- Email: [email protected]
Teaching professionalism during anesthesiology training
Journal of Clinical Anesthesia (2005) 17, 392 – 398
Special article
Teaching professionalism during anesthesiology training Steven B. Edelstein MD (Diplomate, American Board of Anesthesiology, Associate Professor)*, Julia M. Stevenson MD (Resident), Kathleen Broad MD (Diplomate, American Board of Anesthesiology, Assistant Professor) Department of Anesthesiology, Loyola University Medical Center, Maywood, IL 60153, USA Received 20 November 2003; accepted 18 October 2004
Keywords: Anesthesiology; Education; Professionalism; Residency
Abstract Recently, there has been a focus on the teaching of professionalism in postgraduate medical education. Many discussions and studies have been performed to help in teaching professionalism and in the evaluation of the effectiveness of this teaching process. Unfortunately, many anesthesiologists are unaware of the literature and the discussions that have taken place. This review article serves as a primer for those individuals faced with the task of instilling the concepts of professionalism, not only in trainees but also in anesthesiologists practicing today. D 2005 Elsevier Inc. All rights reserved.
1. Introduction Today, we are faced with increasing pressures to train physicians who are not only competent in factual knowledge and procedures but also demonstrate expertise in the area of professionalism. Currently, the Accreditation Council for Graduate Medical Education (ACGME) has listed among its 6 core competencies professionalism which each residency should monitor, teach, and evaluate (ACGME General Competencies, version 1.3, 9.28.99). However, this brings to light many issues regarding the subject, namely, what is the definition of professionalism? Can we teach it, and if so, how? Are there proven methods that have been successful? And how do we evaluate our effectiveness in instruction?
T Corresponding author. Tel.: +1 708 216 0414; fax: +1 708 216 1249. E-mail address: [email protected] (S.B. Edelstein). 0952-8180/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2004.10.006
Professionalism in anesthesiology has some unique aspects. Although most anesthesiologists are engaged in person-to-person interactions, these interactions tend to be short (and getting shorter as pressure increases to speed efficiency through the operative process), but intense. Notable exceptions include the pain clinic setting and the intensive care unit. Both of these anesthesia subspecialties allow for longer periods of discussion with patients and their families, and both subspecialties allow for the discussion of many ethical issues. Many recent articles have been written explaining the need to instruct trainees about professionalism and also trying to come to grips with a unifying definition of the terminology. The American Association of Medical Colleges (AAMC) currently has an ongoing discussion and assessment, bProject ProfessionalismQ; however, the focus is mostly general at best (www.aamc.org). In this article, we discuss professionalism, including its definition, how other specialties are assessing and evaluating its training, and our approach to the subject matter as it pertains to the field of anesthesiology.
Teaching professionalism in residency
2. Definition of professionalism Swick [1] has been instrumental in helping to foster a bnormative definitionQ of the term professionalism. Essentially, he states that medical professionalism is exemplified through what physicians actually do and that it can be composed of a set of behaviors (Table 1). The terminology fostered by Swick has been supported by many proponents of professionalism (eg, AAMC–Project Professionalism); however, other items have been incorporated into the subject of professionalism, notably humanism. Linn et al [2] have put forward a scale with which to measure a physician’s humanistic attitudes, values, and behaviors (Table 2). Frankford et al [3] describe in detail the concept of responsive medical professionalism, in which the starting point of this professionalism is an ethical system supported by an appropriate institutional infrastructure. They put forth the 4 major ideals of responsive medical professionalism: (1) medical professionals should strive for mutual interdependence with patients and society; (2) medical professionals should both respond to and partially create social values; (3) medical work should be valued intrinsically as part of an individual and collective self-identity, and as a contribution to the public good; and (4) medical work should be organized collegially. To achieve these ideals, 3 characteristics of the institutional framework must be present: first, organizations should merge education and practice; second, organizations must make collegial, experiential, reflective, lifelong learning a part of education and practice; and finally, these organizations must maintain close linkages with communities through regular processes and relationships that balance modes of representative and participatory democracy. Frankford et al [3] conclude that organizations should teach professionalism both within and without, rather by action Table 1 The professional behaviors of physicians should include the following ! Subordinate their own interest for the interest of others ! Adhere to high ethical and moral standards ! Respond to societal needs, and their behaviors reflect a social contract with the communities served ! Evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others and trustworthiness ! Exercise accountability for themselves and for their colleagues ! Demonstrate a continuing commitment to excellence ! Exhibit a commitment to scholarship and to advancing their field ! Deal with high levels of complexity and uncertainty (exercise independent judgement to make appropriate decisions in the face of complex and often unstable circumstances usually with incomplete information) ! Reflect upon their actions and decisions Adapted from Swick [1].
393 Table 2 ! ! ! ! ! ! ! !
Physicians humanistic attitudes
Cooperation with medical colleagues Cooperation with paramedical staff Has a good physician-patient relationship Renders comfort and empathy Involves patients in decisions Considers patients’ concerns Puts patient at ease and renders comfort Admits one’s own errors
Adapted from Lin et al [2].
than by exhortation. Here, action means institutionalizing numerous mechanisms through which medical work is influenced by social values, even as it in turn teaches society the value of medical work. Ultimately, their main point is that professionalism is neither taught nor learned through preaching; rather it is taught and assimilated by living a professional life, with a lifelong engagement with other individuals with similar collective social values. Medical schools have been at the forefront of teaching the concepts of medical professionalism. Discussions on the topic have been fostered since the early 1980s, and an aggressive implementation process has been initiated by the AAMC. Currently, medical schools in the United States have well-established professionalism programs that incorporate not only issues regarding professionalism, but also ethics and its role in medicine. Most of these ethical issues are covered in small group discussions with broad exposure to clinicians, ethicists, and educational personnel. Ultimately, these discussions and the students’ viewpoints on ethical issues are evaluated during frequent intervals. Phelan et al [4] describe 7 basic traits and noncognitive behaviors in medical students, including (1) reliability and responsibility, (2) maturity (eg, behaves respectfully, accepts blame for failure), (3) critique (eg, accepts criticism, corrects shortcomings), (4) communication skills, (5) honesty and integrity, (6) respect for patients (eg, maintains patient confidentiality, empathetic behavior, and patience with patient and family), and (7) showing no signs of chemical dependency or mood disorder (eg, change in personality, excessive irritability, depression). Many of these same items are routinely incorporated into evaluation summary forms issued by professional certification boards such as the American Board of Anesthesiology (ABA). Barry et al [5] performed a survey of medical students and residents at the University of Colorado to assess the common challenges to medical professionalism and to ascertain physician satisfaction with training in professionalism. Respondents were asked to evaluate 6 professionalism-related scenarios. Overall, the frequencies of best responses were for minor confidentiality, conflict of interest, and honesty in documentation scenarios. These responses were greater than for physician impairment, sexual harassment, and acceptance of gifts scenarios. Increasing levels of experience were correlated with a modest increase in bbest
394 responseQ for all scenarios. When asked about the setting where discussions regarding professionalism were held, 76% of respondents reported informal discussions, 28% noted course work, and 26% noted teaching rounds. Most noted that teaching rounds and informal discussions were of most value; however, 73% of respondents had less than 10 hours of course work devoted to professionalism, and 40% of respondents expressed dissatisfaction with their education and training in professionalism. The sentinel question is not just what professionalism is, but how does one teach it. The AAMC has had many roundtable discussions [6] on this subject, but most end up with the bI know it when I see it, but don’t know how to teach it.Q Moreover, it is difficult to overcome the bias of individuals who view the teaching of professionalism and its concepts to be of less value than other scientific endeavors. Much of the literature on professionalism is subjective in nature. Randomized, controlled, double-blinded studies are not possible when dealing with the issues of professionalism and how to effectively teach this complicated topic. Many psychological and emotional variables exist, especially when dealing with emotional constructs that have been established since childhood. Another challenge to teaching professionalism was elucidated by Ludmerer [7], who believed that the main limitation of both instructional and mentoring approaches, even when offered together, is what accounts for only some of the factors that influence the development of professionalism. He went on to state that one must consider the profound impact of the entire institutional environment (of the academic health center) on shaping the attitudes, values, beliefs, modes of thought, and behavior of medical students. Ludmerer stressed that an unfriendly institutional culture can easily undermine the well-intentioned efforts of those trying to impart professionalism through the curriculum. Ultimately, whatever definitions are decided upon, the training program must meet the expectations put forth by the ACGME (ACGME General Competencies, version 1.3, 9.28.99) regarding professionalism, which include demonstration of respect, compassion, and needs of the society and patient that supercede self-interest. In addition, accountability to patients, society, and profession; commitment to excellence and ongoing professional development; and cultural, age, and sex sensitivity are essential components. Other specialties in medicine have been actively trying to devise programs that address the teaching of professionalism. Several articles have addressed the issues of professionalism, and some have put forward varying approaches to teach this subject matter.
