Transcript Bearing Bad News

Teaching and Assessing Medical
Professionalism at Mayo Clinic
Paul S. Mueller, MD, MPH
Associate Professor of Medicine
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
What is professionalism?
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
AAMC
Medical School Objectives
Physicians must be:
1. Altruistic
2. Knowledgeable
3. Skillful
4. Dutiful
Accreditation Council for GME
General competencies
http://www.acgme.org/outcome/comp/compFull.asp#5
ABIM/ACP
Charter on Medical Professionalism
Ann 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.
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
Professionalism at Mayo Clinic
Historical perspective
Teamwork
Altruism
ReflectionHumanism
Communication
Excellence
“The best interest of the patient is
the only interest to be considered…
and in order that the sick may
benefit from advancing knowledge
a Union of Forces is necessary”
William J. Mayo, MD
June 1910
3000083-3
Mayo’s primary value
“The needs of the patient come first.”
Mayo’s mission
“Mayo will provide the best care to every patient
every day through integrated clinical practice,
education, and research.”
The Mayo Clinic
Model of Care
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
Should professionalism be
taught?
Patient expections
Ideal physician behaviors
Mayo 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
Mayo Clinic patient satisfaction
High correlation
High satisfaction
2006 PRC 3-Site Outpatient Satisfaction, n=36500
Reasons for concern
• Professionalism lapses
• Conflicts of interest among physicians
common
• Declining trust in the medical profession
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)
Consequences of disruptive
physician behavior
http://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
Reasons for optimism
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.
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
Should professionalism be
taught? Yes.
“Advancing Education in Medical Professionalism.”
ACGME Outcome Project, 2004
• 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
How do you teach
professionalism?
Professionalism
Excellence
Accountability
Humanism
Consider the
elements of
professionalism.
Altruism
Sound ethics
Communication skills
Clinical competence (knowledge)
From: Stern D., ed. Measuring Professionalism
(New York: Oxford University Press, 2006).
25
Teaching professionalism
Methods
“Advancing Education in Medical Professionalism.” ACGME
Outcome Project, 2004
•
•
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•
•
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•
Lectures
Discussion groups
Role plays, simulation
Experiential (eg, clinical setting)
Team learning
Role modeling
Independent learning
Teaching professionalism
Strategies
JAMA 2001;286:1067-1074
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•
•
•
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Establish a climate of humanism
Be practical and relevant
Recognize and use seminal events
Role model
Encourage self-reflection
Address the “hidden” curriculum
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.
How do you assess
professionalism?
Assessing professionalism
Stern 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.
Effective assessment of
professionalism
Stern D, ed. Measuring Professionalism; Oxford, 2006
JAMA 2008;300:1326-1333
• 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
What do you do with the
information?
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•
•
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Formative feedback Using a “professionalism
portfolio”
Summative feedback
Reward exemplars
Evaluate professionalism education
programs and generate research
hypotheses
Teaching and assessing
professionalism at Mayo
All levels:
• Allied health staff
• Administrators
• Medical students
• Resident physicians
and fellows
• Faculty
Mayo Medical School
Required (school year) professionalism
elements
• Bioethics core
• “Safe Harbor”
curriculum(1,3)
professionalism
program (3)
• Anatomy (1):
cadaver as first
• Assessment (1-4)
patient, peer review
– Peer and vertical
• Professionalism
• Result: portfolio on
reflections (2)
professionalism
incorporated into the
Dean’s letter
Mayo Medical School
Elective
• Journal club
• MD Connect (new student
publication)
• 1-month “selective”
Mayo School of Graduate
Medical Education
Residency and fellowship training
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
Assessing internal medicine
resident professionalism at Mayo
•
•
•
•
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Tests of knowledge
OSCEs
Mentor review of “lapses”
Patient complaint review
Electronic 360-degree assessments by
peers, senior residents, faculty, others
• Result: professionalism portfolio
Electronic assessment
Electronic assessment
These 2 questions have the
highest inter-rater reliability.
Electronic assessment of
professionalism at Mayo
JAMA 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
Mayo faculty
Required
• Periodic web-based and interactive
modules
• CALD program
– Professionalism module
– Communication module
• Note ABIM maintenance of certification
• Assessment: attendance, learner
evaluations,360-degree reviews
CALD professionalism module
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•
•
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Reflective listening
Attributes of professionalism
Review data supporting professionalism
Recognizing and responding to
professional and unprofessional
behavior
• Collaborate with a psychologist
• Feedback: outstanding
CALD professionalism module
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
CALD communication module
Mayo faculty
Elective
• Professionalism
conferences
• Annual ethics
conference
• Medical grand rounds
Mayo allied health staff
Minnesota 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
Teamwork is REAL
• The nexus of
professionalism and
quality is teamwork
• Enterprise-wide
program
• Common language
• Outcomes
measured
• Relationship
building
• Effective
communications
• Assertion
• Leading with mutual
respect
Relationship Building
Reflective
Listening
Effective
Work in partnership with all
colleagues for the genuine concern
and well being of our patients
and others
Communications
Listen for understanding
to the diverse opinions
of others
Teamwork
PEARLS
Assertion
Empowered to voice
my opinion and trust that
it will be heard
Leading with
Mutual Respect
SBAR
Tools
Treat one another with respect and courtesy
Acknowledge and value the contributions
of others
Positive
Assertion
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
Thank you
[email protected]
“The best interest of the patient is the
only interest to be considered…
and in order that the sick may benefit
from advancing knowledge
a Union of Forces is necessary”