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The Challenges of Teaching Professionalism
ETHICS/EDITORIAL
The Challenges of Teaching Professionalism Robert Knopp, MD, MA
From the University of Minnesota and Regions Hospital, St. Paul, MN.
0196-0644/$-see front matter Copyright © 2006 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2006.08.012
SEE RELATED ARTICLE, P. 532. [Ann Emerg Med. 2006;48:538-539.] Professionalism has been defined as the attitudes and behaviors that enhance trust by placing the patient’s interest above other interests.1 Although to some, the mere mention of the word evokes memories of a boring lecture or sleep-inducing journal article, to others it is a call to action, a prescription to remedy the shortcomings of our profession. Regardless of one’s reaction, physicians face the challenge of trying to live up to this standard every day. How well are we doing? From one perspective, lack of professionalism is a serious, recurring problem. Papadakis et al2 reviewed the disciplinary actions of the Medical Board of California, involving 68 graduates of 1 medical school during a 10-year period. Unprofessional behavior was the stated reason for 95% of the disciplinary actions. More important, physicians who had comments about unprofessional behavior in their medical school record were “more than twice as likely to be disciplined by the Medical Board of California when they become practicing physicians than were students without such comments.” From another perspective, the message is the same: the daily news reminds us of frequent lapses of ethical judgment and professionalism. The myriad financial relationships between the biomedical industry and physicians in all specialties, including our own, are eroding not only the physician-patient relationship but also the integrity of scientific communication. The Journal of the American Medical Association (JAMA) reported the most recent example in which researchers failed to disclose preexisting consulting relationships with pharmaceutical companies. The researchers responded that they did not report their financial relationship because they did not believe they were relevant to the study.3 JAMA’s editor reports that failure to disclose such relationships is a recurring problem. An even more disturbing report4 described not only concerns with nondisclosure of authors’ financial ties to a medical device manufacturer but also raised the question of how we can objectively determine whether a medical device benefits patient care if the “scientists who did know the science and the data were all on the company’s payroll.” In recent years, medical schools and residency programs have focused greater attention on the topics of professionalism and ethics. How should we prepare medical students and residents for the challenges they will face involving professionalism? What 538 Annals of Emergency Medicine
educational experiences will provide the greatest success for developing and reaffirming professionalism? How should success be measured? The impetus for this attention is multifactorial. Although the most compelling reason is the need to provide better patient care by preparing new physicians for the complex ethical and professional challenges they will encounter, a related reason is that the Accreditation Council for Graduate Medical Education now requires all residency programs to evaluate residents on 6 core competencies as part of the residency accreditation process. The transition to a new model for evaluating residency programs is and will continue to be a slow and difficult process: changing from a primarily process-based evaluation and accreditation model to one linked to outcomes is a daunting challenge, with no guarantee that such a change will result in improved patient outcomes.5 For this new model to succeed, innovative educational programs, effective assessment methodologies, and valid outcome measures are required. Residency programs and medical educators traditionally have been more comfortable assessing medical knowledge rather than professionalism and medical ethics. New educational programs often provide process measures but fail too often to provide outcome measures indicating whether a specific new program is effective not only in increased knowledge but also in establishing or changing behavior and improving clinical outcomes. Because of the difficulty in determining whether a specific intervention produces true behavior change and improved outcomes, we must rely on proxies for behavior change and improved outcomes. Examples of such proxies are clinical quality indicators, patient surveys, employer evaluation of graduates, and national or specialty standardized measures.6 Pilot programs provide hope that educators will create new approaches for medical students, residents, and faculty to develop or enhance the knowledge, skills, and attitudes necessary to provide patient care that is, in the words of the Institute of Medicine, safe, timely, effective, efficient, equitable, and patient-centered. In this issue of Annals, Van Groenou and Bakes7 describe how one residency developed a program with the following 2 goals: “1) to discuss areas of clinical consequence typically outside the scope of the regular academic curriculum, such as ethical dilemmas and the challenges of professionalism; and 2) to encourage reflection on our roles as caregivers on a personal, public health, and political level.” Volume , . : November
