Transcript PROFESSIONALISM

EVALUATING
PROFESSIONALISM IN THE
BASIC SCIENCE CURRICULUM
John A. Talbott, M.D.
Professor of Psychiatry
University of Maryland
School of Medicine
Project Director - HELPERS-PRO
Course Director - “Practice of Medicine”
IAMSE Annual Meeting, July 2004
EVALUATING
PROFESSIONALISM
• “Why is it necessary?”
• “How does it work?”
EVALUATING
PROFESSIONALISM
Why is it necessary?
• The public
– through their actions, e.g. alternative medicine
– through the press, e.g. Geo Harrison’s guitar
– through the courts, e.g. malpractice
• The profession, e.g. ASIM
• Our faculty
– became concerned
– preclinical years early detection and remediation
– for the “Dean’s letter”
• Our residents, “washouts”
• Our medical students, leaders’ email
EVALUATING
PROFESSIONALISM
How does it work?
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What is Professionalism?
How is it evaluated?
Can we select students well?
Can we teach Professionalism?
Where do students learn unprofessional
behavior?
• How about Exemplary Behavior?
What is Professionalism?
• “The wife of a very well-known local celebrity is
seen in gynecology clinic. She is informed of the
results of a recent mammogram, which confirms
the diagnosis of breast cancer. 2 hours later, while
out to lunch at [a popular campus] restaurant, the
resident physician who worked up the patient
discusses the patient's case, referring to her
specifically by name, who her spouse is, and her
diagnosis.”
What is Professionalism?
• Is this Professional behavior?
• How do you know?
– Your upbringing/experience?
– Your training?
– Your gut?
• What then is Professionalism?
What is Professionalism?
Humanism
Ethics
Life-long Learning
Physicians subordinating themselves to their patients
Ethical behavior
Research subjects
Sensitivity to age, culture, disability, diversity and
gender
Professionalism
Respect for Patients, Families and Colleagues
Other (Death and Dying, Impairment, Sexual and
Aggressive Behavior, Physician/Industry relationships
How is it Evaluated
• “I was mentioning to my mother that I thought that I had found a
possible pediatrician for my new baby. It was a faculty member
who I had shadowed for ICP [Introduction to Clinical Practice].
He was great! Good rapport with patients, knowledgeable, and
caring. But there was this nagging in the back of my mind that
something wasn't quite right. A fellow student pointed out the
problem -- he never washed his hands in between patients. He
went from one Strep patient, to a routine high school physical,
from one sick baby exam, to a well baby exam. Yet neither of us
had EVER seen him wash his hands. Regardless of his clinical
skills, the thought of him touching my or any other child totally
turned me off after thinking about his lack of good hygiene.”
How is it Evaluated?
• How do we pick this behavior up?
– Observation
• Periodic (at the end of each course or rotation)
• Twice yearly reviews on each student and reports to the
Academic Advancement Committee
• Physical Diagnosis
• Introduction to Clinical Practice (Interviewing Course)
• Observed Structured Clinical Examinations (OSCE’s)
• How is it reported
– Orally
– In writing - Professionalism Website has forms
http://medschool.umaryland.edu/Professionalism/Evaluation.asp
How is it Evaluated?
A web-based approach
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Course evaluations
Twice-yearly reviews
Student-Student Peer System
Sentinel Events
Feedback Loop
Self-Evaluation
Exemplary Behavior
Pre Clinical Short Form
University of Maryland School of Medicine
Professionalism Evaluation Form 1S for the Pre-Clinical Years
Student’s Name: ________________________
Scale:
Course: ____________________________
E. Exemplary demonstration of professional behavior.
Did not observe any unprofessional behavior
4. Observed 1 or 2 minor lapses of professional behavior
3. Observed 3 or more minor lapses of professional behavior
2. Observed 1 or 2 major lapses of professional behavior
1. Observed 4 or 5 major lapses of professional behavior
N/O. Was not in a position to observe unprofessional behavior
Global Rating of Professionalism
Poor
1
2
3
4
Excellent
5
Comments:
Supervisor’s Name: ___________________
Date:______________
Supervisor’s Signature:_____________________
E
N/O
University of Maryland School of Medicine
Professionalism Evaluation Form 1L for the Pre-Clinical Years
Student’s Name: ________________________
Course: ____________________________
Scale: E. Exemplary demonstration of professional behavior.