2.1. Emergency medicine In a review article, Larkin [8] felt that, although demonstration of ethical and humanistic skills was important, the teaching and assessment of these skills have been left more or less to chance. He believed that the evaluation
S.B. Edelstein et al. of professionalism in emergency medicine was limited by the paucity of evaluation tools and the lack of time for implementation. His recommendations included multipleessay questions on annual in-service examinations that focused on ethical issues in emergency medicine; ethics bobjective structured clinical examinationQ stations during Advanced Cardiac Life Support, Advanced Trauma Life Support, and Pediatric Advanced Life Support courses; and blinded videotape reviews of real-time patient interactions.
2.2. Family medicine Brownell and Cote´ [9] performed a survey to determine how most family medicine residents in Canadian medical training programs obtain their knowledge regarding professionalism. More than 93.5% of residents selected bcontact with positive role modelsQ as their most important method of learning about professionalism. As their second choice, 50% selected bcontact with patients and their next of kin.Q Of note, the third choice by 43.5% of all the residents was bcontact with negative role models.Q The quantity and quality of teaching professionalism were reported (on a scale of 1-5, 1 being inadequate and 5 being superior) as 4.13 F 1.44 and 3.79 F 1.44. Suggestions to facilitate learning included discussions with peers, teachers, and patients; better examples of teachers as role models; workshops and seminars; and formal teaching. Ultimately, the authors stressed that professionalism needed to be on the list of topics for lifelong learning; that is, what one needs to know about professionalism will change and will need to be continually upgraded and refined throughout the physician’s practice.
2.3. Internal medicine A large amount of literature have been written by the internal medicine community and focus on teaching professionalism in the specialty. Recently, an extensive review of the subject was completed by the American Board of Internal Medicine (ABIM) and resulted in the document, bProject Professionalism,Q found on the society’s Web site (http://www.abim.org/pubs/profess.pdf). The ABIM has developed a taxonomy on which professionalism is subdivided into 2 sections: elements of professionalism, which include altruism, accountability, excellence, duty, respect for others, honor, and integrity; and challenges to professionalism, which include abuse of power (breach of confidentiality, inappropriate interactions with patients and colleagues, bias, and sexual harassment), arrogance, greed, misrepresentation, impairment (eg, substance abuse among professionals), lack of conscientiousness, and conflicts of interest (self-referral, acceptance of gifts, use of services, collaboration with industry, and compromising the principles of clinical investigations). In addition, the ABIM has developed an elaborate guide to help program directors teach and evaluate professionalism. Many case-based scenarios and examples are presented to the program directors to serve as guides, especially in
Teaching professionalism in residency regard to the elements of and challenges to professionalism. The ABIM also recommends frequent or even daily evaluations of a resident’s performance in regard to professional behaviors. It has formulated praise or early concern notes designed to enhance feedback and to facilitate the flow of information from faculty to trainee. In addition, the ABIM has developed the Professionalism Remediation Summary to help both the program director and trainee understand behaviors that are deemed unprofessional and problematic. Major descriptors of unprofessional behavior include unmet professional responsibility, lack of effort toward self-improvement and adaptability, diminished relationships with patients and families, and diminished relationships with health care professionals. Robins et al [10] have proposed adapting the taxonomy of the ABIM and applying it to undergraduate medical education at the University of Washington. In addition, that group added a category denoted as bnegotiating power asymmetriesQ because they noticed that medical students were concerned about how to speak up when they observed teachers and other superordinates acting unprofessionally [11]. Essentially, they felt that students were silenced or bewildered by power and that their silence was often misinterpreted as complicity with behaviors they perceived to be unethical or unprofessional. This situation was true not only for medical students, but was also noted among residents who appeared very hesitant to report unprofessional behavior because they were afraid that retribution would take place.
2.4. Anesthesiology In the anesthesia literature, very little has been written regarding professionalism and how it should be taught. In fact, an extensive amount of work has been one in the area of ethics, which is evident, by the excellent American Society of Anesthesiologists Ethics Syllabus (http://www. asahq.org/wlm/Ethics.html). Rhoton [12] performed a study in the late 1980s to identify anesthesia residents who received undesirable scores regarding professional behavior. Rhoton determined the frequency and nature of comments regarding this behavior, assessed predictive relationships for receiving undesirable scores, and identified consistent patterns of performance associated with these scores. Comments by faculty evaluators were distributed over a range of items from behavior and personality issues to abdication of responsibilities inside and outside of the operating room (OR). The author ultimately found that there was a pattern of performance associated with unprofessional behavior and clinical performance; that is, those with unprofessional behavior tended to have problems with clinical performance as well. As mentioned earlier, anesthesiologists are in a unique situation because their patient interactions are short, and discussions regarding patient care are held in an efficient
395 and quick session. However, they often have very prolonged interactions with the OR staff and support personnel, including surgeons, nursing, and housekeeping. How anesthesiologists interact with these individuals is as much a part of professionalism as is the doctor-patient relationship. In fact, Lingard et al [13] explored the nature of communication among the staff in the OR. After 4 months of observation and informal interviews, some themes of prominent communicative events occurred. These themes included time (room turnover, patient cancellation, etc), resources (equipment allocation, personnel distribution), roles (responsibilities, constraints), safety and sterility (aseptic technique), situation control (eg, temperature regulation), and relationships. bThe highest tension levels occurred when this tension extended beyond the content, participants, and context of its original occurrence,Q they reported. Of note, the authors saw most conflicts occurring between nursing and surgeons and little between surgeons and anesthesiologists. However, they go on to state, somewhat disturbingly, that the lack of conflict between surgeons and anesthesiologists may be related to the fact that there was very little communication of any kind between the 2 groups. Where trainees were concerned, the authors noted that novices were involved in more than a third of these high-tension events. Novices also tended to respond in 2 ways: mimicry of the teacher’s discursive style or posture, and withdrawal from the communicative sphere, with withdrawal being the most common response.