Knopp
Challenges of Teaching Professionalism
One of the consultants who reviewed this article stated in the first sentence of his review: “This fascinating work is must reading for anyone involved in resident education.” Other reviewers had similar initial responses. It would be difficult to disagree with this assessment. The topics are important and usually receive inadequate time and attention in formal residency teaching sessions. Nevertheless, as interesting as the topics are and as good as the attendance is, we must dispassionately distinguish between an educational program that is interesting and appears to make people feel better about themselves and one that in addition changes behavior and improves outcomes in measurable ways. For years, institutions provided emergency personnel critical incident stress debriefing with the belief that such interventions provided comfort for caregivers and reduced the likelihood of emotional sequelae. Unfortunately, repeated scientific studies demonstrated that such interventions did not help the caregivers and indeed may have had some adverse effects.8 The adoption of new strategies in medical education should be based on outcome measures. As reflected by critical incident stress debriefing, feeling better may be a necessary but not a sufficient outcome measure. Too often, formal residency training in medical ethics and professionalism has been relegated to a few classroom conferences per year. Medical students, residents, and faculty need to heed the cautionary warning of Branch et al9 and others who suggested that we focus more of our attention on experiences in the clinical setting: “formal courses and other well-motivated endeavors that take place away from patients fail to foster humanistic care.” Faculty role models and bedside teaching that reflect humanistic care demonstrate that residency leadership and individual faculty believe that such an approach to care is important and relevant. Clinical role models play a pivotal role in the medical education of students and residents. The good news for faculty development is that the attributes associated with being an excellent role model can be acquired.10 It would be disingenuous to imply that medical students or recent residency graduates develop the appropriate knowledge, skill and attitudes of professionalism solely as a result of their medical school or residency training. By the time an individual enters medical school, basic personality is already established; however, medical school or residency training can modify behavior to meet professional expectations.11 We commend the authors of this report and hope that pilot projects like the one described by Van Groenou and Bakes7 will undergo further study to determine whether their program
produces appropriate outcome measures. Emergency medicine educators should embrace new approaches to teaching professionalism but ensure that evidence supports such programs. Supervising editor: Kathy J. Rinnert, MD, MPH Funding and support: The author reports this study did not receive any outside funding or support. Reprints not available from the author. Address for correspondence: Robert Knopp, MD, University of Minnesota and Regions Hospital, 640 Jackson St, St. Paul, MN 55101; 651-254-5091, fax 651-254-8756; E-mail [email protected].
REFERENCES 1. Adams J, Schmidt T, Sanders A, et al. Professionalism in emergency medicine: SAEM Ethics Committee: Society for Academic Emergency Medicine. Acad Emerg Med. 1998;5: 1193-1199. 2. Papadakis MA, Hodgson CS, Teherani A, et al. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med. 2004;79: 244-249. 3. Journal editor again says she was misled. New York Times. July 19, 2006:A18. 4. Carey B. Correcting the errors of disclosure. New York Times. July 25, 2006:D5. 5. Hayden SR, Dufel S, Shih R, et al. Definitions and competencies for practice-based learning and improvement. Acad Emerg Med. 2002;9:1242-1248. 6. Accreditation Council for Graduate Medical Education. Timeline: working guidelines. Available at: http://www.acgme.org/outcome/ project/timeline/TIMELINE_index_frame.htm. Accessed August 2, 2006. 7. Van Groenou AA, Bakes KM. Art, chaos, ethnics, and science (ACES): a doctoring curriculum for emergency medicine. Ann Emerg Med. 2006;48:532-537. 8. van Emmerik AA, Kamphuis JH, Hulsbosch AM, Emmelkamp PM. Single session debriefing after psychological trauma: a metaanalysis. Lancet. 2002;360:766-772. 9. Branch WT Jr, Kern D, Haidet P, et al. Teaching the human dimensions of care in clinical settings. JAMA. 2001;286: 1067-1074. 10. Wright SM, Kern DE, Kolodner K, et al. Attributes of excellent attending-physician role models. N Engl J Med. 1998;339: 1986-1993. 11. Duff P. Teaching and assessing professionalism in medicine. Obstet Gynecol. 2004;104:1362-1366.
Did you know?
You can save your online searches and get the results by e-mail.
Visit www.annemergmed.com today to see what else is new online!
