Educating for Professionalism in Medicine: A Fresh Look

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Educating for Professionalism in Medicine A
Fresh Look

• Thomas S. Inui, ScM, MD
• Professor of Medicine, Associate Dean for Health
  Services Research, Indiana University School of
  Medicine
• President and CEO, Regenstrief Institute

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Flurry of Interest and Discussion of
Professionalism in Medicine

• Literature
• Explication of values, desirable attributes
• Construction of courses
• Development of measures
• Exploration of approaches for certification,
  continued learning
• Why all this activity?

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Distress in all the Constructs of Medicine

• Cultural domain - healers
• Guild - skilled trade with restricted entry
• Social good, utility, civil service
• Scientific and technical domain
• Profession

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Many Views of Professionalism in Medicine AAMC
Medical School Objectives

• Knowledgeable (scientific method, biomedicine)
• Skillful (clinical skills, reasoning, condition
  managing, communication)
• Altruistic (respect, compassion, ethical probity,
  honesty, avoidance of COI)
• Dutiful (population health, advocacy and outreach
  to improve non-biologic determinants of health,
  prevention, information management, health
  systems management)

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Many Views of Professionalism in Medicine ACGME
Medical knowledge Practice-based learning and
improvement Patient care Systems-based
practice Interpersonal and communication
skills Professionalism (respect, compassion,
integrity responsiveness to needs altruism
accountabilitycommitment to excellence sound
ethics sensitivity to culture, age,
gender,disabilities
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Many Views of Professionalism in Medicine The
duties of a doctor (General Medical Council)

• Make the care of your patient your first concern.
• Treat every patient politely and considerately.
• Respect patients dignity and privacy.
• Listen to patients and respect their views.
• Give patients information in a way they can
  understand.
• Respect the right of patients to be fully
  involved in decisions.
• Keep your professional knowledge and skills
  up-to-date.

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Many Views of Professionalism in Medicine The
duties of a doctor - continued

• Recognize the limits of your competence.
• Be honest and trustworthy.
• Respect and protect confidential information.
• Make sure that your personal beliefs do not
  prejudice your patients care.
• Act quickly to protect patients from risk (from
  physicians).
• Avoid abusing your position as a doctor.
• Work with colleagues in the ways that best serve
  patients interests.

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All things bright and beautiful
Why do these recitations begin to sound like the
Boy Scout Law? A Scout is trustworthy, loyal,
helpful, friendly, courteous, kind, obedient,
cheerful, thrifty, brave, clean, reverent. The
shared view of medicine as a virtuous activity, a
moral enterprise.
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Core Values of a Life in the Profession of
Medicine
Foundational Value Truth/Science Therapeutic
Alliance Curing, Caring Accepting,
Empathic Right action Reflectiveness,
mindfulness Altruistic
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The Ideals of a Virtuous Life in the Profession
of Medicine
Foundational Value Ideal Truth/Science EBM
Therapeutic Alliance COI (Confluence) Curing,
Caring Healing, comfort Accepting,
Empathic Open heart/mind Right action
Error-free Reflective, mindful Analytic Altru
istic Self-sacrificing
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The Reality of an Ordinary Life in Medicine is
Far from Ideal
Foundational Value Ideal Real
Truth/Science EBM Uncertainty Therapeutic
Alliance COI (Confluence) COI (conflict) Curing,
caring Healing, comfort Risking,
harming Accepting, Empathic Open
heart/mind Arrogant, unmoved Right action
Error-free Mistake-prone Reflective,
mindful Analytic Habitual, knee-jerk Altruistic
Self-sacrificing Avaricious, self- preserv
ing
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The Lived Experience of a Life in the Profession
of Medicine Struggling to Keep Ones Balance in
Precarious Situations
Ideal Real EBM
Uncertainty COI (Confluence) COI
(conflict) Healing, comfort
Risking, harming Open heart/mind
Arrogant, unmoved Error-free
Mistake-prone Analytic Habitual,
knee-jerk Self-sacrificing
Avaricious, self- preserving
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Teaching in this Precarious Situation What is
the resulting Formative Arc of Education?

• Under present circumstances a distressing
  trajectory
• From open-minded and curious to test-driven and
  minimalistic
• From open-hearted to well-defended
• From focused on the formal to focused on the
  hidden curriculum (from noting what we say to
  noting what we do)
• From altruism to cynicism
• How can this situation be changed?

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Educating for Professionalism Two Camps
Duty Accountability Rules
Experience Reflection Values
Measure Feedback Growth
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Professionalism in Medicine How Can We Teach and
Learn More Successfully?

• Focus on sentinel/seminal events in the hidden
  and informal curriculum.
• Create mindfulness, infrastructure for dialogue
  (e.g. about keeping ones balance, uncertainty,
  medical errors, interpersonal conflicts,
  professional performance, values in medicine).
• Primum non tacere.
• Join forces with community, patients, other
  disciplines to track, get feedback, grow
  professionally.