3. Teaching professionalism at the Loyola University Department of Anesthesiology At our institution, we have taken a unique approach to the teaching of professionalism. We have developed a multidisciplinary approach to the subject matter, with a resulting bminicourseQ in professionalism. This minicourse is in addition to an ongoing ethics course that we teach, and it is composed of lectures, literature reviews, articles, and interactive case-based sessions (4-6 sessions per year) on the subject. Lectures basically focus on the nature of professionalism and why we are concerned about the subject, whereas the articles delve into the ongoing discussions regarding professionalism and its evaluation. The program is spread throughout the training period, from clinical base year to conclusion at the end of the CA-3 year (Table 3).
3.1. The role of ethics teaching The American Society of Anesthesiologists Ethics Syllabus states that, bEthics education has been promoted on an assumption that certain moral behavior is expected and is desirable among all physicians, both in their collegial interactions as well as their treatment of patients. Furthermore, ethics education has been promoted on the assumption that certain undesirable practices and personal traits
396
S.B. Edelstein et al.
Table 3 Summary of teaching professionalism at the Loyola University Department of Anesthesiology Ethics teaching ! Case-based discussions ! Journal clubs focusing on recent articles in bioethics ! Ethics grand round presentations Role modeling ! Selecting and promoting role models ! Mentorship programs Interactive sessions with employee assistance Other interactive sessions Evaluation of professionalism education ! 3608 evaluations ! Self-assessments ! Monthly faculty and resident evaluations (observational) ! Standardized patients (in process)
conflict resolution and sexual harassment to understanding cultural diversity. Most of these sessions are led in an informal manner, with the participants identifying items that they find most unprofessional in fellow residents, faculty, and nursing personnel. After extensive lists are generated, usually via a lively exchange of ideas, focused discussions on these items take place, and occasionally, remedies are found. Interestingly, most of the problems of professionalism in the OR seemed to arise during periods of heightened stress. Many faculty and residents felt that the behavior of individuals was adversely affected most when patient management became complicated. As such, we are now trying to quantify and possibly help manage OR stress with the help of the EAP.
3.4. Other interactive sessions have evolved in the medical environment, which a consciously directed moral education can correct.Q Taking this cue, we have developed our own ethics program, in conjunction with the Loyola University Stritch School of Medicine Neiswanger Institute for Biomedical Ethics and Health Policy, which involves multiple formats: ! ! !
Interactive, case-based ethical discussions on a quarterly basis Journal clubs focused on recent articles in bioethics with articles chosen by residents and faculty mentors Ethics grand rounds presentations, usually 2 to 3 formal presentations per year
3.2. Role modeling Paice et al [14] define role models as bpeople we can identify with, who have qualities we would like to have, and are in positions we would like to reach. [Role models] have been shown as a way to inculcate professional values, attitudes, and behaviors in students and young doctors.Q We believe that positive role modeling is an inherent part of any curriculum on professionalism. As such, promoting professionalism among attending physicians and professors is an integral part of our curriculum. Furthermore, the establishment of a formal mentorship program aims at fostering close relationships between attending and resident physicians. At our institution, identifying role models within the anesthesia department is of paramount importance. We actively identify those attending physicians who we believe exemplify professionalism. These individuals are supported by the department and are held up to both faculty and residents as people to be emulated.
3.3. Interactive sessions with employee assistance As for the interactive sessions, we have recently begun a partnership with our institution’s Employee Assistance Program (EAP). Representatives of EAP come to our department and lead discussions on issues ranging from
In addition to the interactive sessions by the EAP and our ethics journal clubs, we have used a modification of the ethics program described by Klein et al [15] from the pediatrics department at the University of Washington. We have formulated a questionnaire that has approximately 6 difficult situations that may confront the anesthesia resident (Table 4). Participants are instructed to rank these situations on a scale from 1 to 6, from most uncomfortable to most comfortable. The results are discussed in an open format with the entire department at 2 highly interactive sessions. Currently, we are tracking these responses and looking for behavioral changes over the continuum of residency training.
3.5. Evaluation and measurement of professionalism This area is one of the most controversial and difficult to achieve. Several tools for evaluating professionalism have been put forward by the AAMC and ABIM, among others, but there is no proof that one is superior to another. Arnold [16] has done an exhaustive review of the subject matter and notes that there are 3 general areas of measurement: (1) measurement of professionalism when evaluating clinical performance, (2) measurement of professionalism as a comprehensive entity, and (3) measurement of separate elements of professionalism. In studies in which the research concentrates on the evaluation of performance, Arnold includes items such as peer evaluation (learners’ assessments of peers) and physicians’ assessments of colleagues, residents, and medical students (which primarily rely on rating scales). Two ways in which this is performed include surveys to measure the professionalism of groups, such as performed by the ABIM, or critical-incident techniques to measure the professionalism of individuals. Arnold has concluded that these longitudinal assessment tools highlight the problem of quantifying professional and unprofessional behaviors. Some behaviors are not quantifiable with the use of a scale.
Teaching professionalism in residency Table 4 Exercise is to assess how prepared you feel you are to deal with challenging situations (1 is most uncomfortable, 6 is most comfortable) Rank – You are a first year resident in anesthesia, and while on-call, a senior resident intervenes in the management of the patient, that is, essentially takes over the case without you asking. – You are away from your significant other a large amount of the time. You have now developed a friendship with someone else at work and you believe that the relationship is at risk for becoming a romantic one. – The recovery room calls about a patient you had given care to earlier in the day. You give an order for morphine (over the phone without assessing the patient) for pain. Twenty minutes later, you show up to the PACU and find out that the patient had arrested shortly after the morphine was given. The recovery team was unable to secure an airway, and the patient had an emergent cricothyrotomy. The patient currently is not responding to commands. – While on the pediatric rotation, you develop a relationship with a patient who is having frequent surgeries. You promise the child that you will take care of him the next day, and he will see you in recovery. The case now is running late, and it will not finish before 8 pm. Your daughter has a recital at school at 7 pm. – After a challenging coronary artery bypass graft surgery, the patient does not survive the procedure because of a medication error on your part. You have had many prior discussions with the family members and feel close to them. The husband looks at you at the end of surgery and asks if anything went wrong. – You have a free night off and have a special dinner planned with friends. After giving report in recovery room, your patient bcrumps,Q and you do not have time to stay and help. Adapted from Klein et al [15, p30].