Volume , . : November
Annals of Emergency Medicine 539
The Challenges of Teaching Professionalism Robert Knopp, MD, MA
From the University of Minnesota and Regions Hospital, St. Paul, MN.
0196-0644/$-see front matter Copyright © 2006 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2006.08.012
SEE RELATED ARTICLE, P. 532. [Ann Emerg Med. 2006;48:538-539.] Professionalism has been defined as the attitudes and behaviors that enhance trust by placing the patient’s interest above other interests.1 Although to some, the mere mention of the word evokes memories of a boring lecture or sleep-inducing journal article, to others it is a call to action, a prescription to remedy the shortcomings of our profession. Regardless of one’s reaction, physicians face the challenge of trying to live up to this standard every day. How well are we doing? From one perspective, lack of professionalism is a serious, recurring problem. Papadakis et al2 reviewed the disciplinary actions of the Medical Board of California, involving 68 graduates of 1 medical school during a 10-year period. Unprofessional behavior was the stated reason for 95% of the disciplinary actions. More important, physicians who had comments about unprofessional behavior in their medical school record were “more than twice as likely to be disciplined by the Medical Board of California when they become practicing physicians than were students without such comments.” From another perspective, the message is the same: the daily news reminds us of frequent lapses of ethical judgment and professionalism. The myriad financial relationships between the biomedical industry and physicians in all specialties, including our own, are eroding not only the physician-patient relationship but also the integrity of scientific communication. The Journal of the American Medical Association (JAMA) reported the most recent example in which researchers failed to disclose preexisting consulting relationships with pharmaceutical companies. The researchers responded that they did not report their financial relationship because they did not believe they were relevant to the study.3 JAMA’s editor reports that failure to disclose such relationships is a recurring problem. An even more disturbing report4 described not only concerns with nondisclosure of authors’ financial ties to a medical device manufacturer but also raised the question of how we can objectively determine whether a medical device benefits patient care if the “scientists who did know the science and the data were all on the company’s payroll.” In recent years, medical schools and residency programs have focused greater attention on the topics of professionalism and ethics. How should we prepare medical students and residents for the challenges they will face involving professionalism? What 538 Annals of Emergency Medicine
educational experiences will provide the greatest success for developing and reaffirming professionalism? How should success be measured? The impetus for this attention is multifactorial. Although the most compelling reason is the need to provide better patient care by preparing new physicians for the complex ethical and professional challenges they will encounter, a related reason is that the Accreditation Council for Graduate Medical Education now requires all residency programs to evaluate residents on 6 core competencies as part of the residency accreditation process. The transition to a new model for evaluating residency programs is and will continue to be a slow and difficult process: changing from a primarily process-based evaluation and accreditation model to one linked to outcomes is a daunting challenge, with no guarantee that such a change will result in improved patient outcomes.5 For this new model to succeed, innovative educational programs, effective assessment methodologies, and valid outcome measures are required. Residency programs and medical educators traditionally have been more comfortable assessing medical knowledge rather than professionalism and medical ethics. New educational programs often provide process measures but fail too often to provide outcome measures indicating whether a specific new program is effective not only in increased knowledge but also in establishing or changing behavior and improving clinical outcomes. Because of the difficulty in determining whether a specific intervention produces true behavior change and improved outcomes, we must rely on proxies for behavior change and improved outcomes. Examples of such proxies are clinical quality indicators, patient surveys, employer evaluation of graduates, and national or specialty standardized measures.6 Pilot programs provide hope that educators will create new approaches for medical students, residents, and faculty to develop or enhance the knowledge, skills, and attitudes necessary to provide patient care that is, in the words of the Institute of Medicine, safe, timely, effective, efficient, equitable, and patient-centered. In this issue of Annals, Van Groenou and Bakes7 describe how one residency developed a program with the following 2 goals: “1) to discuss areas of clinical consequence typically outside the scope of the regular academic curriculum, such as ethical dilemmas and the challenges of professionalism; and 2) to encourage reflection on our roles as caregivers on a personal, public health, and political level.” Volume , . : November