1.Did not observe any unprofessional behavior
4. Observed 1 or 2 minor lapses of professional behavior
3. Observed 3 or more minor lapses of professional behavior
1.2. Observed 1 or 2 major lapses of professional behavior
2.1. Observed 4 or 5 major lapses of professional behavior
N/O. Was not in a position to observe unprofessional behavior
A
Duty: Reliability and Responsibility
1
Completes assigned tasks timely and fully
2
Fulfills obligations undertaken
3
Takes on appropriate share of team
assignments
4
Informs supervisor/course director when
faced with a conflict of interest
B
Excellence: Self Improvement and Adaptability
Accepts constructive feedback
5
6
Recognizes own limitations and seeks
appropriate help
7
Incorporates feedback to make changes in
behavior
Adapts well to changing circumstances
8
Reads up on patient cases
9
1
0
Attends rounds, seminars, small groups
and other learning events at expected
level.
E
5
Exemplary
No lapses
observed
4
1 or 2
Minor
lapses
3
2
1
N/O
3 or more Minor
lapses
1 or 2
Major
lapses
3 or more Major
lapses
Not in a position
to observe
How is it Evaluated?
• Physical Examination- systematic approach and
thoroughness; skill level in applying
fundamental techniques; attention to parts of
examination requiring emphasis; use of special
techniques to delineate abnormal findings.
How is it Evaluated?
(even issues like)
• Altruism- Demonstrates sensitivity to patients’
needs, takes time and effort to explain
information to patients and comfort the sick
patient, listens sympathetically to patients’
concerns, puts patients’ interests before his/her
own, shows respect for patients’ confidentiality.
Clinical Rotations
How is it Evaluated?
A challenge from our students
• Who is in the best position to observe students’
professional and unprofessional behavior?
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The Dean?
The faculty?
The residents?
The students?
• So, how do we utilize that?
Feedback Loop
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http://medschool.umaryland.edu/professionalism/feedback/
Critical Events
(formerly called Sentinel Events)
How is it Evaluated?
Another example
• “A radiology resident read the films of a
patient who is a faculty member here. The
resident lives with a current student and
came home and told the student about a lifethreatening diagnosis for the faculty member
made on the basis of the films.”
How is it Evaluated?
Critical Events, ie Serious
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Referring to oneself as, or holding oneself to be, more qualified than one is
Participating in a conflict of interest
Theft of drugs
Violation of the criminal code
Failure to be available while on call
Failure to respect patients' rights
Breach of confidentiality
Failure to provide transfer of responsibility for patient care
How is it Evaluated?
Critical Events, Continued
• Failure to meet academic codes of behavior (e.g. cheating on an
examination)
• Being disrespectful to patients, colleagues and other professional
staff
• Falsification of medical records or misrepresentation of a clinical
situation
• Assaulting a patient, colleague or staff member
• Sexual impropriety with a patient or colleague
• Sexual harassment
• Threat or hate crime
• Being under the influence of alcohol or drugs while participating in
patient care or on call
• Any other conduct unbecoming of a physician
How is it Evaluated?
• Oral vs Written
• Anonymous vs Identified
• With whom and for what (advice vs action):
– the person(s) who was felt to have breached
Professional behavior, eg class leaders’ email
– his/her superior
– the student’s mentor/advisor/faculty “friend”
– course director
– Dean of Student Affairs
– The Director of the Professionalism Project
Can we select students well?
• “While I was on my 3rd year surgical rotation, one of the
patients our team followed had an extremely foul
smelling abdominal wound infection- so foul that it
smelled up the entire floor. One day on rounds, the
attending and fellow began making jokes about the
stench...while in the patient's room as if he weren't even
there. Tears welled up in the patient's eyes. The
attending realized this, and told the patient flippantly,
"Oh, we're sorry" and turned to the fellow and said,
"look- we've made the poor man cry". They promptly
left the room and went on to the next patient as if the
whole thing had never happened.”
Can we select students well?
• Tough question
• But we’re now trying through:
– Heightened awareness
– Questions on interview
– Word of mouth and internet
Can we teach Professionalism?
