Vanessa Thompson, MD Andrea Marmor, MD Assistant Professor, Medicine Associate Professor, Pediatrics

University of California, San Francisco

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Introductions Defining the problem:

What is professionalism? Why is it important?

Description of the SOAP approachWork on cases in small groupsLarge group review and wrap-up

1. Recognize categories of professionalism challenges in learners

2. Apply the SOAP model to help further understand and assist learners in difficulty

3. Review strategies for communicating about professionalism concerns with a learner

4. Develop an initial approach to addressing professionalism issues in trainees

One or two KEY WORDS: E.g., late, rude, deferential, slacking off

Think of a person you feel exemplifies professionalism Try to describe why

1-2-4-All 1 minute alone (write or think) 2 minutes in pairs (share) 4 minutes in groups of 4 (compare/contrast) 5 minutes all (each group shares ONE idea)

Definitions ABMS (2012): “…a belief system about how

best to organize and deliver health care…shared competency standards and ethical values”▪ Includes means to ensure these are lived up to

Lucey (2010): “…not an innate quality but a skill developed with deliberate practice over time…”▪ Observed in interpersonal and organizational domains

Frameworks Wilkinson/Papadakis

Unprofessional behavior correlated with Subsequent disciplinary action by Board

(Papadakis) Medical errors Poor patient satisfaction Staff turnover Institutional reputation Health care costs

Dayton J Qual & Patient Saf 2007;33:34-44.Gewande Surgery 2003; 133:614-621.While Obstet Gynecol 2005;105:1031-38.Lingard Qual Saf Health Care 2004;13:300-334.

1. Recognize categories of professionalism challenges in learners

2. Apply the SOAP model to help further understand and assist learners in difficulty

3. Review strategies for communicating about professionalism concerns with a learner

4. Develop an initial approach to addressing professionalism issues in trainees

1. Recognize categories of professionalism challenges in learners

2. Apply the SOAP model to help further understand and assist learners in difficulty

3. Review strategies for communicating about professionalism concerns with a learner

4. Develop an initial approach to addressing professionalism issues in trainees

Application of a clinical framework to an educational problem Learner-centered, instead of patient-

centeredTakes us from our impressions

(subjective) to a plan for action and reassessment

The sense/judgment that there is a problem “Current Complaint”

Should drive initial hypotheses (“differential diagnoses”) but not assessment

Consider: Personal reactions Alternate explanations for behavior

Collection of information to support/refute hypotheses (“differential diagnosis”)

Consider the scope of problem Domains/areas of professionalism Settings affected Isolated vs. pattern Individual vs. Interpersonal vs. Societal

Consider multiple sources of information

Classroom Attendance Faculty evaluations Peer evaluations Paper or SP Exams

Practice-Based Patient satisfaction Self-administered

rating scales 360 degree

evaluations

Clinical Training Faculty/resident/

student evaluations Critical incidents Observation of

clinical encounters Completion of the

medical record

Develop a “working diagnosis” Incorporate collected objective data

Consider the differential Are there other possibilities? How will you distinguish between them?

Put your nickel down Pick ONE issue to focus on

What level of intervention is appropriate?

1. Open the conversation What will you say? What will they say?

2. Coach What strategies would you use?

3. Reassess When? How?

Vignettes that represent different challenging learners

Your task: 20 minutes Use the discussion guide to apply the

SOAP method to these learners May modify the specifics to suit your

setting Large group discussion:

Be prepared to present what you learned, and your INITIAL approach to the learner

Each group will present…1.ONE new idea/revelation

Did anything surprise you?2.How would you OPEN your discussion with this learner?

Senior resident on inpatient serviceReputation for academic strengthRecently has acted

disinterested/burnt-out Interns/students intimidatedBackground:

First in family to attend college, leader in professional school

Junior student with a PhDLate to rounds, poor job on H and P

and presentation However, good knowledge of

pathophysiologyDoes not respond to feedback on

these issuesThinks he performed well, feels others

are uncomfortable with his intelligence

Senior student on specialty elective Expresses enthusiasm about learning,

and gets her work done Looking at/typing in smart phone on

rounds, in patient rooms and during teaching

Others have noticed, but aren’t sure how to handle it

Unclear if she is using phone for learning or personal

Residency previously intervened re: duty hours

Devoted to her patients, but consistently behind on patient care and charting

Defensive when approached about unfinished notes

1. Recognize categories of professionalism challenges in learners

2. Apply the SOAP model to help further understand and assist learners in difficulty

3. Review strategies for communicating about professionalism concerns with a learner

4. Develop an initial approach to addressing professionalism issues in trainees

1. Recognize categories of professionalism challenges in learners

2. Apply the SOAP model to help further understand and assist learners in difficulty

3. Review strategies for communicating about professionalism concerns with a learner

4. Develop an initial approach to addressing professionalism issues in trainees

Pick one case to delve into more deeply

What are the components of an effective plan for this learner?

1. Open the conversation Address learner directly, kindly Focus on behavior, not personality Pause for response: assess learners’ self-

awareness2. Coach

Redefine the goal Individualized intervention, based on assessment

3. Reassess Shared accountability Must be able to document “competence”

“Cup of Coffee” conversation

Ask, Tell, Ask

Use real incidents as examples

Instruction with practice, feedback and reflection

Set clear, consistent expectations

Attributed to Gandhi