Teaching Professionalism in the Community-Based Setting

1. Teaching Professionalism in the Community-Based Setting GIMGEL 30 November 2001 David T. Stern, MD, PhD University of Michigan VA Ann Arbor Healthcare System

2. Plenary Session 2 • What is a professional? • What is the evidence for when, where, and how are professional values are taught? • How are values taught in community-based settings? • A case study

3. What is a Professional? • A professional has command of a special body of knowledge and skills. • A professional is given specific rights not generally provided to the public. • A professional has specific responsibilities or duties not generally expected of the public.

4. Professionals have specialized knowledge and skills • Physicians: Therapies, surgical procedures • Lawyers: Details of the content and process of the law (local, state, and federal) • Clergy: Religious ritual and scriptural interpretation

5. Professionals havespecific rights • Physicians: Asking private questions, prescribing narcotics, performing operations • Lawyers: Lawyer-Client privilege (confidential conversations) • Clergy: Participation, leadership, and access to certain religious rituals

6. Professionals havespecific duties • Excellence • Compassion • Confidentiality • Integrity • Inter-professional respect • Responsibility • Self-policing

7. How Did You Learn to “Act Like a Doctor?”

8. How are students learning Professional Behaviors? • Some are learned as a child, and are well in place before medical school. • Some are learned in the formal curriculum of medical school. • Some are learned through role-modeling during medical school.

9. Values Change in Training P = 0.02 Eron, 1967

10. Attitudes Change in Training • Dislike for cancer patients (Kaye) • Disdain for the emotionally ill (Stoller) • Hostility towards suicidal patients (Ghodse) • Alcoholics as “morally weak” (Fisher) • Negative attitude towards geriatric patients (Spence)

11. Take-home Point • Professional behaviors change during the course of medical education. (Although not necessarily in the way that we would like.)

12. How are students learning Professional Behaviors? • Some are learned as a child, and are well in place before medical school. • Some are learned in the formal curriculum of medical school. • Some are learned through role-modeling during medical school.

13. How are we teaching Professional Behaviors? • Formal (Explicit) Curriculum • Informal (Hidden) Curriculum

14. Formal Curriculumof Values Teaching • White coat ceremony • ITTP course • Ethics rounds • Honor council • Standardized patients • Evaluation

15. Finding the Hidden Curriculum • An Exercise • What knowledge is being taught? • What skills are being taught? • What values are being taught?

16. The Hidden Curriculum This hidden curriculum can also be represented by the three R’s but not the familiar one of reading, ‘riting, and ‘rithmetic. It is, instead, the curriculum of rules, regulations, and routines, of things teachers and students must learn if they are to make their way with minimum pain in the social institution called the school. -Jackson, 1966

17. When Are Values Taught? p < 0.01 p < 0.01

18. Where Are Values Taught? p < 0.01

19. Take-home Points • Professional behaviors change during the course of medical education. • Professionalism is taught in the “hidden curriculum.”

20. How are students learning Professional Behaviors? • Some are learned as a child, and are well in place before medical school. • Some are learned in the formal curriculum of medical school. • Some are learned through role-modeling during medical school.

21. Role Modeling • Role modeling - demonstration without explanation. The physician’s attitudes, mind-set, moral stance, and the hour-by-hour decisions about how to use one’s time - all these and many other matters, even including how and what and how much to feel, are observed by the student and imitated assiduously. Even where the explicit message is “Do as I say, not as I do,” the implicit message is “Do whatever you think is right, but if you want to survive in this world you’d better be like me.” Mel Konner, Becoming a Doctor

22. Demonstration with explanation: Reflective Practice • Student observes • Student reflects on the expert’s demonstration • Student demonstrates • Teacher instructs the student on how well the attempt matched the teacher’s expectation

23. Using Parables to Teach In my whole career, I've been a nephrologist now for 25 years. Uh, I've lost one kidney doing biopsies every year. And there was this schizophrenic patient who we biopsied, I did not allow the fellow to do the biopsy because I knew it was going to be a difficult one. I did it myself because I know I’m fast. And the patient screamed at the moment I was in the kidney, . . . and there was a tear in the kidney. We tried to do angiography to stop the bleeding. The kidney was finally removed, this patient lost the kidney. This was one of the most dramatic situations I've ever had, and it's actually quite rare to have a significant complication, to have a nephrectomy, it’s one in one thousand.

24. Using Conflict to Teach Values • Professionalism is rarely taught as a simple, single expression of values: “Honesty is the best policy,” “Primum non nocere.” • Professionalism is more commonly taught as conflicts between two or more, sometimes equally worthy values. (Honesty versus efficiency)

25. Values Conflict (Example) • Resident: Oh, they're gonna read [the slides] today? • Student: I told them it was very important; our patient has taken a turn for the worse, and it's very important that we have these read today . . . The subintern said they do that all the time. She's like, they're totally nice about it, just call them and tell them that there's an emergency.

26. Values Conflict (Example) • Resident: My God, my entire team is involved in a deception! • Student:. . . don't you hate waiting for exam results though? • Resident: I hate waiting for anything. • Student: So aren't you glad we called and told them to make it urgent? • Resident: No.

27. Take-home Points • Professional behaviors change during the course of medical education. • Professionalism is taught in the “hidden curriculum.” • The teaching of professionalism can be made more effective by talking about it.

28. Which Values Are Taught in the Inpatient Setting? • Interprofessional Relationships (48/182) • Service and Duty (30/182) • Accountability and Responsibility (25/182) • Industry (21/182) • Integrity (13/182)

29. Interprofessional Relationships • Four Positive and 44 Negative Statements • Well, you know what they say about surgeons: if they’ve done one, they’ve clearly seen it happen; if they’ve done two, they have a lot of experience with it, and if they’ve done three, then they’ve got an extensive series.

30. Practicing What We Preach? • Recommended and Taught • Accountability and Compassion • Recommended and Not Taught • Integrity and Public Service • Recommended and Taught as the Opposite Value • Interprofessional disrespect and the burden of service

31. Is community-based medicine the antidote to inpatient medicine? • How is the teaching of professional behavior different in community-based settings? • What teaching of professionalism do we do uniquely well and positively in the community-based setting?

32. Case Study • Question 1: Would you go to the ER and see this patient on your way home? • Question 2: How would you respond to the nurse practitioner who comes to you with this request?

33. Case Study (cont.) • Question 3: It’s now 5:15, and if you leave the office right now, you can catch the last 10 minutes of your daughter’s championship soccer game. What do you do? • Question 4: What does the medical student at your side learn from the way you handle this situation?

34. Conclusions • Professional values are most often taught in the hidden curriculum. • Many of the values expressed in the community are valuable, worthy, and absent from the inpatient curriculum. • Community-based preceptors are uniquely situated to provide professional education.