Presentation - Michigan Association for Medical Education

Report
A Practical Approach to
Developing a
Professionalism Curriculum
MAME Workshop
May 23, 2012
Disclosure

Drs. Frohna and McGregor have no
conflicts of interest to report
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.
My favorite Great Lake is
1.
2.
3.
4.
5.
Huron
Ontario
Michigan
Erie
Superior
57%
29%
7%
7%
0%
1
2
3
4
5
My Educational Domain
1.
2.
3.
4.
5.
6.
Institutional
Program
Undergraduate
Medical Education
Nursing Education
Faculty
Development
Other
47%
33%
13%
7%
1
2
3
0%
0%
4
5
6
What is your discipline?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Anesthesiology
Family Medicine
Internal Medicine
Neurology
OB-Gyn
Ophthalmology
Pediatrics
Psychiatry
Surgery
Other
40%
20%
20%
0%
1
2
3
0%
0%
0%
4
5
6
7%
7%
7%
7
8
9
10
Does your program have a formal
professionalism curriculum?
1.
2.
Yes
No
50%
1
50%
2
Does your institution have a centralized
professionalism curriculum?
1.
2.
Yes
No
71%
29%
1
2
Do you evaluate your
curriculum?
1.
2.
Yes
No
50%
1
50%
2
What is your best method for
evaluating your residents?
1.
2.
3.
4.
5.
6.
7.
Critical event
documentation
Global evaluation forms
Multisource feedback
OSCE
Peer evaluation
Professionalism minievaluation exercise (PMEX)
Small group faculty
evaluation
43%
36%
7%
1
2
3
0%
0%
4
5
7%
7%
6
7
What is the next best method
for evaluating your residents?
1.
2.
3.
4.
5.
6.
7.
Critical event
documentation
Global evaluation forms
Multisource feedback
OSCE
Peer evaluation
Professionalism minievaluation exercise (PMEX)
Small group faculty
evaluation
42%
25%
17%
0%
1
8%
8%
6
7
0%
2
3
4
5
Have you previously attended a workshop
on developing a professionalism curriculum?
No
2. Yes, at my institution
3. Yes, with my
program director
association
4. Yes, at another site
1.
53%
20%
13%
1
2
3
13%
4
Getting to your definition
of professionalism
Small Groups
Brainstorm characteristics of
unprofessional behavior
 Establish the elements that define
professionalism
 Report out

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

Six Step Approach to Curriculum
Development

Problem Identification
and General Needs
Assessment
– Health Care Problem
– Current v Ideal Approach

Goals and Objectives
Educational Strategies
– Content
– Method

Implementation
– Resources
– Barriers
– Delivering Curriculum
Targeted Needs
Assessment
– Learners
– Learning Environment



Evaluation and Feedback
– Learners
– Program
Curriculum Development for Medical Education: A Six-Step Approach
Eds. Kern, Thomas, Hughes. 2009
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
Step 2: Targeted Needs
Assessment
Shared definition at an institutional
level
 Defining the local issues

– Remediating unprofessional behavior
– Advancing professionalism
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

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
Professionalism
Altruism
Accountability
Humanism
Excellence
Ethical and Legal Understanding
Communication Skills
Clinical Competence (Knowledge of Medicine)
Stern DT (ed.), Measuring Medical Professionalism,
Oxford University Press, 2006
Step 3: Goals and Objectives
The Physician Charter
 ABIM: Project Professionalism
 ABP/APPD: Teaching and Assessing
Professionalism
 Royal College of Physicians
 ACGME

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.
The Charter as a Blueprint for
Program Directors


Promoting Professionalism: A
Definition
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 in Patient Care
–
–
–
–



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
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
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.
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.
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.
Case of JM
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.

This is a serious lapse in
professional behavior
1.
2.
3.
4.
5.
6.
7.
Strongly Agree
Agree
Somewhat Agree
Neutral
Somewhat
Disagree
Disagree
Strongly Disagree
38%
15%
15%
15%
8%
8%
0%
1
2
3
4
5
6
7
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.

This is a serious lapse in
professional behavior
1.
2.
3.
4.
5.
6.
7.
Strongly Agree
Agree
Somewhat Agree
Neutral
Somewhat
Disagree
Disagree
Strongly Disagree
38%
15%
8%
1
2
8%
8%
3
4
15%
8%
5
6
7
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.

This is a serious lapse in
professional behavior
1.
2.
3.
4.
5.
6.
7.
Strongly Agree
Agree
Somewhat Agree
Neutral
Somewhat
Disagree
Disagree
Strongly Disagree
24%
24%
18%
6%
1
18%
6%
2
3
6%
4
5
6
7
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?
JM facts
She does get called in.
 When reached, she denies she knew she
was on call.

This is a serious lapse in
professional behavior
1.
2.
3.
4.
5.
6.
7.
Strongly Agree
Agree
Somewhat Agree
Neutral
Somewhat
Disagree
Disagree
Strongly Disagree
94%
6%
1
2
0%
0%
0%
0%
0%
3
4
5
6
7
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.”

This is a serious lapse in
professional behavior
1.
2.
3.
4.
5.
6.
7.
Strongly Agree
Agree
Somewhat Agree
Neutral
Somewhat
Disagree
Disagree
Strongly Disagree
87%
7%
1
2
7%
3
0%
0%
0%
0%
4
5
6
7
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.

