Professionalism: A Moving Target

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Professionalism A Moving Target

• Joseph Gilhooly, MD
• Doernbecher Childrens Hospital

Grand Rapids Medical Education Research
Center September 30, 2009
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Disclosures

• I have no relevant financial relationships with
  the manufacturer of any commercial product or
  provider of commercial services discussed in this
  CME activity. I do not intend to discuss an
  unapproved/investigative use of a commercial
  product/device in my presentation.

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Objectives

• Define Professionalism
• Explain why we need to teach professionalism
• Describe professionalism to learners as specific
  expected behaviors
• Recognize that as values change, so will our
  definition of professionalism
• Identify several current hot topics in
  professionalism

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What is Professionalism?
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• Profess
• Profession
• Professional
• Professionalism

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profess Etymology Middle English, from
profes, having professed one's vows, from
Anglo-French, from Late Latin professus, from
Latin, past participle of profiteri to profess,
confess, from pro- before fateri to
acknowledge Date 1300s 1 to receive formally
into a religious community following a novitiate
by acceptance of the required vows 2 to declare
or admit openly or freely affirm 3 to confess
one's faith in or allegiance to
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profession Date 1300s 1 the act of taking
the vows of a religious community 2 an act of
openly declaring or publicly claiming a belief,
faith, or opinion 3 an avowed religious faith 4
a a calling requiring specialized knowledge and
often long and intensive academic preparation
b a principal calling, vocation, or employment
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We are on a mission from GodProfessional
MusiciansThe Blues Brothers, 1980
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• professional
• Date 1606
• 1 a of, relating to, or characteristic of a
  profession
• b engaged in one of the learned professions
  characterized by or conforming to the technical
  or ethical standards of a profession exhibiting
  a courteous, conscientious, and generally
  businesslike manner in the workplace

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professionalism Date 1856 1 the
conduct, aims, or qualities that characterize or
mark a profession or a professional person
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Those behaviors by which we demonstrate that we
are worthy of the trust bestowed upon us by your
patients and the public...
Swick HM. Toward a Normative Definition of
Medical Professionalism. Academic Medicine
200075612-16
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Were not worthyUnprofessional Talk Show
HostsWayne Garth, 1992
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Why do we need to teach professional behavior?
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Disciplinary Action by Medical Boards and Prior
Behavior in Medical SchoolMA Papadakis, et al.
NEJM. 20053532673-82.

• Disciplinary action among practicing physicians
  by medical boards was strongly associated with
  unprofessional behavior in medical school

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Professional behavior is a concept that those
entering the medical profession may not have been
exposed toyou cant assume this behavior is
intrinsic to our trainees
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Influences on Behavior

• Your age
• Society
• Role models
• Laws
• Parents
• Context
• Career stage
• Culture
• Religion
• Professional code

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Medical Professional Code of Conduct

• Honesty and integrity
• Reliability and responsibility
• Respectful of others
• Compassion and empathy
• Self-improvement
• Self-awareness and knowledge limitations
• Communication and collaboration
• Altruism and advocacy

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Break it downM.C. Hammer 1990
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Normative Definition of ProfessionalismOperation
alizing ProfessionalismPractical Professionalism
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Practical Professionalism

• Under each component of professionalism specific
  behaviors are listed
• Do not raise your voice at another team member
• Say, I dont know, when you dont know
• Be courteous on all email communication
• These specific behaviors are more easily measured
  compared to Honesty/Integrity

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https//www.abp.org/abpwebsite/publicat/profession
alism.pdf
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The 10 Commitments

• Professional competence
• Honesty
• Patient confidentiality
• Appropriate patient relationships
• Improving quality of care
• Improving access to care
• Just distribution of finite resources
• Scientific knowledge
• Maintain trust by managing conflict of interest
• Professional responsibilities

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Professionalism is a Team Sport

• There are individual and collective
  responsibilities for teaching, modeling,
  evaluating, and improving behavior

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Professionalism A Moving Target

• What does altruism mean in 2009?
• What is professional dress?
• How do we use new technology in a professional
  manner?
• How do duty hour limitations fit into
  professionalism?
• What is the impact of burnout on professionalism?

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Must one sacrifice your personal life to maintain
professionalism?
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ABP Vignettes on Professionalism, 2000

• You are leaving your office to go to your sons
  graduation when you receive a call from the ED
  that a child with asthma, whom you follow, has
  just been admitted with severe respiratory
  distress. The mother is insisting you be
  contacted to come in because you are the only one
  who has been able to keep her son out of the
  hospital.

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Altruism

• An ethical doctrine that holds that individuals
  have a moral obligation to help, serve, or
  benefit others, if necessary at the sacrifice of
  self interest.

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Medical Professionalism in the New Millennium A
Physician CharterAnnals of Internal Medicine
2002136243-6

• Professionalismdemands placing the interests of
  patients above those of the physician
• Principle of primacy of patient welfare
• Dedication to serving the interest of the patient

Self-Interest vs. Patient-Interest Mutually
exclusive?
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Altruism

• What is self interest
• Financial
• Yourself
• Employer
• Career advantage
• Enhanced reputation
• Personal life

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Prioritizing Life-Work Balance Is it good for
the profession?
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Generational Values

• Silent Generation
• Patriotism
• Sacrifice hard work
• Respect for authority
• Adherence to rules
• Delayed rewards

• Boomers
• Status and power
• Being liked by others
• Optimism
• Reaching consensus
• Youthfulness

• Millennials
• Life-work balance
• Global community
• Achievement
• Morality
• Technology

• Generation X
• Life-work balance
• Fun at work
• Informality
• Practicality
• Independence

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Claire Raines, Connecting Generations, 2003

• Todays residents are brilliant and articulate.
  They have lives. They love caring for
  patients, and they're high-quality individuals.
  But they have different values.

