A Practical Approach to Developing a

Professionalism Curriculum

MAME WorkshopMay 23, 2012

Disclosure

Drs. Frohna and McGregor have no conflicts of interest to report

Objectives for this Session

List the key elements of professional behavior, as identified in the “Physician Charter.”

Describe three interactive methods for teaching professionalism to residents/fellows.

Use a tool to create learning cases. Identify useful online resources for

teaching and evaluating professionalism. Discuss evaluation strategies for a

professionalism curriculum in your home program.

My favorite Great Lake is

1 2 3 4 5

7%

0%

29%

7%

57%1. Huron2. Ontario3. Michigan4. Erie5. Superior

My Educational Domain

1 2 3 4 5 6

47%

33%

13%

0%0%

7%

1. Institutional2. Program3. Undergraduate

Medical Education

4. Nursing Education

5. Faculty Development

6. Other

What is your discipline?

1 2 3 4 5 6 7 8 9 10

0%

20% 20%

0%

40%

7%7%7%

0%0%

1. Anesthesiology2. Family Medicine3. Internal Medicine4. Neurology5. OB-Gyn6. Ophthalmology7. Pediatrics8. Psychiatry9. Surgery10. Other

Does your program have a formal professionalism

curriculum?

1 2

50%50%1. Yes2. No

Does your institution have a centralized professionalism

curriculum?

1 2

71%

29%

1. Yes2. No

Do you evaluate your curriculum?

1 2

50%50%1. Yes2. No

What is your best method for evaluating your

residents?

1 2 3 4 5 6 7

7%

36%

43%

7%7%

0%0%

1. Critical event documentation

2. Global evaluation forms

3. Multisource feedback4. OSCE5. Peer evaluation6. Professionalism mini-

evaluation exercise (P-MEX)

7. Small group faculty evaluation

What is the next best method for evaluating your

residents?

1 2 3 4 5 6 7

0%

42%

25%

8%8%

17%

0%

1. Critical event documentation

2. Global evaluation forms

3. Multisource feedback4. OSCE5. Peer evaluation6. Professionalism mini-

evaluation exercise (P-MEX)

7. Small group faculty evaluation

Have you previously attended a workshop on developing a

professionalism curriculum?

1 2 3 4

53%

13%13%

20%

1. No2. Yes, at my

institution3. Yes, with my

program director association

4. Yes, at another site

Getting to your definition of

professionalism

Small Groups

Brainstorm characteristics of unprofessional behavior

Establish the elements that define professionalism

Report out

Your Definition of Professionalism

Accountable Respectful Compassionate Humility Approachable Dress Punctual Adaptable Ethical

Integrity Responsible Ambassador Hardworking Emotional Intelligence Ownership of Pts Positive Attitude Responsive Lifelong Learner Interacting Well with

Staff, Patients, Families

Six Step Approach to Curriculum Development

Problem Identification and General Needs Assessment– Health Care Problem– Current v Ideal

Approach Targeted Needs

Assessment– Learners– Learning Environment

Goals and Objectives

Educational Strategies– Content– Method

Implementation– Resources– Barriers– Delivering Curriculum

Evaluation and Feedback– Learners– Program

Curriculum Development for Medical Education: A Six-Step ApproachEds. Kern, Thomas, Hughes. 2009

Step 1: Problem Identification

Residents must be educated in a humanistic educational environment that protects their safety, and nurtures professionalism and the effacement of self interest that is the core of the practice of medicine and the profession in the United States.

Nasca 2010, Open Letter

Step 2: Targeted Needs Assessment

Shared definition at an institutional level

Defining the local issues– Remediating unprofessional behavior– Advancing professionalism

Your Definition of Professionalism

Accountable Respectful Compassionate Humility Approachable Dress Punctual Adaptable Ethical

Integrity Responsible Ambassador Hardworking Emotional Intelligence Ownership of Pts Positive Attitude Responsive Lifelong Learner Interacting Well with

Staff, Patients, Families

Stern’s Definition of Professionalism

“Professionalism is demonstrated through a foundation of clinical competence, communication skills, and ethical understanding, upon which is built the aspiration to, and wise application of the principles of professionalism: excellence, humanism, accountability, and altruism.”