• “At [an ambulatory setting] a resident discussed
private information about one student she was
seeing as a patient over the phone in front of
another student she was teaching. The
information was very sensitive in nature. The
student who overheard the info told the resident
that she knew the student involved, but the
resident continued to make numerous phone calls
to the same patient-student revealing further
sensitive information over the next two weeks in
front of the other student she was teaching.”
Can we teach Professionalism?
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I’m not certain
But I know we have to try
There are models out there - e.g. McGill
Our attempt is called “The Practice of Medicine”
Can we teach Professionalism?
“The Practice of Medicine”
• How will it be different? By doing:
– Grades
– Standardized patient exercises and OSCE’s as part of new
course
– PBL to be changed to Year I Jan to Year II Jan
– Writing the curriculum so that ICP and Human Behavior
support one another
– Presenting Human Behavior/ICP components at beginning of
Year I, Year II and Year III
– Perhaps adding service learning
– Potentially shift some ethics/professionalism into time
currently occupied by preventive health in Year III
– Anchoring simulation exercises within this course tied to PD
Can we teach Professionalism?
“The Practice of Medicine”
• It includes new course and material as well as portions of
existing courses, i.e.:
– Human Behavior
– Introduction to Clinical Practice, especially its element on
the History of Medicine
– Problem Based Learning
– Intimate Human Behavior
– Physical Diagnosis
– Parts of longitudinal ambulatory and AHEC
– Orientation to the 1st, 2nd and 3rd years
– New initiatives in professionalism
– New simulation/technology experiments - e.g. OSCE’s
– “Capstone week”
Can we teach Professionalism?
“The Practice of Medicine”
• How will it be different? By adding:
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Medical ethics and ethical behavior
Death and dying, pain and palliation, breaking bad news
House staff treatment of students
Communication, the doctor/patient relationship, boundaries
Strains and stresses of becoming and being a physician
Religion and spirituality
Cultural, ethnic, gender, sexual and socioeconomic diversity
Patient safety/medical errors
Physician/Industry relationships and gifts from industry
Impairment
Treating the VIP, HIV patients, smokers, the mentally and physically
handicapped
– Sexual harassment.
– The stresses and strains of medicine (e.g. substance abuse, divorce)
How about Exemplary Behavior?
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“Ms. X is the epitome of professionalism and ethics in a medical student, and
is the type of individual that the UMB School of Medicine strives to cultivate
as a future physician. I have personally witnessed countless instances of her
example of integrity, morals, and respect for others, throughout the first 3
years of medical school. This sentiment is echoed by many of my fellow
classmates, residents, and attending physicians, who have mentioned her
professionalism and integrity several months after completing a rotation with
her. To receive these sort of remarks well after the fact means that she has
made a lasting impression in her profession and has achieved something very
special in her personal encounters with others. Of utmost importance to her,
however, is that she holds her patients in the highest regard, and displays an
unwavering compassion, altruism, and empathy in her care of them. She also
demonstrates a continuing commitment to excellence and exhibits a
commitment to scholarship that is unrivaled amongst our fellow classmates.
She is an inspiration to her fellow students, the physicians she works under,
and especially to her patients.”
How about Exemplary Behavior?
• How do I report it?
– In a fellow student
– In a resident
– In a faculty member
• Anytime via the Website; use the
Exemplary Comment Form
• But there are special opportunities
How about Exemplary Behavior?
The special opportunities
• For students
– At the end of each small group experience
– At the beginning of the 4th year for the 10% of
the class for the Humanism Honor Society
• For residents
– When the 4th year Honor Society selects 6
• For faculty
– When the 4th year Honor Society class pick 1
HELPERS-PRO
Website References
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The Professionalism Website
– http://medschool.umaryland.edu/Professionalism/defalt.asp
The Evaluations page
– http://medschool.umaryland.edu/Professionalism/evaluations.asp
The Humanism page
– http://medschool.umaryland.edu/Professionalism/humanism/defalt.asp
The Feedback Loop
- http://medschool.umaryland.edu/Professionalism/feedback
Gifts from Industry
– http://medschool.umaryland.edu/Professionalism/gifts.asp
Oaths and Codes
– http://medschool.umaryland.edu/Professionalism/Oaths.asp
QUESTIONS?