Putting Professionalism into Practice

1. Putting Professionalism into Practice Andy Anderson, MD, MBA Program Director and Vice Chair, Department of Medicine Assistant Dean for Medical Education, NorthShore University HealthSystem Clinical Professor of Medicine, University of Chicago Pritzker School of Medicine

2. Hidden Curriculum • The informal and unplanned experiences residents encounter and learn from in an effort to survive their residency with minimal pain and struggle • The implied set of values residents observe in their day-to-day interactions

3. Medical Professionalism Physician Charter Fundamental principles • Primacy of patient welfare • Patient autonomy • Social justice

4. Primacy of Patient Welfare • Dedication to serving the interest of the patient • Altruism contributes to the trust that is central to patient-physician relationship • Market forces, societal pressures and administrative exigencies must not compromise this principle

5. Patient autonomy • Physicians must have respect for patient autonomy • Physicians must be honest with their patients and empower them to make informed decisions about their treatment • Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care

6. Social justice • The medical profession must promote justice in the health care system, including the fair distribution of health care resources • Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion or any other social category

7. Putting Professionalism into Practice Grantfunded by ABIM Foundation Diane Wayne Aashish Didwania Kevin O’Leary R. Andy Anderson Northshore University Health System Vineet M. Arora Jeanne M. Farnan Shalini T. Reddy Holly J. Humphrey University of Chicago Pritzker School of Medicine Feinberg School of Medicine Northwestern University University of Chicago Pritzker School of Medicine

8. Background • Medical education is a transformative process

9. Hafferty, F. Measuring professionalism: a commentary. In: Stern DT, ed. Measuring Medical Professionalism. New York, NY: Oxford University Press; 22006:281-306

10. * p<0.05 Reddy, et al. 2006

11. Expanded Work to Interns in 3 Chicago Programs • Partnered with Northwestern University & NorthShore University HealthSystem • Participation and perception of behaviors before and after internship • Participation in egregious behaviors unchanged…

12. Participation in On-Call Unprofessional Behaviors Site adjusted logistic regression in press Academic Medicine

13. What is the most important professionalism issue? Survey of MS3 students

14. Summary of Earlier Work • More work to understand effect of possible role models, esp hospitalists • Interventions should focus on patient care behaviors in internal medicine • Disparaging ER and PCP for missed findings • Blocking admissions • Misrepresenting tests as urgent • Try new ways to educate to avoid ‘hostility’ toward professionalism teaching • Use of video scenarios with interactive debrief

15. ABIM Grant Proposal • Ascertain participation and perception of unprofessional behaviors among hospitalists at our 3 institutions • Develop and implement a video-based educational intervention to reduce on-call unprofessional behaviors • Hospitalists and residents

16. Team Progress to Date • IRB approval received at 3 institutions • Developed and implemented hospitalist survey • Data collection ongoing • Interim analysis today • Script development & filming underway

17. Very Interim Analysis • Response rate: 52.8% (47/89) from 2 of 3 sites • No site differences in analysis to date • Typical respondent • Male (55%) • Attended US medical school (88%) • Completed residency after 2000 (88%) • 1-4 years spent with current group (54%) • Unfamiliar with residents (68%) • Planning longterm career as hospitalist (77%)

18. Interactions with Students 1Wilcoxon rank sum test to compare perception by whether participated in behavior

19. Patient Care Behaviors 1Wilcoxon rank sum test to compare perception by whether participated in behavior

20. Other Notable Behaviors 1Wilcoxon rank sum test to compare perception by whether participated in behavior

21. Participation in Behaviors & Familiarity with Residents All P<0.05

22. Next Steps • Complete data collection & analysis • Appears that higher participation in unprofessional behaviors related to patient care • Explore role of ‘familiarity with residents’ • Faculty who are familiar with residents  lapses in professionalism (blurred boundaries) • Faculty who engage in unprofessional behavior  become popular with residents? • Mechanisms of ‘familiarity’ • Trained at institution? Involved in education? Younger? ….

23. Video Scenario Development • 3 scripts developed & reviewed • Housestaff & faculty at 3 sites • 3 external experts • Patient care behaviors • Disparaging ED/ PCP • Misrepresenting test as urgent • Blocking / celebrating blocked admission • Actors and videographer recruited • Prelim shooting to begin this week! • 2 residents with film/TV experience

24. Questions? Suggestions?

25. ABIM Foundation Dan Wolfson Amy Cunningham Hospitalist Leaders Dr. Mark Williams Dr. David Meltzer Dr. David Lovinger Project Staff Meryl Prochaska James Iwaz Mark Saathoff Sara Tanaka Acknowledgments

26. Hospitalist Survey • Survey development and administration • 46-item survey • Reviewed by site investigators for institutional relevance and face validity • Reported observation, participation, and perception of unprofessional behaviors • Likert scale (1 = unprofessional, 5 = professional) • Example questions • Patient care item: Ordering a routine test as “urgent” in order to get it expedited • Trainee item: Not correcting someone who mistakes a student for a physician