These tools also bring up the problems of focusing only on unprofessional behaviors because it relies on feedback from faculty. The absence of a report about a student’s behavior is not necessarily a testament to his or her conduct. Other articles have focused on evaluating professionalism, including that of Ginsburg et al [17] who looked at several different methods including evaluations by faculty supervisors, peer evaluations, self-evaluations, use of bstandardized patients,Q and longitudinal observations. Although no one system appeared to be the best, the authors saw great potential in self-evaluation and peer evaluation formats. They also stressed the idea that professional behavior is very context-dependent. The authors stated that it is crucial to be aware of the specific context in which a behavior occurs before attempting to evaluate it. Ginsburg et al recommended that future efforts in evaluating professionalism must focus on behaviors rather than personality traits or vague concepts of character and that these evaluations must include context and conflict to be relevant and valid.
397
4. Evaluation of professionalism teaching at the Loyola University Department of Anesthesiology As stated earlier, several tools for evaluating professionalism have been put forward by the ACGME and ABIM, as well as other organizations, but there is no proof that one method of evaluation is superior to another. We have included several different methods by which we evaluate not only individual resident physicians, but also our syllabus on professionalism as a whole. At the end of each clinical rotation, attending physicians are asked to evaluate specifically the resident’s interactions with patients as well as other coworkers. Detailed feedback is requested so that residents can gain an understanding of their strengths and weaknesses in their interpersonal relations. Further directions currently being investigated include the use of the standardized patient and objective structured clinical examinations. Although the use of standardized patients has been used successfully for internal medicine and family practice, its role is less clearly defined in anesthesiology. The use of standardized patients focuses on the patient-physician interaction; however, in our field, this interaction is usually short. Therefore, it is essential to concentrate not only on the physician-patient relationship, but also on the physicianphysician and physician–allied professional relationship. However, this is an area in which we are currently focusing some energy and may ultimately be able to incorporate into our educational program. In an attempt to evaluate our progress in teaching professionalism, we have instituted a series of 3608 evaluations. Currently, residents are evaluated on a quarterly basis, not only by the faculty, but also by the recovery room personnel and selected OR personnel (physicians and nurses). The residents, in turn, are allowed to comment on these individuals. Patient involvement in the 3608 evaluation has been the most difficult to obtain because many patients do not recall specific individuals who participated in their care, only their overall experience. When we do receive specific unsolicited comments from patients via our quality assurance process, these comments are distributed to
Table 5 Points covered by the 3608 evaluation of anesthesiology resident Demonstrates ethical/moral behavior Reacts to stressful situations appropriately Demonstrates respect for the dignity of patients Medical management of the postoperative patient is appropriate ! Communicates/works effectively with patients and colleagues ! Demonstrates appropriate concern for patients ! Record keeping is complete and accurate ! Recognizes gaps in knowledge and expertise ! ! ! !
398 the appropriate personnel for discussion and feedback. The questionnaire used is essentially a distilled version of the semiannual evaluation forms put forth by the ABA. This allows for easier tracking and consistency when evaluations are reviewed not only by the resident’s mentor, but also by our Clinical Competency Committee and residency director (on a quarterly basis). A sample of questions is seen in Tables 4 and 5, and rankings are from excellent, satisfactory, poor, and unsatisfactory to not applicable. Another tool of measurement is the self-assessment. At the conclusion of each clinical rotation, residents are asked to evaluate their own performance. Each resident is asked to rate himself or herself in regard to overall performance and interaction with ancillary staff and faculty. At each quarterly resident’s status meeting, discussing how a resident’s selfassessment measures up against faculty and ancillary staff evaluations has been a powerful tool in identifying not only areas for improvement in medical knowledge and practical skills, but also areas to focus on improving interpersonal skills and behaviors.
5. Summary Professionalism has been a topic of much discussion in academic medicine. In the field of anesthesiology, we have the added challenge of developing professionalism courses that reflect the environment in which we practice, notably the OR setting. Incorporation of interactive teaching sessions, role modeling, multidisciplinary discussion panels, and even stress reduction therapy all play a role in helping train the resident in this important area of medicine. Devising the bperfectQ course for teaching professionalism is most likely an unrealistic goal, but critical evaluation of processes and new techniques should be encouraged whenever possible.
S.B. Edelstein et al.
References [1] Swick HM. Toward a normative definition of medical professionalism. Acad Med 2000;75:612 - 6. [2] Linn LS, DiMatteo MR, Cope DW, Robbins A. Measuring physician’s humanistic attitudes, values, and behaviors. Med Care 1987;25:504 - 15. [3] Frankford DM, Patterson MA, Konrad TR. Transforming practice organizations to foster lifelong learning and commitment to medical professionalism. Acad Med 2000;75:708 - 17. [4] Phelan S, Obenshain SS, Galey WR. Evaluation of the noncognitive professional traits of medical students. Acad Med 1993;68:799 - 803. [5] Barry D, Cyran E, Anderson RJ. Common issues in medical professionalism: room to grow. Am J Med 2000;108:136 - 42. [6] AAMC Reporter 1999. 8. www.aamc.org/newsroom/reporter/may99/ rdtbl.htm. [7] Ludmerer KM. Instilling professionalism in medical education. JAMA 1999;282:881 - 2. [8] Larkin GL. Evaluating professionalism in emergency medicine: clinical ethical competence. Acad Emerg Med 1999;6:302 - 11. [9] Brownell AK, Cote´ L. Senior residents’ views on the meaning of professionalism and how they learn about it. Acad Med 2001; 76:734 - 77. [10] Robins LS, Braddock III CH, Fryer-Edwards KA. Using the American Board of Internal Medicine’s bElements of professionalismQ for undergraduate ethics education. Acad Med 2002;77:523 - 31. [11] Clever SL, Edwards KA, Feudtner C, Braddock III CH. Ethics and communication: does students’ comfort addressing ethical issues vary by specialty team? J Gen Intern Med 2001;16:559 - 63. [12] Rhoton MF. Professionalism and clinical excellence among anesthesiology residents. Acad Med 1994;69:313 - 5. [13] Lingard L, Reznick R, Espin S, Regehr G, DeVito I. Team communications in the operating room: talk patterns, sites of tension, and implications for novices. Acad Med 2002;77:232 - 7. [14] Paice E, Heard S, Moss F. How important are role models in making good doctors? BMJ 2002;325:707 - 10. [15] Klein EJ, Jackson JC, Kratz L, et al. Teaching professionalism to residents. Acad Med 2003;78:26 - 34. [16] Arnold L. Assessing professional behavior: yesterday, today, and tomorrow. Acad Med 2002;77:502 - 15. [17] Ginsburg S, Regehr G, Hatala R, et al. Context, conflict, and resolution: a new conceptual framework for evaluating professionalism. Acad Med 2000;75(10 Suppl):S6 - S11.
