Teaching and Assessing Medical Professionalism at Mayo Clinic

1. Teaching and Assessing Medical Professionalism at Mayo Clinic Paul S. Mueller, MD, MPH Associate Professor of Medicine

2. Objectives • Define professionalism • Describe the rationale for teaching and assessing professionalism • Describe methods for teaching and assessing professionalism • Describe Mayo Clinic experiences with teaching and assessing professionalism

3. What is professionalism?

4. Hallmarks of a profession • Competence in a specialized body of knowledge • Acknowledgment of specific duties and responsibilities • Autonomy to train, admit, monitor, and discipline its members; a privilege granted by society through licensure

5. AAMCMedical School Objectives • Physicians must be: • Altruistic • Knowledgeable • Skillful • Dutiful

6. Accreditation Council for GMEGeneral competencieshttp://www.acgme.org/outcome/comp/compFull.asp#5

7. ABIM/ACPCharter on Medical ProfessionalismAnn Intern Med 2002;136:243-246 and Ann Intern Med 2003;138:839-841 Less than 15 months after its release, the Charter was endorsed by more than 90 specialty societies.

8. Professionalism Excellence Accountability Humanism Altruism Sound ethics Communication skills Clinical competence (knowledge) From: Stern D., ed. Measuring Professionalism (New York: Oxford University Press, 2006). 8

9. “The best interest of the patient is the only interest to be considered…and in order that the sick may benefit from advancing knowledgea Union of Forces is necessary” William J. Mayo, MDJune 1910 Professionalism at Mayo ClinicHistorical perspective Teamwork Altruism Reflection Humanism Communication Excellence 3000083-3

10. Mayo’s primary value“The needs of the patient come first.”

11. Mayo’s mission“Mayo will provide the best care to every patient every day through integrated clinical practice, education, and research.”

12. The Mayo Clinic Model of Care

13. What makes Mayo unique? • Not smart physicians or breadth of science • Rather: • Patient-centered care • Multidisciplinary teamwork • Allied health personnel • Remarkable facilities • Unique culture and ethos

14. Should professionalism be taught?

15. Patient expectionsIdeal physician behaviorsMayo Clin Proc. 2006;81:338-344. 192 patients in 14 specialty settings: • Confident: engenders trust • Empathetic: “Understands my feelings” • Humane: compassionate and kind • Personal: patient is a person, not a disease • Forthright: “Tells me what I need to know” • Respectful: “Takes my input seriously” • Thorough: conscientious and persistent

16. Mayo Clinic patient satisfaction High correlation High satisfaction 2006 PRC 3-Site Outpatient Satisfaction, n=36500

17. Reasons for concern • Professionalism lapses • Conflicts of interest among physicians common • Declining trust in the medical profession

18. Reasons for concern • Unprofessional behavior in training associated with later disciplinary action by licensing boards (NEJM 2005;353:2673-2682) • Nearly all physician leaders and nurses have experienced disruptive physician behavior (Phys Exec 2004;Sept-Oct:6-14, Am J Nurs 2005;105:54-64, AORN J 2001;74:317-331)

19. Consequences of disruptive physician behaviorhttp://cme.medscape.com/viewarticle/590319 • Reduced employee satisfaction, morale and productivity and increased employee turnover • Reduced communication, teamwork, and efficiency and increased costs • Decreased learner satisfaction, burnout, depression and unprofessional behavior

20. Reasons for optimism

21. Professionalism can be taught“Advancing Education in Medical Professionalism.” ACGME Outcome Project, 2004. • Formal and informal curricula influence professional attitudes and beliefs, moral reasoning, and behaviors • Role models influence attitudes and behavior; “hidden curriculum” Professionalism is not simply innate.

22. Professionalism is associated with important outcomes“Advancing Education in Medical Professionalism.” ACGME Outcome Project, 2004. • Increased patient satisfaction and trust • Increased patient treatment adherence • Patients more likely to “stay with” and recommend physician • Fewer patient complaints • Less patient litigation • Overall physician excellence

23. We are a profession AAMC, ACGME, ABIM, and JCAHO recommendations and requirements Expectations of patients and society Formal and informal curricula influence professional attitudes and beliefs, moral reasoning, and behaviors Associated with important outcomes Should professionalism be taught? Yes.“Advancing Education in Medical Professionalism.” ACGME Outcome Project, 2004

24. How do you teach professionalism?

25. Professionalism Excellence Accountability Humanism Altruism Sound ethics Communication skills Clinical competence (knowledge) Consider the elements of professionalism. From: Stern D., ed. Measuring Professionalism (New York: Oxford University Press, 2006). 25

26. Teaching professionalismMethods“Advancing Education in Medical Professionalism.” ACGME Outcome Project, 2004 • Lectures • Discussion groups • Role plays, simulation • Experiential (eg, clinical setting) • Team learning • Role modeling • Independent learning

