Teaching and Assessing Medical Professionalism at Mayo Clinic

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Teaching and Assessing Medical Professionalism at
Mayo Clinic

• Paul S. Mueller, MD, MPH
• Associate Professor of Medicine

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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

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What is professionalism?
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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

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AAMCMedical School Objectives

• Physicians must be
• Altruistic
• Knowledgeable
• Skillful
• Dutiful

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Accreditation Council for GMEGeneral
competencieshttp//www.acgme.org/outcome/comp/com
pFull.asp5
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ABIM/ACPCharter on Medical ProfessionalismAnn
Intern Med 2002136243-246 and Ann Intern Med
2003138839-841
Less than 15 months after its release, the
Charter was endorsed by more than 90 specialty
societies.
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From Stern D., ed. Measuring Professionalism
(New York Oxford University Press, 2006).
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Professionalism at Mayo ClinicHistorical
perspective
Reflection
Communication
Teamwork
Altruism
Humanism
Excellence

• The best interest of the patient is the only
  interest to be consideredand in order that the
  sick may benefit from advancing knowledgea Union
  of Forces is necessary
• William J. Mayo, MDJune 1910

3000083-3
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Mayos primary valueThe needs of the patient
come first.
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Mayos missionMayo will provide the best care
to every patient every day through integrated
clinical practice, education, and research.
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The Mayo Clinic Model of Care
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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

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Should professionalism be taught?
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Patient expectionsIdeal physician behaviorsMayo
Clin Proc. 200681338-344.

• 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

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Mayo Clinic patient satisfaction
High correlation
High satisfaction
2006 PRC 3-Site Outpatient Satisfaction, n36500
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Reasons for concern

• Professionalism lapses
• Conflicts of interest among physicians common
• Declining trust in the medical profession

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Reasons for concern

• Unprofessional behavior in training associated
  with later disciplinary action by licensing
  boards (NEJM 20053532673-2682)
• Nearly all physician leaders and nurses have
  experienced disruptive physician behavior (Phys
  Exec 2004Sept-Oct6-14, Am J Nurs
  200510554-64, AORN J 200174317-331)

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Consequences of disruptive physician
behaviorhttp//cme.medscape.com/viewarticle/59031
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• 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

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Reasons for optimism
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Professionalism can be taughtAdvancing
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.
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Professionalism is associated with important
outcomesAdvancing 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

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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

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How do you teach professionalism?
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Consider the elements of professionalism.
From Stern D., ed. Measuring Professionalism
(New York Oxford University Press, 2006).
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Teaching professionalismMethodsAdvancing
Education in Medical Professionalism. ACGME
Outcome Project, 2004

• Lectures
• Discussion groups
• Role plays, simulation
• Experiential (eg, clinical setting)
• Team learning
• Role modeling
• Independent learning

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Teaching professionalismStrategiesJAMA
20012861067-1074

• Establish a climate of humanism
• Be practical and relevant
• Recognize and use seminal events
• Role model
• Encourage self-reflection
• Address the hidden curriculum

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Should professionalism be assessed? Yes.

• Professionalism can be assessed (Stern DT.
  Measuring Professionalism Oxford, 2006)
• Formative and summative feedback
• They dont 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.
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How do you assess professionalism?
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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.
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Effective assessment of professionalism Stern D,
ed. Measuring Professionalism Oxford, 2006JAMA
20083001326-1333

• 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

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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
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Teaching and assessing professionalism at Mayo

• All levels
• Allied health staff
• Administrators
• Medical students
• Resident physicians and fellows
• Faculty

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Mayo Medical SchoolRequired (school year)
professionalism elements

• 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 Deans letter

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Mayo Medical SchoolElective

• Journal club
• MD Connect (new student publication)
• 1-month selective

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Mayo School of Graduate Medical
EducationResidency 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
• MM ethics and professionalism sessions
• Professionalism OSCEs
• Assessment

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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

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Electronic assessment
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Electronic assessment
These 2 questions have the highest inter-rater
reliability.
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Electronic assessment of professionalism at
MayoJAMA 20083001326-1333

• The mean score for top 20 (highly
  professional) IM residents was 4.40, and for the
  remainder was 4.02 (Plt.001)
• High professionalism scores were associated with
  greater knowledge, skills, and conscientious
  behaviors

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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

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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

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CALD professionalism module
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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

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CALD communication module
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Mayo facultyElective

• Professionalism conferences
• Annual ethics conference
• Medical grand rounds

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Mayo allied health staffMinnesota Medicine.
20079047-49.

• Nearly 3000 DOM allied health staff
• Didactic lectures, video vignettes, and role
  plays
• gt95 reported benefit
• Increased patient satisfaction in all divisions

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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

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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

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Thank youmueller.pauls_at_mayo.edu
The best interest of the patient is the only
interest to be consideredand in order that the
sick may benefit from advancing knowledgea Union
of Forces is necessary