Special article
Teaching professionalism during anesthesiology training Steven B. Edelstein MD (Diplomate, American Board of Anesthesiology, Associate Professor)*, Julia M. Stevenson MD (Resident), Kathleen Broad MD (Diplomate, American Board of Anesthesiology, Assistant Professor) Department of Anesthesiology, Loyola University Medical Center, Maywood, IL 60153, USA Received 20 November 2003; accepted 18 October 2004
Keywords: Anesthesiology; Education; Professionalism; Residency
Abstract Recently, there has been a focus on the teaching of professionalism in postgraduate medical education. Many discussions and studies have been performed to help in teaching professionalism and in the evaluation of the effectiveness of this teaching process. Unfortunately, many anesthesiologists are unaware of the literature and the discussions that have taken place. This review article serves as a primer for those individuals faced with the task of instilling the concepts of professionalism, not only in trainees but also in anesthesiologists practicing today. D 2005 Elsevier Inc. All rights reserved.
1. Introduction Today, we are faced with increasing pressures to train physicians who are not only competent in factual knowledge and procedures but also demonstrate expertise in the area of professionalism. Currently, the Accreditation Council for Graduate Medical Education (ACGME) has listed among its 6 core competencies professionalism which each residency should monitor, teach, and evaluate (ACGME General Competencies, version 1.3, 9.28.99). However, this brings to light many issues regarding the subject, namely, what is the definition of professionalism? Can we teach it, and if so, how? Are there proven methods that have been successful? And how do we evaluate our effectiveness in instruction?
T Corresponding author. Tel.: +1 708 216 0414; fax: +1 708 216 1249. E-mail address: [email protected] (S.B. Edelstein). 0952-8180/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2004.10.006
Professionalism in anesthesiology has some unique aspects. Although most anesthesiologists are engaged in person-to-person interactions, these interactions tend to be short (and getting shorter as pressure increases to speed efficiency through the operative process), but intense. Notable exceptions include the pain clinic setting and the intensive care unit. Both of these anesthesia subspecialties allow for longer periods of discussion with patients and their families, and both subspecialties allow for the discussion of many ethical issues. Many recent articles have been written explaining the need to instruct trainees about professionalism and also trying to come to grips with a unifying definition of the terminology. The American Association of Medical Colleges (AAMC) currently has an ongoing discussion and assessment, bProject ProfessionalismQ; however, the focus is mostly general at best (www.aamc.org). In this article, we discuss professionalism, including its definition, how other specialties are assessing and evaluating its training, and our approach to the subject matter as it pertains to the field of anesthesiology.
Teaching professionalism in residency
2. Definition of professionalism Swick [1] has been instrumental in helping to foster a bnormative definitionQ of the term professionalism. Essentially, he states that medical professionalism is exemplified through what physicians actually do and that it can be composed of a set of behaviors (Table 1). The terminology fostered by Swick has been supported by many proponents of professionalism (eg, AAMC–Project Professionalism); however, other items have been incorporated into the subject of professionalism, notably humanism. Linn et al [2] have put forward a scale with which to measure a physician’s humanistic attitudes, values, and behaviors (Table 2). Frankford et al [3] describe in detail the concept of responsive medical professionalism, in which the starting point of this professionalism is an ethical system supported by an appropriate institutional infrastructure. They put forth the 4 major ideals of responsive medical professionalism: (1) medical professionals should strive for mutual interdependence with patients and society; (2) medical professionals should both respond to and partially create social values; (3) medical work should be valued intrinsically as part of an individual and collective self-identity, and as a contribution to the public good; and (4) medical work should be organized collegially. To achieve these ideals, 3 characteristics of the institutional framework must be present: first, organizations should merge education and practice; second, organizations must make collegial, experiential, reflective, lifelong learning a part of education and practice; and finally, these organizations must maintain close linkages with communities through regular processes and relationships that balance modes of representative and participatory democracy. Frankford et al [3] conclude that organizations should teach professionalism both within and without, rather by action Table 1 The professional behaviors of physicians should include the following ! Subordinate their own interest for the interest of others ! Adhere to high ethical and moral standards ! Respond to societal needs, and their behaviors reflect a social contract with the communities served ! Evince core humanistic values, including honesty and integrity, caring and compassion, altruism and empathy, respect for others and trustworthiness ! Exercise accountability for themselves and for their colleagues ! Demonstrate a continuing commitment to excellence ! Exhibit a commitment to scholarship and to advancing their field ! Deal with high levels of complexity and uncertainty (exercise independent judgement to make appropriate decisions in the face of complex and often unstable circumstances usually with incomplete information) ! Reflect upon their actions and decisions Adapted from Swick [1].
393 Table 2 ! ! ! ! ! ! ! !
Physicians humanistic attitudes
Cooperation with medical colleagues Cooperation with paramedical staff Has a good physician-patient relationship Renders comfort and empathy Involves patients in decisions Considers patients’ concerns Puts patient at ease and renders comfort Admits one’s own errors
Adapted from Lin et al [2].
than by exhortation. Here, action means institutionalizing numerous mechanisms through which medical work is influenced by social values, even as it in turn teaches society the value of medical work. Ultimately, their main point is that professionalism is neither taught nor learned through preaching; rather it is taught and assimilated by living a professional life, with a lifelong engagement with other individuals with similar collective social values. Medical schools have been at the forefront of teaching the concepts of medical professionalism. Discussions on the topic have been fostered since the early 1980s, and an aggressive implementation process has been initiated by the AAMC. Currently, medical schools in the United States have well-established professionalism programs that incorporate not only issues regarding professionalism, but also ethics and its role in medicine. Most of these ethical issues are covered in small group discussions with broad exposure to clinicians, ethicists, and educational personnel. Ultimately, these discussions and the students’ viewpoints on ethical issues are evaluated during frequent intervals. Phelan et al [4] describe 7 basic traits and noncognitive behaviors in medical students, including (1) reliability and responsibility, (2) maturity (eg, behaves respectfully, accepts blame for failure), (3) critique (eg, accepts criticism, corrects shortcomings), (4) communication skills, (5) honesty and integrity, (6) respect for patients (eg, maintains patient confidentiality, empathetic behavior, and patience with patient and family), and (7) showing no signs of chemical dependency or mood disorder (eg, change in personality, excessive irritability, depression). Many of these same items are routinely incorporated into evaluation summary forms issued by professional certification boards such as the American Board of Anesthesiology (ABA). Barry et al [5] performed a survey of medical students and residents at the University of Colorado to assess the common challenges to medical professionalism and to ascertain physician satisfaction with training in professionalism. Respondents were asked to evaluate 6 professionalism-related scenarios. Overall, the frequencies of best responses were for minor confidentiality, conflict of interest, and honesty in documentation scenarios. These responses were greater than for physician impairment, sexual harassment, and acceptance of gifts scenarios. Increasing levels of experience were correlated with a modest increase in bbest
394 responseQ for all scenarios. When asked about the setting where discussions regarding professionalism were held, 76% of respondents reported informal discussions, 28% noted course work, and 26% noted teaching rounds. Most noted that teaching rounds and informal discussions were of most value; however, 73% of respondents had less than 10 hours of course work devoted to professionalism, and 40% of respondents expressed dissatisfaction with their education and training in professionalism. The sentinel question is not just what professionalism is, but how does one teach it. The AAMC has had many roundtable discussions [6] on this subject, but most end up with the bI know it when I see it, but don’t know how to teach it.Q Moreover, it is difficult to overcome the bias of individuals who view the teaching of professionalism and its concepts to be of less value than other scientific endeavors. Much of the literature on professionalism is subjective in nature. Randomized, controlled, double-blinded studies are not possible when dealing with the issues of professionalism and how to effectively teach this complicated topic. Many psychological and emotional variables exist, especially when dealing with emotional constructs that have been established since childhood. Another challenge to teaching professionalism was elucidated by Ludmerer [7], who believed that the main limitation of both instructional and mentoring approaches, even when offered together, is what accounts for only some of the factors that influence the development of professionalism. He went on to state that one must consider the profound impact of the entire institutional environment (of the academic health center) on shaping the attitudes, values, beliefs, modes of thought, and behavior of medical students. Ludmerer stressed that an unfriendly institutional culture can easily undermine the well-intentioned efforts of those trying to impart professionalism through the curriculum. Ultimately, whatever definitions are decided upon, the training program must meet the expectations put forth by the ACGME (ACGME General Competencies, version 1.3, 9.28.99) regarding professionalism, which include demonstration of respect, compassion, and needs of the society and patient that supercede self-interest. In addition, accountability to patients, society, and profession; commitment to excellence and ongoing professional development; and cultural, age, and sex sensitivity are essential components. Other specialties in medicine have been actively trying to devise programs that address the teaching of professionalism. Several articles have addressed the issues of professionalism, and some have put forward varying approaches to teach this subject matter.