Stern DT (ed.), Measuring Medical Professionalism, Oxford University Press, 2006

Clinical Competence (Knowledge of Medicine)

Communication Skills

Ethical and Legal Understanding

Ex

celle

nc

e

Hu

man

ism

Ac

co

un

tab

ility

Altru

ism

Professionalism

Stern DT (ed.), Measuring Medical Professionalism, Oxford University Press, 2006

Step 3: Goals and Objectives

The Physician Charter ABIM: Project Professionalism ABP/APPD: Teaching and Assessing

Professionalism Royal College of Physicians ACGME

Physician Charter Three Fundamental Principles Ten Professional Responsibilities with

Commitment to:– Professional competence– Honesty with patients– Patient confidentiality– Maintaining appropriate relations– Improving quality of care– Improving access to care– Just distribution of finite resources– Scientific knowledge– Maintaining trust by managing conflicts of interest– Professional responsibilities

Medical Professionalism in the New Millennium: A Physician Charter. Ann Intern Med 2002;136:243-6.

The Charter as a Blueprint for Program Directors

Promoting Professionalism: A Definition

Professionalism in Patient Care– Professional competence– Honesty with patients– Patient confidentiality– Maintaining appropriate relations

Professionalism With Physician Colleagues and Other Health Professionals– Improving quality of care– Professional responsibilities– Teamwork

Stress and Its Impact on Professionalism– Professional responsibilities– Self-Awareness– Balancing Personal and Professional Commitments

Professionalism and Society– Improving access to care– Just distribution of finite resources– Scientific knowledge– Maintaining trust by managing conflicts of interest

Professionalism Beyond Residency– Professional competence

Step 4: Educational Strategies

Setting Expectations– Ceremonies, Policies, Orientation,

Charters Providing Experiences

– Formal, Informal, Hidden Curricula– Context– Developmental Process

Evaluating Outcomes– Assessments before residency– Multiple perspectives

Context

Does professionalism represent a set of stable traits of the individual?

Disconnect between how education approaches knowledge and skills versus behavior

Tied to role responsibilities

Ginsburg S, Regehr G, Hatala R, et al. Context, conflict, and resolution: A new conceptual framework for evaluating professionalism. Acad Med 2000;75:S6-11.

Developmental Achievement Levels

Professional Identity Among Cadets– Early: Professional values and standards

as rules to be followed– Transition: Internalize profession’s

values as internal qualities– Later: Own the values, can assess them,

and are able to reconcile conflicts

Forsythe GB, et al. Making Sense of Officership: Developing a Professional Identity for 21st Century Army Officers. In: The Future of the Army Profession. New York: McGraw-Hill, 2002.

Developmental Achievement Levels

Professional Identity Among Residents– Early: Explicit rules to be followed,

attendance, finishing dictations, sign outs

– Transition: Internalize profession’s values class rules, creed of accepted conduct

– Later: Own the values, can assess them, seniors assess internsForsythe GB, et al. Making Sense of Officership: Developing a Professional

Identity for 21st Century Army Officers. In: The Future of the Army Profession. New York: McGraw-Hill, 2002.

Case of JM

Case of JM

Jeopardy call rules – available on-site within three hours.

She is on jeopardy call and tests her luck by going two hours away on a workday.

This is a serious lapse in professional behavior

1 2 3 4 5 6 7

0%

38%

15%

8%

15%15%

8%

1. Strongly Agree2. Agree3. Somewhat

Agree4. Neutral5. Somewhat

Disagree6. Disagree7. Strongly

Disagree

Case of JM

Jeopardy call rules – available on-site within three hours.

She is on jeopardy call and tests her luck by going two hours away on a workday.

She is away because she is looking for a place to live for her fellowship, which begins in a month.