27. Teaching professionalismStrategiesJAMA 2001;286:1067-1074 • Establish a climate of humanism • Be practical and relevant • Recognize and use seminal events • Role model • Encourage self-reflection • Address the “hidden” curriculum

28. Should professionalism be assessed? Yes. • Professionalism can be assessed (Stern DT. Measuring Professionalism; Oxford, 2006) • Formative and summative feedback • “They don’t respect what you expect; they respect what you inspect.” (Cohen JJ. Forward. In Measuring Professionalism; Oxford, 2006) • Evaluate education programs Failure to assess sends conflicting messages to learners, physicians, and patients.

29. How do you assess professionalism?

30. Assessing professionalismStern D, ed. Measuring Professionalism; Oxford, 2006 “Most practicing physicians observe each others’ behaviors only in the hallways and conference rooms--rarely with patients. The solution to this problem is to expand the number of observers and the settings in which they observe.

31. Multiple observers and instruments Variety of settings Realistic context Situations that involve conflict Not overly stringent Transparency; learners know purpose of assessment Symmetry; all levels of the hierarchy are assessed Effective assessment of professionalism Stern D, ed. Measuring Professionalism; Oxford, 2006JAMA 2008;300:1326-1333

32. What do you do with the information? • Formative feedback • Summative feedback • Reward exemplars • Evaluate professionalism education programs and generate research hypotheses Using a “professionalism portfolio”

33. Teaching and assessing professionalism at Mayo All levels: • Allied health staff • Administrators • Medical students • Resident physicians and fellows • Faculty

34. Bioethics core curriculum(1,3) Anatomy (1): cadaver as first patient, peer review Professionalism reflections (2) “Safe Harbor” professionalism program (3) Assessment (1-4) Peer and vertical Result: portfolio on professionalism incorporated into the Dean’s letter Mayo Medical SchoolRequired (school year) professionalism elements

35. Mayo Medical SchoolElective • Journal club • MD Connect (new student publication) • 1-month “selective”

36. Required for all: ACGME core competency for all programs Orientation module on professionalism Web-based curriculum in development DOM additional requirements: Core curriculum M+M ethics and professionalism sessions Professionalism OSCEs Assessment Mayo School of Graduate Medical EducationResidency and fellowship training

37. Assessing internal medicine resident professionalism at Mayo • Tests of knowledge • OSCEs • Mentor review of “lapses” • Patient complaint review • Electronic 360-degree assessments by peers, senior residents, faculty, others • Result: professionalism portfolio

38. Electronic assessment

39. Electronic assessment These 2 questions have the highest inter-rater reliability.

40. Electronic assessment of professionalism at MayoJAMA 2008;300:1326-1333 • The mean score for top 20% (“highly professional”) IM residents was 4.40, and for the remainder was 4.02 (P<.001) • High professionalism scores were associated with greater knowledge, skills, and conscientious behaviors

41. Mayo facultyRequired • Periodic web-based and interactive modules • CALD program • Professionalism module • Communication module • Note ABIM maintenance of certification • Assessment: attendance, learner evaluations,360-degree reviews

42. CALD professionalism module • Reflective listening • Attributes of professionalism • Review data supporting professionalism • Recognizing and responding to professional and unprofessional behavior • Collaborate with a psychologist • Feedback: outstanding

43. CALD professionalism module

44. CALD communication module • Communication a core competency • Reflective listening re-emphasized • 3-function model: • Relationship building • Information gathering • Patient education (eg, new diagnosis) • Didactic, video vignettes, and role play • Feedback: outstanding

45. CALD communication module

46. Mayo facultyElective • Professionalism conferences • Annual ethics conference • Medical grand rounds

47. Mayo allied health staffMinnesota Medicine. 2007;90:47-49. • Nearly 3000 DOM allied health staff • Didactic lectures, video vignettes, and role plays • >95% reported benefit • Increased patient satisfaction in all divisions

48. The nexus of professionalism and quality is teamwork Enterprise-wide program Common language Outcomes measured Relationship building Effective communications Assertion Leading with mutual respect Teamwork is REAL

49. Relationship Building ReflectiveListening PositiveAssertion PEARLS SBAR Work in partnership with all colleagues for the genuine concern and well being of our patientsand others EffectiveCommunications Assertion Teamwork Listen for understandingto the diverse opinionsof others Empowered to voicemy opinion and trust thatit will be heard Leading withMutual Respect Treat one another with respect and courtesy Acknowledge and value the contributionsof others Tools

50. Conclusions • Medical professionalism is a core competency • Professionalism is associated with important clinical outcomes • Professionalism should be taught and assessed • Professionalism can be taught, learned and assessed