2.1. Emergency medicine In a review article, Larkin [8] felt that, although demonstration of ethical and humanistic skills was important, the teaching and assessment of these skills have been left more or less to chance. He believed that the evaluation
S.B. Edelstein et al. of professionalism in emergency medicine was limited by the paucity of evaluation tools and the lack of time for implementation. His recommendations included multipleessay questions on annual in-service examinations that focused on ethical issues in emergency medicine; ethics bobjective structured clinical examinationQ stations during Advanced Cardiac Life Support, Advanced Trauma Life Support, and Pediatric Advanced Life Support courses; and blinded videotape reviews of real-time patient interactions.
2.2. Family medicine Brownell and Cote´ [9] performed a survey to determine how most family medicine residents in Canadian medical training programs obtain their knowledge regarding professionalism. More than 93.5% of residents selected bcontact with positive role modelsQ as their most important method of learning about professionalism. As their second choice, 50% selected bcontact with patients and their next of kin.Q Of note, the third choice by 43.5% of all the residents was bcontact with negative role models.Q The quantity and quality of teaching professionalism were reported (on a scale of 1-5, 1 being inadequate and 5 being superior) as 4.13 F 1.44 and 3.79 F 1.44. Suggestions to facilitate learning included discussions with peers, teachers, and patients; better examples of teachers as role models; workshops and seminars; and formal teaching. Ultimately, the authors stressed that professionalism needed to be on the list of topics for lifelong learning; that is, what one needs to know about professionalism will change and will need to be continually upgraded and refined throughout the physician’s practice.
2.3. Internal medicine A large amount of literature have been written by the internal medicine community and focus on teaching professionalism in the specialty. Recently, an extensive review of the subject was completed by the American Board of Internal Medicine (ABIM) and resulted in the document, bProject Professionalism,Q found on the society’s Web site (http://www.abim.org/pubs/profess.pdf). The ABIM has developed a taxonomy on which professionalism is subdivided into 2 sections: elements of professionalism, which include altruism, accountability, excellence, duty, respect for others, honor, and integrity; and challenges to professionalism, which include abuse of power (breach of confidentiality, inappropriate interactions with patients and colleagues, bias, and sexual harassment), arrogance, greed, misrepresentation, impairment (eg, substance abuse among professionals), lack of conscientiousness, and conflicts of interest (self-referral, acceptance of gifts, use of services, collaboration with industry, and compromising the principles of clinical investigations). In addition, the ABIM has developed an elaborate guide to help program directors teach and evaluate professionalism. Many case-based scenarios and examples are presented to the program directors to serve as guides, especially in
Teaching professionalism in residency regard to the elements of and challenges to professionalism. The ABIM also recommends frequent or even daily evaluations of a resident’s performance in regard to professional behaviors. It has formulated praise or early concern notes designed to enhance feedback and to facilitate the flow of information from faculty to trainee. In addition, the ABIM has developed the Professionalism Remediation Summary to help both the program director and trainee understand behaviors that are deemed unprofessional and problematic. Major descriptors of unprofessional behavior include unmet professional responsibility, lack of effort toward self-improvement and adaptability, diminished relationships with patients and families, and diminished relationships with health care professionals. Robins et al [10] have proposed adapting the taxonomy of the ABIM and applying it to undergraduate medical education at the University of Washington. In addition, that group added a category denoted as bnegotiating power asymmetriesQ because they noticed that medical students were concerned about how to speak up when they observed teachers and other superordinates acting unprofessionally [11]. Essentially, they felt that students were silenced or bewildered by power and that their silence was often misinterpreted as complicity with behaviors they perceived to be unethical or unprofessional. This situation was true not only for medical students, but was also noted among residents who appeared very hesitant to report unprofessional behavior because they were afraid that retribution would take place.
2.4. Anesthesiology In the anesthesia literature, very little has been written regarding professionalism and how it should be taught. In fact, an extensive amount of work has been one in the area of ethics, which is evident, by the excellent American Society of Anesthesiologists Ethics Syllabus (http://www. asahq.org/wlm/Ethics.html). Rhoton [12] performed a study in the late 1980s to identify anesthesia residents who received undesirable scores regarding professional behavior. Rhoton determined the frequency and nature of comments regarding this behavior, assessed predictive relationships for receiving undesirable scores, and identified consistent patterns of performance associated with these scores. Comments by faculty evaluators were distributed over a range of items from behavior and personality issues to abdication of responsibilities inside and outside of the operating room (OR). The author ultimately found that there was a pattern of performance associated with unprofessional behavior and clinical performance; that is, those with unprofessional behavior tended to have problems with clinical performance as well. As mentioned earlier, anesthesiologists are in a unique situation because their patient interactions are short, and discussions regarding patient care are held in an efficient
395 and quick session. However, they often have very prolonged interactions with the OR staff and support personnel, including surgeons, nursing, and housekeeping. How anesthesiologists interact with these individuals is as much a part of professionalism as is the doctor-patient relationship. In fact, Lingard et al [13] explored the nature of communication among the staff in the OR. After 4 months of observation and informal interviews, some themes of prominent communicative events occurred. These themes included time (room turnover, patient cancellation, etc), resources (equipment allocation, personnel distribution), roles (responsibilities, constraints), safety and sterility (aseptic technique), situation control (eg, temperature regulation), and relationships. bThe highest tension levels occurred when this tension extended beyond the content, participants, and context of its original occurrence,Q they reported. Of note, the authors saw most conflicts occurring between nursing and surgeons and little between surgeons and anesthesiologists. However, they go on to state, somewhat disturbingly, that the lack of conflict between surgeons and anesthesiologists may be related to the fact that there was very little communication of any kind between the 2 groups. Where trainees were concerned, the authors noted that novices were involved in more than a third of these high-tension events. Novices also tended to respond in 2 ways: mimicry of the teacher’s discursive style or posture, and withdrawal from the communicative sphere, with withdrawal being the most common response.
