Teaching and Assessing Patient Centred Professionalism in the Undergraduate Curriculum

1. Teaching and Assessing Patient Centred Professionalism in the Undergraduate Curriculum Trudie Roberts Kathy Boursicot www.medev.ac.uk

2. Workshop format • Setting the scene – What is Professionalism in the 21st century • Defining patient centred professionalism • Development of professionalism in undergraduates • How to teach professionalism in context? • Methods for assessing professionalism • Devising an assessment strategy? • General discussion www.medev.ac.uk

3. What is Professionalism in the 21st Century www.medev.ac.uk

4. Content • Conceptualisation and Definitions • Why teach and assess professionalism? • What do we mean by professionalism today? • Changes in the workplace • Changes in workforce www.medev.ac.uk

5. What is Professionalism? • Profession (Latin) meaning: “speaking forth” • In the future everyone will be a professional www.medev.ac.uk

6. Why do we need to teach and assess professionalism? • Most complaints against doctors are because of conduct not competence. • Students do not arrive at medical school with a full complement of professional behaviours - needing only teaching of medical knowledge and skills. • All students are vulnerable to lapses in professional behaviour and can benefit from explicit systematic attention in this domain. • Evidence that there may be a deterioration in professional attitudes: idealism → cynicism. • Recent evidence about lack of professionalism in a student’s UG career is linked to problems later in their careers (Papadakis) www.medev.ac.uk

7. Changing world of work • Can medical professionalism survive in the modern healthcare environment? • Erosion of autonomy • Employee/technician • Increased accountability • EWTD • Up-skilling of other healthcare workers www.medev.ac.uk

8. Changing world of work • Unique point in time – 4 distinct groups of workers Duxbury 2002 www.medev.ac.uk

9. Types • Traditionalists • Baby boomers • Generation X • Generation Y www.medev.ac.uk

10. Pre 1946 Traditionalists • Totally committed to the ‘company’ • Horrified by unemployment • Would go down with the ship • Typified by unquestioning loyalty www.medev.ac.uk

11. 1947- 1967 Baby Boomers • Workaholics • Accept stress as part of the job • Used to belt tightening and sacrifice • Work predicated on delayed gratification • Value titles and status symbols www.medev.ac.uk

12. 1968 – 1980 Generation X • Place more importance on career than personal life • Mistrustful and suspicious of employers • Products of downsizing and cost cutting • Usually had experience of many jobs • Not committed to a particular company • Want immediate gratification www.medev.ac.uk

13. 1980 – 1995 Generation Y • Want a balance of work and personal life • Take time off for personal life enhancement • Demand flexible environments and benefits • Do not expect a job for life • Expanding job market and shrinking work force • Expect and get immediate reward www.medev.ac.uk

14. How do our students and our Faculty interpret professionalism? www.medev.ac.uk

15. Workshop format • Setting the scene – Professionalism in the 21st century • Defining professionalism • How to teach professionalism • How to assess professionalism and ensure fitness to practice • Summary www.medev.ac.uk

16. Conceptualisation Themes from the literature • Interpersonal professionalism - meeting the demand for adequate contact with patients • Altruism, respect, integrity, honesty • Public professionalism – meeting the demands society • Accountability, excellence, self regulation • Intrapersonal professionalism – meeting the demands to function as an individual in a profession • Lifelong learning, self awareness, morality Van de Camp et al 2004 www.medev.ac.uk

17. Definitions • UK’s GMC • Duties of a Doctor • Good Medical Practice • CanMEDS • Medical expert, communicator, collaborator, manager, health advocate, scholar, professional • ABIM/ACP/EFIM – “A Physician Charter” • Patient welfare • Patient autonomy • Social justice www.medev.ac.uk

18. Tomorrow’s Doctors 2003 • Attitudes and behaviour that are suitable for a doctor must be developed. • The core curriculum must set out the essential knowledge, skills and attitudes students must have by the time they graduate. • Only those students who are fit to practice as doctors should be allowed to complete the curriculum. • Students who do not meet the necessary standards in terms of demonstrating appropriate knowledge , skills, attitudes and behaviour must be advised to follow alternative careers. www.medev.ac.uk

19. Patient Centred Professionalism www.medev.ac.uk

20. www.medev.ac.uk

21. Definitions RCP Medical professionalism – definition Medical professionalism signifies a set of values, behaviours, and relationships that underpins the trust the public has in doctors. www.medev.ac.uk

22. RCP Medical professionalism – description Medicine is a vocation in which a doctor’s knowledge, clinical skills, and judgement are put in the service of protecting and restoring human well-being. This purpose is realised through a partnership between patient and doctor, one based on mutual respect, individual responsibility, and appropriate accountability. www.medev.ac.uk

23. Definitions (2) • Swick • Need for a definition • 9 professional behaviours • Cruess & Cruess • Physician as Healer / as Professional • Damaged social contract • Cosgrove • Professionalism – state not trait www.medev.ac.uk

24. Definitions (3) • Calman “The Profession of Medicine” • High ethical standards • CPD, change and improvement, R&D • Teamwork • Health as well as illness • Concern with clinical effectiveness & outcomes • Ability to communicate www.medev.ac.uk

25. Elements of Professionalism • Literature • Knowledge • Altruism • Accountability • Respect • Integrity • Ethical code • Lifelong learning • Honesty • Compassion • Excellence • Self regulation • From research • Knowledge and skills (appropriate) • Altruism • Respect • Integrity • Ethical • Working with others • Empathy • Honour • Reflection www.medev.ac.uk