This is a serious lapse in professional behavior

1 2 3 4 5 6 7

8%

38%

8% 8%

15%15%

8%

1. Strongly Agree2. Agree3. Somewhat

Agree4. Neutral5. Somewhat

Disagree6. Disagree7. Strongly

Disagree

Case of JM

Jeopardy call rules – available on-site within three hours.

She is on jeopardy call and tests her luck by going two hours away on a workday.

She is away because she is looking for a place to live for her fellowship, which begins in a month.

Several classmates note a photo of her new apartment on her Facebook dated the day of her scheduled call.

This is a serious lapse in professional behavior

1 2 3 4 5 6 7

6%

24%

6% 6%

18%

24%

18%

1. Strongly Agree2. Agree3. Somewhat

Agree4. Neutral5. Somewhat

Disagree6. Disagree7. Strongly

Disagree

Thoughts about JM?

Is it a professionalism issue if she tests limits and is not called in?

What if she is scheduled to graduate in 4 weeks and needs to relocate for fellowship?

What if she had tried to trade call unsuccessfully?

What about stretching the rules and electronically documenting her behavior?– Unprofessional? – or just not so smart?

JM facts

She does get called in. When reached, she denies she knew

she was on call.

This is a serious lapse in professional behavior

1 2 3 4 5 6 7

94%

6%

0% 0%0%0%0%

1. Strongly Agree2. Agree3. Somewhat

Agree4. Neutral5. Somewhat

Disagree6. Disagree7. Strongly

Disagree

JM facts

She does get called in. When reached, she denies she knew

she was on call. She calls back and says she was

indeed aware but cannot return within 3 hours to take call. “Just call in the back-up jeopardy person.”

This is a serious lapse in professional behavior

1 2 3 4 5 6 7

87%

7% 7%

0%0%0%0%

1. Strongly Agree2. Agree3. Somewhat

Agree4. Neutral5. Somewhat

Disagree6. Disagree7. Strongly

Disagree

JM facts

She does get called in. When reached, she denies she knew

she was on call. She calls back and says she was

indeed aware but cannot return within 3 hours to take call. “Just call in the back-up jeopardy person.”

She had an appointment with the school district about her special needs son’s placement.

This is a serious lapse in professional behavior

1 2 3 4 5 6 7

50%

21%

14%

0%0%0%

14%

1. Strongly Agree2. Agree3. Somewhat

Agree4. Neutral5. Somewhat

Disagree6. Disagree7. Strongly

Disagree

Dénouement

Back up called She had to pay back call to back up Professionalism sign off deferred until

six months into fellowship Precedent set

Designing Professionalism Cases

Select a case Prepare for discussion Decide how to reveal the case and

the conflicts Prepare a short discussion

Designing Professionalism Cases

Select a case– Tell a story– Ok to merge cases– Identify context and key conflicts

Prepare for discussion Decide how to reveal the case and

the conflicts Prepare a short discussion

Designing Professionalism Cases

Select a case Prepare for discussion

– Adapt to levels of learners– Anticipate issues that may arise– Generational issues– Re-evaluate case

Decide how to reveal the case and the conflicts

Prepare a short discussion

Designing Professionalism Cases

Select a case Prepare for discussion Decide how to reveal the case and

the conflicts– Create tension!– Highlight competing conflicts in the case

Prepare a short discussion

Designing Professionalism Cases

Select a case Prepare for discussion Decide how to reveal the case and

the conflicts Prepare a short discussion

– Review learning objectives– Tie back to Physician Charter– Summarize discussion

Small Groups

Design your own case!!!

Step 5: Implementation

Political Support/buy-in Resources

– Faculty– Time

Implementing, Sustaining, and Improving the Curriculum

Teaching Strategies

Setting expectations Appreciative inquiry Cultural norm setting

– Retreats, Play of the Week– P.A.D.S.