3. Teaching professionalism at the Loyola University Department of Anesthesiology At our institution, we have taken a unique approach to the teaching of professionalism. We have developed a multidisciplinary approach to the subject matter, with a resulting bminicourseQ in professionalism. This minicourse is in addition to an ongoing ethics course that we teach, and it is composed of lectures, literature reviews, articles, and interactive case-based sessions (4-6 sessions per year) on the subject. Lectures basically focus on the nature of professionalism and why we are concerned about the subject, whereas the articles delve into the ongoing discussions regarding professionalism and its evaluation. The program is spread throughout the training period, from clinical base year to conclusion at the end of the CA-3 year (Table 3).
3.1. The role of ethics teaching The American Society of Anesthesiologists Ethics Syllabus states that, bEthics education has been promoted on an assumption that certain moral behavior is expected and is desirable among all physicians, both in their collegial interactions as well as their treatment of patients. Furthermore, ethics education has been promoted on the assumption that certain undesirable practices and personal traits
396
S.B. Edelstein et al.
Table 3 Summary of teaching professionalism at the Loyola University Department of Anesthesiology Ethics teaching ! Case-based discussions ! Journal clubs focusing on recent articles in bioethics ! Ethics grand round presentations Role modeling ! Selecting and promoting role models ! Mentorship programs Interactive sessions with employee assistance Other interactive sessions Evaluation of professionalism education ! 3608 evaluations ! Self-assessments ! Monthly faculty and resident evaluations (observational) ! Standardized patients (in process)
conflict resolution and sexual harassment to understanding cultural diversity. Most of these sessions are led in an informal manner, with the participants identifying items that they find most unprofessional in fellow residents, faculty, and nursing personnel. After extensive lists are generated, usually via a lively exchange of ideas, focused discussions on these items take place, and occasionally, remedies are found. Interestingly, most of the problems of professionalism in the OR seemed to arise during periods of heightened stress. Many faculty and residents felt that the behavior of individuals was adversely affected most when patient management became complicated. As such, we are now trying to quantify and possibly help manage OR stress with the help of the EAP.
3.4. Other interactive sessions have evolved in the medical environment, which a consciously directed moral education can correct.Q Taking this cue, we have developed our own ethics program, in conjunction with the Loyola University Stritch School of Medicine Neiswanger Institute for Biomedical Ethics and Health Policy, which involves multiple formats: ! ! !
Interactive, case-based ethical discussions on a quarterly basis Journal clubs focused on recent articles in bioethics with articles chosen by residents and faculty mentors Ethics grand rounds presentations, usually 2 to 3 formal presentations per year
3.2. Role modeling Paice et al [14] define role models as bpeople we can identify with, who have qualities we would like to have, and are in positions we would like to reach. [Role models] have been shown as a way to inculcate professional values, attitudes, and behaviors in students and young doctors.Q We believe that positive role modeling is an inherent part of any curriculum on professionalism. As such, promoting professionalism among attending physicians and professors is an integral part of our curriculum. Furthermore, the establishment of a formal mentorship program aims at fostering close relationships between attending and resident physicians. At our institution, identifying role models within the anesthesia department is of paramount importance. We actively identify those attending physicians who we believe exemplify professionalism. These individuals are supported by the department and are held up to both faculty and residents as people to be emulated.
3.3. Interactive sessions with employee assistance As for the interactive sessions, we have recently begun a partnership with our institution’s Employee Assistance Program (EAP). Representatives of EAP come to our department and lead discussions on issues ranging from
In addition to the interactive sessions by the EAP and our ethics journal clubs, we have used a modification of the ethics program described by Klein et al [15] from the pediatrics department at the University of Washington. We have formulated a questionnaire that has approximately 6 difficult situations that may confront the anesthesia resident (Table 4). Participants are instructed to rank these situations on a scale from 1 to 6, from most uncomfortable to most comfortable. The results are discussed in an open format with the entire department at 2 highly interactive sessions. Currently, we are tracking these responses and looking for behavioral changes over the continuum of residency training.
3.5. Evaluation and measurement of professionalism This area is one of the most controversial and difficult to achieve. Several tools for evaluating professionalism have been put forward by the AAMC and ABIM, among others, but there is no proof that one is superior to another. Arnold [16] has done an exhaustive review of the subject matter and notes that there are 3 general areas of measurement: (1) measurement of professionalism when evaluating clinical performance, (2) measurement of professionalism as a comprehensive entity, and (3) measurement of separate elements of professionalism. In studies in which the research concentrates on the evaluation of performance, Arnold includes items such as peer evaluation (learners’ assessments of peers) and physicians’ assessments of colleagues, residents, and medical students (which primarily rely on rating scales). Two ways in which this is performed include surveys to measure the professionalism of groups, such as performed by the ABIM, or critical-incident techniques to measure the professionalism of individuals. Arnold has concluded that these longitudinal assessment tools highlight the problem of quantifying professional and unprofessional behaviors. Some behaviors are not quantifiable with the use of a scale.
Teaching professionalism in residency Table 4 Exercise is to assess how prepared you feel you are to deal with challenging situations (1 is most uncomfortable, 6 is most comfortable) Rank – You are a first year resident in anesthesia, and while on-call, a senior resident intervenes in the management of the patient, that is, essentially takes over the case without you asking. – You are away from your significant other a large amount of the time. You have now developed a friendship with someone else at work and you believe that the relationship is at risk for becoming a romantic one. – The recovery room calls about a patient you had given care to earlier in the day. You give an order for morphine (over the phone without assessing the patient) for pain. Twenty minutes later, you show up to the PACU and find out that the patient had arrested shortly after the morphine was given. The recovery team was unable to secure an airway, and the patient had an emergent cricothyrotomy. The patient currently is not responding to commands. – While on the pediatric rotation, you develop a relationship with a patient who is having frequent surgeries. You promise the child that you will take care of him the next day, and he will see you in recovery. The case now is running late, and it will not finish before 8 pm. Your daughter has a recital at school at 7 pm. – After a challenging coronary artery bypass graft surgery, the patient does not survive the procedure because of a medication error on your part. You have had many prior discussions with the family members and feel close to them. The husband looks at you at the end of surgery and asks if anything went wrong. – You have a free night off and have a special dinner planned with friends. After giving report in recovery room, your patient bcrumps,Q and you do not have time to stay and help. Adapted from Klein et al [15, p30].