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IUSM Student Professionalism Journal Activity

• Occurs during Internal Medicine Clerkship
• Students encouraged to contribute
• Incentive plan grade modifier
• Heighten awareness of professionalism issues
• Promote self-reflection
• Web-based and password protected
• Complete anonymity
• Only Clerkship Director and administrative staff
  have complete access
• Journal entries (edited) printed out and
  distributed for small group discussions

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Medical Student
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Professionalism Journal Data Feb. 2004 through
Jan. 2005

• students in IM Clerkship 263
• students who made journal entries at least
  197 (75)
• Total entries 445
• Range of entries by students 1 to 12
• Avg. entries per participating student 2.26
• Two-thirds of the entries describe positive
  experiences one-third negative

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Professionalism Journal Small Group Discussions

• Two sessions per month. Dialogue in the round.
• Closed session with tight document security.
• Students choose narratives to read, faculty
  facilitate open discussion.
• Much better received and rated by students than
  prior format (lectures and discussion of paper
  cases)
• Discussion of their their classmates own
  stories lived experiences ? more relevance and
  interest

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Sample Narratives

• To Err is Human
• Closing the Door
• Asking for help
• Staying Behind

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Impact of Student Journals at Indiana University
School of Medicine
Professionalism Competency (UME)
Students Prof. Journal Narratives
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Impact of Student Journals at Indiana University
School of Medicine
Professionalism Competency (UME)
IM Clerkship Prof. Narrative Dialogues
Students Prof. Journal Narratives
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Impact of Student Journals at Indiana University
School of Medicine
Professionalism Competency (UME)
MS3 Intersession
IM Clerkship Prof. Narrative Dialogues
Students Prof. Journal Narratives
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Impact of Student Journals at Indiana University
School of Medicine
Professionalism Competency (UME)
MS3 Intersession
IM Clerkship Prof. Narrative Dialogues
Students Prof. Journal Narratives
Other IUSM Courses/ clerkships Using
similar narratives
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Impact of Student Journals at Indiana University
School of Medicine
Professionalism Competency (UME)
MS3 Intersession
IM Clerkship Prof. Narrative Dialogues
Students Prof. Journal Narratives
Housestaff Orientation Retreats
Other IUSM Courses/ clerkships Using
similar narratives
26
Impact of Student Journals at Indiana University
School of Medicine
Professionalism Competency (UME)
MS3 Intersession
IM Clerkship Prof. Narrative Dialogues
Students Prof. Journal Narratives
Housestaff Orientation Retreats
Departmental Grand Rounds
Other IUSM Courses/ clerkships Using
similar narratives
27
Impact of Student Journals at Indiana University
School of Medicine
Professionalism Competency (UME)
MS3 Intersession
IM Clerkship Prof. Narrative Dialogues
Students Prof. Journal Narratives
Housestaff Orientation Retreats
Departmental Grand Rounds
Hospital Staff Physician Meetings
Other IUSM Courses/ clerkships Using
similar narratives
28
Impact of Student Journals at Indiana University
School of Medicine
Professionalism Competency (UME)
MS3 Intersession
IM Clerkship Prof. Narrative Dialogues
Students Prof. Journal Narratives
Housestaff Orientation Retreats
Faculty Development
Departmental Grand Rounds
Hospital Staff Physician Meetings
Other IUSM Courses/ clerkships Using
similar narratives
29
Impact of Student Journals at Indiana University
School of Medicine
Professionalism Competency (UME)
MS3 Intersession
IM Clerkship Prof. Narrative Dialogues
Students Prof. Journal Narratives
Housestaff Orientation Retreats
Faculty Development
Departmental Grand Rounds
Hospital Staff Physician Meetings
Other IUSM Courses/ clerkships Using
similar narratives
National Prof. Meeting Workshops Plenaries
30
Impact of Student Journals at Indiana University
School of Medicine
Professionalism Competency (UME)
MS3 Intersession
IM Clerkship Prof. Narrative Dialogues
Students Prof. Journal Narratives
Housestaff Orientation Retreats
Faculty Development
Departmental Grand Rounds
Hospital Staff Physician Meetings
Publication Forthcoming Book Chapter
Other IUSM Courses/ clerkships Using
similar narratives
National Prof. Meeting Workshops Plenaries
31
Impact of Student Journals at Indiana University
School of Medicine
Professionalism Competency (UME)
MS3 Intersession
IM Clerkship Prof. Narrative Dialogues
Students Prof. Journal Narratives
Housestaff Orientation Retreats
Faculty Development
Departmental Grand Rounds
Hospital Staff Physician Meetings
Publication Forthcoming Book Chapter
Other IUSM Courses/ clerkships Using
similar narratives
National Prof. Meeting Workshops Plenaries
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Maytee Boonyapredee 8 and ½ Medical Students
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Professional Formation An Alternative
Educational Model

• Education is the process by which an individual
  becomes the person who can successfully serve a
  calling
• Engaging in service
• Reiterating cycles of experience and reflection
• Growth in knowledge of self and of the field
• Constant attention to the inner life as well as
  the life of action
• Who am I becoming as I move towards this life of
  service?

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Educating for Professionalism Two Camps
Duty Accountability Rules
Experience Reflection Values
Measure Feedback Growth
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Enhancing Education for Professionalism in
Medicine Organizational Action Agenda Options(A
Flag in the Wind Table 7, pp. 23-25)

• Focus on
• Key institutional roles and accountabilities.
• Organizational performance and management.
• The role of professionalism in trainee/physician/p
  rogram performance and feedback.
• Resources for continued learning and professional
  development in the hidden curriculum.
• Resources that make explicit the link between
  personal and professional growth and development.

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A Flag in the Wind Educating for Professionalism
in Medicine (http//www.aamc.org/meded/start.htm)
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Education for Professionalism Additional Recent
Publications

• Academic Medicine theme issue October 2005
• Coulehan J Todays professionalism Engaging
  the mind but not the heart. Academic Medicine
  80 892-898, 2005.
• Arnold L, Shue CK, Kritt B, Ginsburg S, Stern D
  Medical students views on peer assessment of
  professionalism. JGIM 20 819-824, 2005.
• Skiles J. Teaching professionalism A medical
  students opinion. The Clinical Teacher 2
  66-71, 2005.