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You are an organized physician and your patients appreciate and expect your promptness. Your start times for rounds and clinic have been reviewed on several occasions with Bill a third year student on his comprehensive community clerkship. Routinely Bill shows up late, unprepared in ripped jeans and a base ball cap. What strategies would you use in your discussions with Bill?
Teaching Professionalism: Critical Conversations With Our Learners Northern Constellations 2013 Sudbury, Ontario January 19, 2013 James Goertzen MD MClSc CCFP Associate Professor , NOSM Medical Director Faculty Development, NOSM Laurel Snyder MD CCFP-EM Associate Professor, NOSM Kenora Site Director, NOSM
Conflict Disclosure Information: No financial or industry relationships to disclose. Creative Commons Attribution Noncommercial/No Derivative Works Canada License
Learning Objectives: ►Review contextual nature of professional behavior. ►Review critical role of preceptors in development of professionalism among learners. ►Provide effective strategies for dealing with learner unprofessional behavior.
Core Competency Professionalism is a core competency for students, residents and practicing physicians. Preceptors have critical roles in assisting their learners in the development of professionalism. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012.
Preceptor Challenges Though it is essential to provide feedback that addresses the professional behavior of learners, preceptors tend to be silent about professional expectations and rationalize lapses in professionalism. Goertzen J. Developing professionalism in our learners: Critical conversations. The Foundation for Medical Practice Education, 2011.
Professionalism: Biased Perception • As physicians we accept that we all have limits to our medical knowledge & expertise. • In contrast, physicians are less comfortable in acknowledging their professional failings, attitudes and behaviors. Ladouceur R. Family physicians and professionalism. Can Fam Physician 2009;55:961.
Define Professionalism:
Definition of Professionalism • Adherence to ethical practice principles. • Effective interactions with patients and with people important to those patients. • Reliability and accountability. Wilkinson T, Wade W. A blueprint to asses professionalism: Results of a systematic review. Acad Med 2009;84:551-8.
Definition of Professionalism • Effective interactions with people working within the health care system. • Commitment to maintenance and improvement of competence in self, others, and systems. Wilkinson T, Wade W. A blueprint to assess professionalism: Results of a systematic review. Acad Med 2009;84:551-8.
Definition of Professionalism • Professionalism can be difficult to define since is not limited to a static set of traits or characteristics. • Concepts of professionalism evolve with changes in social norms and patient expectations. Goertzen J. Developing professionalism in our learners: Critical conversations. The Foundation for Medical Practice Education, 2011.
Definition of Professionalism Professionalism is largely contextual and best understood as a series of behaviors within a clinical setting rather than a series of personal character traits or attributes. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Preceptor Challenges The challenge for preceptors is to provide relevance for their learners to the seemingly abstract concepts of professionalism within the clinical setting. Goertzen J. Developing professionalism in our learners: Critical conversations. The Foundation for Medical Practice Education, 2011.
Preceptor Challenges Within the clinical setting, patient problems rarely have black and white solutions. Learners often struggle to balance competing demands. Leong R. Do FP agree on what professionalism is? No. Can Fam Physician 2009;55:969-71.
Role of Preceptors Preceptors can assist learners by linking the principles of professionalism to their relationships with patients, with other physicians and health care professionals, with communities, and with self. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Attaining Competence Development of professionalism follows a parallel process to attaining clinical competence. Following the introduction of the principles of professionalism, application with in the clinical setting leads to competence. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Role Modeling Within the clinical setting, as students and residents internalize the concepts of professionalism, they are greatly influenced through the role modeling of their preceptors and other health care professionals. Cruess Rl, Cruess SR. Teaching professionalism: General principles. Med Teacher 2006;28(3):205-8
Role Modeling Effective preceptors exhibit the positive aspects of professionalism articulating the rational for their behaviors. They provide clinical opportunities for learners to exhibit professional behaviors along with time to reflect and discuss experiences. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Purposeful Preceptoring Involving learners in common clinical scenarios can be purposeful when the encounter is used as a catalyst for discussion of potential patient physician conflict such as requests for diagnostic tests or negotiating length of work absences. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Program Expectations It is important that programs clarify professional values and expectations with all learners. These expectations can act as a frame of reference by which lapses in professional behavior can be measured. Larkin GL, Binder L, Houry D, Adams J. Defining and evaluating professionalism: A core competency for graduate emergency medical education. Acad Emer Med 2002;9(11):1249-56.
You are an organized physician and your patients appreciate and expect your promptness. Your start times for rounds and clinic have been reviewed on several occasions with Bill a third year student on his comprehensive community clerkship. Routinely Bill shows up late, unprepared in ripped jeans and a base ball cap.
DISCUSSION: 1. How is Bill’s behavior unprofessional? 2. What strategies would you use when discussing your concerns with Bill?
DISCUSSION: How would you respond to Bill’s concern that it is unfair that his day starts earlier than the other students and preceptors in your community?
DISCUSSION: 4. Due to your responsibilities as Department Head for Family Medicine, you have been late for several of your clinics over the week. How would you respond to Bill’s comments that you are not always on time?
Learning Objectives: ►Review contextual nature of professional behavior. ►Review critical role of preceptors in development of professionalism among learners.