These tools also bring up the problems of focusing only on unprofessional behaviors because it relies on feedback from faculty. The absence of a report about a student’s behavior is not necessarily a testament to his or her conduct. Other articles have focused on evaluating professionalism, including that of Ginsburg et al [17] who looked at several different methods including evaluations by faculty supervisors, peer evaluations, self-evaluations, use of bstandardized patients,Q and longitudinal observations. Although no one system appeared to be the best, the authors saw great potential in self-evaluation and peer evaluation formats. They also stressed the idea that professional behavior is very context-dependent. The authors stated that it is crucial to be aware of the specific context in which a behavior occurs before attempting to evaluate it. Ginsburg et al recommended that future efforts in evaluating professionalism must focus on behaviors rather than personality traits or vague concepts of character and that these evaluations must include context and conflict to be relevant and valid.
397
4. Evaluation of professionalism teaching at the Loyola University Department of Anesthesiology As stated earlier, several tools for evaluating professionalism have been put forward by the ACGME and ABIM, as well as other organizations, but there is no proof that one method of evaluation is superior to another. We have included several different methods by which we evaluate not only individual resident physicians, but also our syllabus on professionalism as a whole. At the end of each clinical rotation, attending physicians are asked to evaluate specifically the resident’s interactions with patients as well as other coworkers. Detailed feedback is requested so that residents can gain an understanding of their strengths and weaknesses in their interpersonal relations. Further directions currently being investigated include the use of the standardized patient and objective structured clinical examinations. Although the use of standardized patients has been used successfully for internal medicine and family practice, its role is less clearly defined in anesthesiology. The use of standardized patients focuses on the patient-physician interaction; however, in our field, this interaction is usually short. Therefore, it is essential to concentrate not only on the physician-patient relationship, but also on the physicianphysician and physician–allied professional relationship. However, this is an area in which we are currently focusing some energy and may ultimately be able to incorporate into our educational program. In an attempt to evaluate our progress in teaching professionalism, we have instituted a series of 3608 evaluations. Currently, residents are evaluated on a quarterly basis, not only by the faculty, but also by the recovery room personnel and selected OR personnel (physicians and nurses). The residents, in turn, are allowed to comment on these individuals. Patient involvement in the 3608 evaluation has been the most difficult to obtain because many patients do not recall specific individuals who participated in their care, only their overall experience. When we do receive specific unsolicited comments from patients via our quality assurance process, these comments are distributed to
Table 5 Points covered by the 3608 evaluation of anesthesiology resident Demonstrates ethical/moral behavior Reacts to stressful situations appropriately Demonstrates respect for the dignity of patients Medical management of the postoperative patient is appropriate ! Communicates/works effectively with patients and colleagues ! Demonstrates appropriate concern for patients ! Record keeping is complete and accurate ! Recognizes gaps in knowledge and expertise ! ! ! !
398 the appropriate personnel for discussion and feedback. The questionnaire used is essentially a distilled version of the semiannual evaluation forms put forth by the ABA. This allows for easier tracking and consistency when evaluations are reviewed not only by the resident’s mentor, but also by our Clinical Competency Committee and residency director (on a quarterly basis). A sample of questions is seen in Tables 4 and 5, and rankings are from excellent, satisfactory, poor, and unsatisfactory to not applicable. Another tool of measurement is the self-assessment. At the conclusion of each clinical rotation, residents are asked to evaluate their own performance. Each resident is asked to rate himself or herself in regard to overall performance and interaction with ancillary staff and faculty. At each quarterly resident’s status meeting, discussing how a resident’s selfassessment measures up against faculty and ancillary staff evaluations has been a powerful tool in identifying not only areas for improvement in medical knowledge and practical skills, but also areas to focus on improving interpersonal skills and behaviors.
5. Summary Professionalism has been a topic of much discussion in academic medicine. In the field of anesthesiology, we have the added challenge of developing professionalism courses that reflect the environment in which we practice, notably the OR setting. Incorporation of interactive teaching sessions, role modeling, multidisciplinary discussion panels, and even stress reduction therapy all play a role in helping train the resident in this important area of medicine. Devising the bperfectQ course for teaching professionalism is most likely an unrealistic goal, but critical evaluation of processes and new techniques should be encouraged whenever possible.
S.B. Edelstein et al.
References [1] Swick HM. Toward a normative definition of medical professionalism. Acad Med 2000;75:612 - 6. [2] Linn LS, DiMatteo MR, Cope DW, Robbins A. Measuring physician’s humanistic attitudes, values, and behaviors. Med Care 1987;25:504 - 15. [3] Frankford DM, Patterson MA, Konrad TR. Transforming practice organizations to foster lifelong learning and commitment to medical professionalism. Acad Med 2000;75:708 - 17. [4] Phelan S, Obenshain SS, Galey WR. Evaluation of the noncognitive professional traits of medical students. Acad Med 1993;68:799 - 803. [5] Barry D, Cyran E, Anderson RJ. Common issues in medical professionalism: room to grow. Am J Med 2000;108:136 - 42. [6] AAMC Reporter 1999. 8. www.aamc.org/newsroom/reporter/may99/ rdtbl.htm. [7] Ludmerer KM. Instilling professionalism in medical education. JAMA 1999;282:881 - 2. [8] Larkin GL. Evaluating professionalism in emergency medicine: clinical ethical competence. Acad Emerg Med 1999;6:302 - 11. [9] Brownell AK, Cote´ L. Senior residents’ views on the meaning of professionalism and how they learn about it. Acad Med 2001; 76:734 - 77. [10] Robins LS, Braddock III CH, Fryer-Edwards KA. Using the American Board of Internal Medicine’s bElements of professionalismQ for undergraduate ethics education. Acad Med 2002;77:523 - 31. [11] Clever SL, Edwards KA, Feudtner C, Braddock III CH. Ethics and communication: does students’ comfort addressing ethical issues vary by specialty team? J Gen Intern Med 2001;16:559 - 63. [12] Rhoton MF. Professionalism and clinical excellence among anesthesiology residents. Acad Med 1994;69:313 - 5. [13] Lingard L, Reznick R, Espin S, Regehr G, DeVito I. Team communications in the operating room: talk patterns, sites of tension, and implications for novices. Acad Med 2002;77:232 - 7. [14] Paice E, Heard S, Moss F. How important are role models in making good doctors? BMJ 2002;325:707 - 10. [15] Klein EJ, Jackson JC, Kratz L, et al. Teaching professionalism to residents. Acad Med 2003;78:26 - 34. [16] Arnold L. Assessing professional behavior: yesterday, today, and tomorrow. Acad Med 2002;77:502 - 15. [17] Ginsburg S, Regehr G, Hatala R, et al. Context, conflict, and resolution: a new conceptual framework for evaluating professionalism. Acad Med 2000;75(10 Suppl):S6 - S11.