This is a serious lapse in
professional behavior
1.
2.
3.
4.
5.
6.
7.
Strongly Agree
Agree
Somewhat Agree
Neutral
Somewhat
Disagree
Disagree
Strongly Disagree
50%
21%
14%
1
2
3
14%
4
0%
0%
0%
5
6
7
Dénouement
Back up called
 She had to pay back call to back up
 Professionalism sign off deferred until six
months into fellowship
 Precedent set

Designing Professionalism Cases
Select a case
 Prepare for discussion
 Decide how to reveal the case and the
conflicts
 Prepare a short discussion

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

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

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
Designing Professionalism Cases
Select a case
 Prepare for discussion
 Decide how to reveal the case and the
conflicts
 Prepare a short discussion

– Review learning objectives
– Tie back to Physician Charter
– Summarize discussion
Small Groups
Design your own case!!!
Step 5: Implementation
Political Support/buy-in
 Resources

– Faculty
– Time

Implementing, Sustaining, and Improving
the Curriculum
Teaching Strategies
Setting expectations
 Appreciative inquiry
 Cultural norm setting

– Retreats, Play of the Week
– P.A.D.S.
Lectures/Curriculum
 Reflective exercises
 Professionalism series

St. Christopher’s Hospital for
Children
Target audience –clinical fellows
 Three, small group didactic – followed by
case-based reflection (90 minute sessions)
 Curriculum – 1/3 of ABP/APPD Guide per
session
 Evaluation – Retrospective pre-test and
post-test

University of Wisconsin

Noon conference facilitated discussions,
focusing on each of the sections of the
APPD-ABP book:
– Content discussion (5 min)
– Vignettes
– Longer cases
Newer strategies

Peer review system (Bonder J, Elwood D,
Heckman J, et al. PM&R 2010;2(2):117-24)

Reader’s Theatre – scripted faculty
development (Bell SK, Wideroff M, Gaufberg L.
Pt Ed & Couns 2010;80(3):354-7.)

Wikis - (Varga-Atkins T, Dangerfield P, Brigden
D. Med Teach 2010;32(10):824-9.)
Step 6: Evaluation and
Feedback

The Learners
– Evaluations can also help set professionalism
expectations
– Role of reflection

The Program
Evaluating Learners
360 or multi-source evaluations
 Nursing evaluations
 Peer evaluations
 Small groups*
 Professionalism mini-evaluation exercise
(P-MEX)**

*Haidet et al. The Role of the Student-Teacher Relationship in the Formation of Physicians The
Hidden Curriculum as Process. J Gen Intern Med 2006; 21:S16–20.
**Cruess R, McIlroy JH, Cruess S, Ginsburg S, Steinert Y. The professionalism mini-evaluation
exercise: A preliminary investigation. Acad Med 2006;81:S74-8.
Evaluating Learners (cont)
Critical events & reflection
 Professionalism Series
 Conscientiousness index*

*McLachlan JCP, et al. The conscientiousness index: A novel tool to explore students’
professionalism. 2009 Acad Med 84:559-565
Evaluations
Importance of Reflection
Faculty and residents
need to gain
additional experience
in observing and
reflecting on their
own and others’
behavior
 Learners should be
encouraged to share
their stories during all
teaching sessions

Evaluating the Curriculum
Satisfaction
 Examine trends on global, peer, 360
evaluations over time
 Changes in behaviors (need mechanism to
monitor)
 Reflections

Six Step Approach to Curriculum
Development

Problem Identification
and General Needs
Assessment
– Health Care Problem
– Current v Ideal Approach

Goals and Objectives
Educational Strategies
– Content
– Method

Implementation
– Resources
– Barriers
– Delivering Curriculum
Targeted Needs
Assessment
– Learners
– Learning Environment



Evaluation and Feedback
– Learners
– Program
Curriculum Development for Medical Education: A Six-Step Approach
Eds. Kern, Thomas, Hughes. 2009
It’s ALL our jobs!
Thanks!!

John Frohna
– [email protected]

Rob McGregor
– [email protected]
Some sample ways of
teaching this
Curriculum

233 program directors surveyed
– 1/3 no curriculum or formal professionalism
experience
– ~1/3 combined with ethics
– ~1/3 independent curriculum

Barriers –
– Faculty expertise / Need for faculty
development
– Curricular crowding
Lang CW et al. Ethics and Professionalism in the Pediatric Curriculum: A Survey of Pediatric
Program Directors Pediatrics 2009.
Philadelphia Professionalism
Series
Children's Hospital of Philadelphia (CHOP)
Residents
 St. Christopher’s Hospital for Children
(SCHC) Fellowships

CHOP Model
Ten, monthly sessions at 7:30-8:30 AM
 20-24 house staff and 3-4 preceptors
 Ten major themes (6 from the ABP/APPD
Guide)

CHOP Series





All sessions rated “very helpful, helpful” by at least 50%
Attendance mean – 5.0 (range 1-9)
Numbers per group – 9.43 (range5-10)
Qualitative outcomes – global –societal topics not as well
received
Best received
– Fatigue and Burnout and Their Impact on Clinical Care**
– Coping with Medical Errors*

Small group important
** Designed internal module
SCHC
75% attendance
 Likert scale 4.2 acceptance
 Pre-post test scores still being processed
 Adding similar sessions for the residents
 Fellows may function as teachers in next
year’s iteration


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