26. Group Work - 1 • Define ‘patient-centered professionalism’ • What are the characteristics you consider desirable in a professional in training? www.medev.ac.uk

27. Workshop format • Setting the scene – Professionalism in the 21st centuary • Defining professionalism • How to teach professionalism? • How to assess professionalism and ensure fitness to practice? • Summary www.medev.ac.uk

28. Development of Professionalism • Is professionalism passively ‘caught’ during the undergraduate years Or • Should it be formally taught? www.medev.ac.uk

29. PERIOD OF PROTO-PROFESSIONALISM NEW MEDICAL STUDENT MATURE PROF- ESSIONAL MATURITY PHRONESIS EXPERIENCE SDL NAIVE PBL +ve ROLE MODELS Y1 Y2 Y3 Y4 Y5 Q Reg  PGT Hilton and Slotnick 2005 www.medev.ac.uk O NAÏVE N

30. PERIOD OF PROTO-PROFESSIONALISM NEW MEDICAL STUDENT MATURE PROF- ESSIONAL IDEALISTIC BAD EXPERIENCES -ve ROLE MODELS FATIGUE CYNICAL POLITICS ADDICTIVE BEHAVIOURS Y1 Y2 Y3 Y4 Y5 Q Reg  PGT Hilton and Slotnick www.medev.ac.uk O NAÏVE N

31. Hierarchy of professional attitudes • Are some attitudes more important than others? www.medev.ac.uk

32. How Can Professionalism Be Taught? • Role Models • Didactics on History of Medicine, Self-Regulation and Public Policy • Small Group Discussions • Grand Rounds • Named Lectures • Teaching ward rounds • Clinical Vignettes • Reflective Exercises • Self-Assessment/Narratives www.medev.ac.uk

33. Group work - 2 • Design a framework for teaching professionalism in your own institution/context • Specific modules? • Part of other modules of teaching? • Teaching methods? www.medev.ac.uk

34. Workshop format • Setting the scene – Professionalism in the 21st century • Defining professionalism • How to teach professionalism? • How to assess professionalism and ensure fitness to practice? • Summary www.medev.ac.uk

35. Behaviour~ skills/attitudes Does Knowshow Cognition~ knowledge Knows Showshow Model of competence Professional authenticity Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine (Supplement) 1990; 65: S63-S67. www.medev.ac.uk

36. Performance assessment in vivo: Work based assessment, Video, Audits Does Performance assessment in vitro: OSCE, SP-based test….. Knows how (Clinical) Context based tests: EMQ, essay type, oral….. Knows Factual tests: MCQ, essay type, oral….. Shows how Climbing the pyramid...... Does Shows how Knows how Knows www.medev.ac.uk

37. New skills emphasized • learning how to learn • self-appraisal • leadership • team skills • metacognition • professionalism • reflectiveness/reflexiveness……. www.medev.ac.uk

38. Does Does Shows how Knows how Knows how “Meta” skills Knows Knows Shows how Extending the pyramid www.medev.ac.uk

39. How to assess “meta-skills”? • Self assessment • Peer assessment • Co-assessment(combined self, peer, teacher assessment) • Patient ratings • Log book/diary • Structured evaluations (mini cex etc) • Portfolio assessment…….. www.medev.ac.uk

40. How to assess “meta-skills”? • Basic principles: • Information gathering relying on descriptiveand qualitative judgemental information • Systematic documentation • Use of multiple tools • Processes for making judgements on the information collected www.medev.ac.uk

41. Designing an system to assess student professional behaviour and fitness to practise • ?different schemes/overlap between professional behaviour and FtP • FtP can include issues other than professional behaviour • Assessment tools should assess the characteristics defined as ‘professional behaviour’ • They must exist within a system of • Systematic data collection • Processes for dealing with unacceptable behaviour www.medev.ac.uk

42. Group work – 3 Design a system of assessing professionalism in your undergraduates • Choose the tools you are going to use • Outline a scheme for your institution www.medev.ac.uk

43. Remediation • Is it possible? • Attitudes vs behaviours www.medev.ac.uk

44. Attitudes and behaviours • Relationship between attitude and behaviour is complex • Behaviour is influenced by attitude • Measures of general attitudes do not necessarily predict specific behaviours But • They do have a good correlation to behaviour over a period of time in a range of situations and contexts (aggregation principle) www.medev.ac.uk

45. Subjective norm to performing behaviour Belief about ability to perform behaviour Attitude to performing behaviour Behaviour intent Behaviour Theory of Planned Behaviour www.medev.ac.uk

46. Theory of planned behaviour • Ajzen 1991 • A=Σb1.e1 • Where: • A=attitude, • b=belief about likelihood of consequence 1 • e=evaluation of consequence 1. www.medev.ac.uk

47. Changing behaviour • Probably means changing underlying fundamental beliefs www.medev.ac.uk

48. Workshop format • Setting the scene – Professionalism in the 21st centuary • Defining professionalism • How to teach professionalism • How to assess professionalism and ensure fitness to practice • Summary www.medev.ac.uk

49. Future issues • To find a holistic measure(s) of professionalism • Understanding ways of changing professional attitude/behaviour www.medev.ac.uk

50. Thank you www.medev.ac.uk