Lapses in Professionalism Lapses in professional behavior by learners are common and to be expected. It is through the experience of learning within a supervised clinical setting that the principles of professionalism can be truly integrated. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Learner Defenses Maladaptive defence mechanisms for unprofessional behavior: • Denial It was really a lapse. • Discounting He did yell at the nurse but she had it coming. • Distancing It was a mistake but we are all human. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Lapses in Professionalism A lapse in professional behavior can be transformed into a critical learning scenario when we have a collegial conversation with our learner and encourage reflection and assimilation of appropriate professional behaviors. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Collegial Conversation Assuming each clinical situation has one right answer may truncate dialogue, raising the likelihood that the learner will become defensive and limit exploration of alternatives to their behavior. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Collegial Conversation Allow the learner to initially explain the clinical context and rational for apparent unprofessional behavior. In many clinical situations, conflict may result from two or more divergent professional or personal values. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Context and Process When preceptors understand the clinical context and process used by the learner which resulted in the lapse of professionalism, effective educational interventions can be developed which are learner specific. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Context and Process Lapses in professionalism can be resolved when learners realize the negative impact of their behavior with patients, physician colleagues, other health care professionals, or the profession. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Lapses Occur on a Continuum Preceptors can address the majority of learner professional lapses with a confidential collegial conversation linked to a learner commitment to a change in their professional behavior. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Lapses Occur on a Continuum Following the collegial conversation, it is essential for the preceptor to provide the learner with further clinical encounters to address the lapse along with specific feedback and appropriate reinforcement. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Lapses Occur on a Continuum Lapses of a more serious nature require a staged response: collegial conversation, clarification of context and process resulting in the lapse, learner reflection, and planning of future educational activities. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Lapses Occur on a Continuum Documentation of the lapse is important. Learners should be notified of the consequences of not improving their behavior. Consult with your program director for support and to ensure you are following proper process. Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical Education: a teacher’s handbook, 2012
Your second year resident aspires to be an excellent physician. She is early at rounds & clinics along with reading around cases. She is always on her smart phone and you have received complaints from patients and nurses. When you observe a patient interview, she looks at her phone every time it buzzes with seemingly personal calls. What strategies would you use in your discussions with Janice?
DISCUSSION: 1. How is Janice’s behavior unprofessional? 2. What strategies would you use when discussing your concerns with Janice?
DISCUSSION: While discussing the impact of her phone use on patient care, Janice is searching for articles to prove that today’s youth are better multi-taskers than their older preceptors. You leave the meeting fuming and threatening to fail her. What do you do next?
Lapses in Professionalism It is critical that preceptors address lapses of professionalism during medical training since student unprofessional behavior is associated with residency difficulties and disciplinary action by licensing bodies in practice. Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med 2004;79(3):244-9.
UNPROFESSIONAL BEHAVIOR Purpose: Determine if medical students who demonstrate unprofessional behavior are more likely to have subsequent licensing board disciplinary action. Method: Case control study of all California medical school graduates disciplined by the California Medical Board from 1990-2000 (68 graduates). Control graduates (196) were matched by medical school graduation year and specialty. Variables examined included gender, undergraduate GPA, MCAT scores, National Board Examination Part 1 scores, negative excerpts describing unprofessional behavior in rotation evaluations, Deans letters for residency placement, and administrative correspondence. Out come variable was state board disciplinary action. Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med 2004;79(3):244-9.
UNPROFESSIONAL BEHAVIOR Results: Medical students graduated from 1943-89. 95% of disciplinary actions were for deficiencies in professionalism. Prevalence of negative excerpts in undergraduate evaluations was 38% and 19% in controls. Logistic regression analysis showed that disciplined physicians were more likely to have negative excerpts (Odds ratio 2.15; 95% CI 1.15-4.02; p = .02). Conclusion: Problematic behaviour in medical school is associated with subsequent disciplinary action by a state medical board. Professionalism is an essential competency that must be demonstrated for a student to graduate from medical school. Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med 2004;79(3):244-9.
UNPROFESSIONAL BEHAVIOR Purpose: Identify the domains of unprofessional behavior that in medical school that are linked to disciplinary outcomes in practice. Method: Case control study of all California medical school graduates disciplined by the California Medical Board from 1990-2000 (68 graduates). Control graduates (196) were matched by medical school graduation year and specialty. Negative excerpts describing unprofessional behavior in rotation evaluations, Deans letters for residency placement, and administrative correspondence were extracted. Qualitative analysis was carried out to clarify domains of behaviors that had been indentified as unprofessional by faculty. Teherani A, Hodgson CS, Banach M, Papadakis MA. Domains of unprofessional behavior during medical school associated with future disciplinary action by a state medical board. Acad Med 2005;80(10):S17-20.
UNPROFESSIONAL BEHAVIOR Results: Three domains of unprofessional behavior emerged that were significantly related to later disciplinary action: poor reliability and responsibility, lack of self-improvement and adaptability, poor initiative and motivation. Conclusion: Medical students experiencing difficulty in any of the three identified domains of unprofessional behavior were more likely to be disciplined in future practice. Study findings suggest that faculty include assessment of these behaviors in their evaluation of medical students. Teherani A, Hodgson CS, Banach M, Papadakis MA. Domains of unprofessional behavior during medical school associated with future disciplinary action by a state medical board. Acad Med 2005;80(10):S17-20.
Hidden Curriculum During medical training, learners must often grapple with the dissonance between espoused virtues and professional responsibilities and the actual behaviors exhibited by physicians in every day clinical practice. Gaufberg EH, Batalden M, Sands R, Bell SK. The hidden curriculum; What can we learn from third-year medical student narrative reflections? Acad Med 2010;85(11):1709-16.
Define Hidden Curriculum:
Hidden Curriculum Learning that occurs through informal interactions among students, faculty, and others and/or Learning that occurs through organizational and cultural factors intrinsic to training institutions. Gaufberg EH, Batalden M, Sands R, Bell SK. The hidden curriculum; What can we learn from third-year medical student narrative reflections? Acad Med 2010;85(11):1709-16.
