalism • ABP/APPD: Teaching and Assessing Professionalism • Royal College of Physicians • ACGME

24. 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.

26. 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 The Charter as a Blueprint for Program Directors

27. 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

28. 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.

29. 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.

30. 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 interns 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.

31. Case of JM

32. 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.

33. This is a serious lapse in professional behavior • Strongly Agree • Agree • Somewhat Agree • Neutral • Somewhat Disagree • Disagree • Strongly Disagree

34. 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.

35. This is a serious lapse in professional behavior • Strongly Agree • Agree • Somewhat Agree • Neutral • Somewhat Disagree • Disagree • Strongly Disagree

36. 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.

37. This is a serious lapse in professional behavior • Strongly Agree • Agree • Somewhat Agree • Neutral • Somewhat Disagree • Disagree • Strongly Disagree

38. 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?

39. JM facts • She does get called in. • When reached, she denies she knew she was on call.

40. This is a serious lapse in professional behavior • Strongly Agree • Agree • Somewhat Agree • Neutral • Somewhat Disagree • Disagree • Strongly Disagree

41. 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.”

42. This is a serious lapse in professional behavior • Strongly Agree • Agree • Somewhat Agree • Neutral • Somewhat Disagree • Disagree • Strongly Disagree

43. 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.

44. This is a serious lapse in professional behavior • Strongly Agree • Agree • Somewhat Agree • Neutral • Somewhat Disagree • Disagree • Strongly Disagree

45. Dénouement • Back up called • She had to pay back call to back up • Professionalism sign off deferred until six months into fellowship • Precedent set

47. Designing Professionalism Cases • Select a case • Prepare for discussion • Decide how to reveal the case and the conflicts • Prepare a short discussion

48. 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

49. 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

50. 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