Lectures/Curriculum Reflective exercises Professionalism series

St. Christopher’s Hospital for Children

Target audience –clinical fellows Three, small group didactic –

followed by case-based reflection (90 minute sessions)

Curriculum – 1/3 of ABP/APPD Guide per session

Evaluation – Retrospective pre-test and post-test

University of Wisconsin

Noon conference facilitated discussions, focusing on each of the sections of the APPD-ABP book:– Content discussion (5 min)– Vignettes– Longer cases

Newer strategies

Peer review system (Bonder J, Elwood D, Heckman J, et al. PM&R 2010;2(2):117-24)

Reader’s Theatre – scripted faculty development (Bell SK, Wideroff M, Gaufberg L. Pt Ed & Couns 2010;80(3):354-7.)

Wikis - (Varga-Atkins T, Dangerfield P, Brigden D. Med Teach 2010;32(10):824-9.)

Step 6: Evaluation and Feedback

The Learners– Evaluations can also help set

professionalism expectations– Role of reflection

The Program

Evaluating Learners 360 or multi-source evaluations Nursing evaluations Peer evaluations Small groups* Professionalism mini-evaluation

exercise (P-MEX)**

*Haidet et al. The Role of the Student-Teacher Relationship in the Formation of Physicians The Hidden Curriculum as Process. J Gen Intern Med 2006; 21:S16–20.

**Cruess R, McIlroy JH, Cruess S, Ginsburg S, Steinert Y. The professionalism mini-evaluation exercise: A preliminary investigation. Acad Med 2006;81:S74-8.

Evaluating Learners (cont)

Critical events & reflection Professionalism Series Conscientiousness index*

*McLachlan JCP, et al. The conscientiousness index: A novel tool to explore students’ professionalism. 2009 Acad Med 84:559-565

Evaluations

Importance of Reflection

Faculty and residents need to gain additional experience in observing and reflecting on their own and others’ behavior

Learners should be encouraged to share their stories during all teaching sessions

Evaluating the Curriculum

Satisfaction Examine trends on global, peer, 360

evaluations over time Changes in behaviors (need

mechanism to monitor) Reflections

Six Step Approach to Curriculum Development

Problem Identification and General Needs Assessment– Health Care Problem– Current v Ideal

Approach Targeted Needs

Assessment– Learners– Learning Environment

Goals and Objectives

Educational Strategies– Content– Method

Implementation– Resources– Barriers– Delivering Curriculum

Evaluation and Feedback– Learners– Program

Curriculum Development for Medical Education: A Six-Step ApproachEds. Kern, Thomas, Hughes. 2009

It’s ALL our jobs!

Thanks!!

John Frohna– frohna@wisc.edu

Rob McGregor– Robert.McGregor@DrexelMed.edu

Some sample ways of teaching this

Curriculum

233 program directors surveyed – 1/3 no curriculum or formal

professionalism experience– ~1/3 combined with ethics– ~1/3 independent curriculum

Barriers – – Faculty expertise / Need for faculty

development– Curricular crowding

Lang CW et al. Ethics and Professionalism in the Pediatric Curriculum: A Survey of Pediatric Program Directors Pediatrics 2009.

Philadelphia Professionalism Series

Children's Hospital of Philadelphia (CHOP) Residents

St. Christopher’s Hospital for Children (SCHC) Fellowships

CHOP Model

Ten, monthly sessions at 7:30-8:30 AM

20-24 house staff and 3-4 preceptors Ten major themes (6 from the

ABP/APPD Guide)

CHOP Series

All sessions rated “very helpful, helpful” by at least 50%

Attendance mean – 5.0 (range 1-9) Numbers per group – 9.43 (range5-10) Qualitative outcomes – global –societal topics not

as well received Best received

– Fatigue and Burnout and Their Impact on Clinical Care**– Coping with Medical Errors*

Small group important

** Designed internal module

SCHC

75% attendance Likert scale 4.2 acceptance Pre-post test scores still being

processed Adding similar sessions for the

residents Fellows may function as teachers in

next year’s iteration