Knopp
Challenges of Teaching Professionalism
One of the consultants who reviewed this article stated in the first sentence of his review: “This fascinating work is must reading for anyone involved in resident education.” Other reviewers had similar initial responses. It would be difficult to disagree with this assessment. The topics are important and usually receive inadequate time and attention in formal residency teaching sessions. Nevertheless, as interesting as the topics are and as good as the attendance is, we must dispassionately distinguish between an educational program that is interesting and appears to make people feel better about themselves and one that in addition changes behavior and improves outcomes in measurable ways. For years, institutions provided emergency personnel critical incident stress debriefing with the belief that such interventions provided comfort for caregivers and reduced the likelihood of emotional sequelae. Unfortunately, repeated scientific studies demonstrated that such interventions did not help the caregivers and indeed may have had some adverse effects.8 The adoption of new strategies in medical education should be based on outcome measures. As reflected by critical incident stress debriefing, feeling better may be a necessary but not a sufficient outcome measure. Too often, formal residency training in medical ethics and professionalism has been relegated to a few classroom conferences per year. Medical students, residents, and faculty need to heed the cautionary warning of Branch et al9 and others who suggested that we focus more of our attention on experiences in the clinical setting: “formal courses and other well-motivated endeavors that take place away from patients fail to foster humanistic care.” Faculty role models and bedside teaching that reflect humanistic care demonstrate that residency leadership and individual faculty believe that such an approach to care is important and relevant. Clinical role models play a pivotal role in the medical education of students and residents. The good news for faculty development is that the attributes associated with being an excellent role model can be acquired.10 It would be disingenuous to imply that medical students or recent residency graduates develop the appropriate knowledge, skill and attitudes of professionalism solely as a result of their medical school or residency training. By the time an individual enters medical school, basic personality is already established; however, medical school or residency training can modify behavior to meet professional expectations.11 We commend the authors of this report and hope that pilot projects like the one described by Van Groenou and Bakes7 will undergo further study to determine whether their program
produces appropriate outcome measures. Emergency medicine educators should embrace new approaches to teaching professionalism but ensure that evidence supports such programs. Supervising editor: Kathy J. Rinnert, MD, MPH Funding and support: The author reports this study did not receive any outside funding or support. Reprints not available from the author. Address for correspondence: Robert Knopp, MD, University of Minnesota and Regions Hospital, 640 Jackson St, St. Paul, MN 55101; 651-254-5091, fax 651-254-8756; E-mail [email protected].
REFERENCES 1. Adams J, Schmidt T, Sanders A, et al. Professionalism in emergency medicine: SAEM Ethics Committee: Society for Academic Emergency Medicine. Acad Emerg Med. 1998;5: 1193-1199. 2. Papadakis MA, Hodgson CS, Teherani A, et al. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med. 2004;79: 244-249. 3. Journal editor again says she was misled. New York Times. July 19, 2006:A18. 4. Carey B. Correcting the errors of disclosure. New York Times. July 25, 2006:D5. 5. Hayden SR, Dufel S, Shih R, et al. Definitions and competencies for practice-based learning and improvement. Acad Emerg Med. 2002;9:1242-1248. 6. Accreditation Council for Graduate Medical Education. Timeline: working guidelines. Available at: http://www.acgme.org/outcome/ project/timeline/TIMELINE_index_frame.htm. Accessed August 2, 2006. 7. Van Groenou AA, Bakes KM. Art, chaos, ethnics, and science (ACES): a doctoring curriculum for emergency medicine. Ann Emerg Med. 2006;48:532-537. 8. van Emmerik AA, Kamphuis JH, Hulsbosch AM, Emmelkamp PM. Single session debriefing after psychological trauma: a metaanalysis. Lancet. 2002;360:766-772. 9. Branch WT Jr, Kern D, Haidet P, et al. Teaching the human dimensions of care in clinical settings. JAMA. 2001;286: 1067-1074. 10. Wright SM, Kern DE, Kolodner K, et al. Attributes of excellent attending-physician role models. N Engl J Med. 1998;339: 1986-1993. 11. Duff P. Teaching and assessing professionalism in medicine. Obstet Gynecol. 2004;104:1362-1366.
Did you know?
You can save your online searches and get the results by e-mail.
Visit www.annemergmed.com today to see what else is new online!
Volume , . : November
Annals of Emergency Medicine 539