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Values

• Definition
• Principles, standards, or qualities considered
  worthwhile or desirable by the person who holds
  them

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Professionalism

• Built on values, and as values change so will the
  definition of professionalism.

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Dress Professionally
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NYSE trading floors casual Friday first GAP
jeans for everyone!LA Times, August 18, 2009
In what was billed as a historic first, the 1,100
or so folks working on the trading floor of the
NYSE on Friday morning will be wearing blue jeans.
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A Role Model?

• The Honorable John Kitzhaber, MD
• Former governor of the State of Oregon

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TLC's Clinton Kelly tells Portland what not to
wearThe Oregonian November 9, 2008

• Re Denim on denim?
• "In the East, we call it a Texas tuxedo. Over
  here, I heard you call it a Canadian tuxedo.
  Don't do it. Not cute."

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What do patients want?

• Professional uniforms
• Based on photographic studies
• Well dressed but not too well dressed (nerdy is
  good)
• White Coat
• Men Glasses/stethoscope, matching leather belt
  and shoes
• Women Shoulder length or shorter hair, below
  knee skirt

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What patients want Conclusions

• A doctors dress may only be applicable to
  first encounters with patients
• Doctor-patient relationship more important

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Emergence of New Technology
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Is it professional to use your Blackberry during
a meeting or a lecture?
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Where do you draw the zigzag line?

• In the car
• In the hospital hallway
• During a conversation
• Resident applicant at noon conference
• Faculty at Grand Rounds
• Physicians on National Committees

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Should I allow patients/families to be my
Facebook friends?
Practicing Medicine in the Age of Facebook. NEJM
2009361649-51
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• 64 of UF medical students had an account
• 62 of accounts were public
• 7 of 10 had photos with alcohol
• 3 of 10 had unprofessional content

Thompson LA, et al. J Gen Intern Med
200823954-7
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and along came
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GMEC May 28, 2009 1200 - 130 Mackenzie Hall
Marquam Room AGENDA 1. Internal Review of
Surgery 2. Internal Review of Public
Health/Preventive Med 3. Review of ACGME Resident
Surveys 4. Duty Hours Subcommittee Expansion 5.
GMEC Exec Update 6. Volunteers for Internal
Reviews 7. Blogs/Twitters with HIPAA
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Is a resident not obeying duty hour limits
unprofessional?
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Faculty Guidance

• Dont worry about your duty hours, we will make
  them look right.
• Not following duty hour limits is
  unprofessional.
• Leaving your patient at a critical time is
  unprofessional.

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The Linear Argument?

• Long hours of work make you fatigued
• Fatigue can lead to errors
• Errors can cause patient harm
• Causing patient harm is unprofessional

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Its not the years, honey, its the miles

• Professor Indiana Jones, 1981

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Fatigue
EQ (Emotional Intelligence)
Hours on task
Your Health
Life
Stress
Genetics
Lack of Sleep
The Task
Burnout
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Medical Errors
Workload Intensity
Human Fatigue
Judgment
Systems
Hand-offs
Communication
Experience
Supervision
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Examples from the airline industry with highly
regulated duty hours
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Pilots slept, overflew destinationAssociated
Press August 4, 2009

• Pilots fell asleep while plane on autopilot
• Captain had Obstructive Sleep Apnea
• Several days of early (0600) start times

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Buffalo crash pilots discussed sickness, low
payAssociated Press July 27, 2009

• Co-pilot felt ill would have skipped flight but
  didnt want to pay for hotel room
• Co-pilot commuted from Seattle to Newark
• Both pilots napped in a crew lounge rather than
  pay for a hotel room before flight

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Buffalo crash pilots discussed sickness, low
payAssociated Press July 27, 2009

• Every Colgan Air pilot has an absolute
  obligation as a professional to show up for work
  fit for duty. As is common in the airline
  industry, we have reserve pilots available in
  case they are not.

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Being professional is coming to work the best
prepared you can beevery day
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Residents Duty Hours and ProfessionalismJohn D.
Rybock, MD, NEJM August 27, 2009

• Although we added professionalism as a training
  goal, we began giving our trainees the choice
  between abandoning a patient and lying.
• If we fail to return professional decision
  making to the residents, we will end up with a
  large number of medical workers, not medical
  professionals.

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Burnout affects all components of professionalism
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An Epidemic of Burnout

• Emotional exhaustion
• Depersonalization
• Low personal accomplishment

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Its better to burn out than fade awayHey Hey,
My My Neil Young 1979Suicide Note Curt
Cobain 1994
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Student ResidentBurnout
Lack of life-work balance
Workload Intensity
Limited control
Lack of respect
Dysfunctional system
Debt
Grades
Unhealthy learning environment
Negative life events
Relationships
Uncertain future
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Effects of ACGME Duty Hour Limits on Sleep, Work,
Hours, and SafetyCP Landrigan, et al. Pediatrics
2008122250-258

• No change in
• Sleep hours, medication errors, motor vehicle
  crashes, occupational exposures
• Burnout decreased from 75 to 57 (p0.007)

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Establishing life-work balance, a sense of
well-being, and avoiding burnout could have a
very significant positive impact on professional
behavior
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Others inspire us, information feeds us,
practice improves our performance, but we need
quiet time to figure things out, to emerge with
new discoveries, to unearth original answers.
Ester Buchholz
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Summary Professionalism

• Is a unique set of expected behaviors
• Must and can be taughtas a team
• Concepts should be relevant to the daily practice
  of medicine
• Changing values change the definition
• New issues must be addressed as they arise in our
  culture
• Burnout is a significant threat