Klein, Eileen J. MD, MPH; Jackson, J. Craig MD; Kratz, Lyn MSW; Marcuse, Edgar K. MD, MPH; McPhillips, Heather A. MD, MPH; Shugerman, Richard P. MD; Watkins, Sandra MD; Stapleton, F. Bruder MD
There is a renewed interest in professionalism and the importance of teaching it in medical schools and residency training programs.1,2 The Accreditation Council for Graduate Medical Education (ACGME) defines professionalism as a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.3 The ACGME believes professionalism should be taught and evaluated as one of the components of competence for medical residents and will require documentation of these efforts beginning in 2007.4 The American Academy of Pediatrics (AAP) has identified eight key components of professionalism: honesty/integrity, reliability/responsibility, respect for others, compassion/empathy, self-improvement, self-awareness/knowledge of limits, communication/collaboration, and altruism/advocacy. The American Board of Pediatrics (ABP) has requested that program directors evaluate professionalism and document such training on the Verification of Clinical Competence form filled out for each resident who applies for board certification. An applicant who receives an unsatisfactory evaluation in professionalism or interpersonal skills and communication either may complete an additional period of training in general comprehensive pediatrics in an accredited program or will be required to complete a period of observation before reapplying to the ABP. A plan for remediation must be submitted for review and approval by the ABP.5
Recently, several publications have discussed integration of the educational tenants of professionalism into the medical school curriculum.6,7,8,9 Today, most medical schools involve students in activities intended to enhance knowledge and understanding of the expectations of physicians in the area of professionalism. These medical school activities have been aided by the guidelines created by the Medical School Objectives Project (MSOP). The first activity of that project, which, in part, was undertaken because of the need to emphasize physicians' professionalism, was described in a session at the 1997 annual meeting of the Association of American Medical Colleges (AAMC) and the results reported by the Medical School Objectives Writing Group in 1999.10,11 The goal of that part of the MSOP program was to define knowledge, skills, attitudes, and values that medical students should demonstrate before graduating, such as altruism, respect, compassion, honesty, integrity, etc. The second phase focused on roles played by the physician related to medical informatics and population health, such as lifelong learner, educator, clinician, communicator, researcher, and manager.12 An example of how a medical school has integrated qualities of professionalism into its curriculum is the Program for Professional Values and Ethics in Medical Education (PPVEME) created by Tulane University School of Medicine.13 It is a learner-driven program that emphasizes the themes of integrity, communication, teamwork, leadership, and service.
As financial constraints worsen throughout the field of medicine and alter the nature of the traditional doctor—patient relationship, many authors have questioned the ability of physicians to maintain the lofty standards for professionalism that are being created through such initiatives.14,15,16,17 However, in an effort to emphasize professional behavior in medical education and to assure professional behavior at the completion of training, rating scales have been created to assess residents' professionalism18; systems created that encourage the reporting of unethical and unprofessional behavior19,20; and strategies developed for increased self-awareness.21
In this article we describe a curriculum for introducing the principles of professionalism into a pediatrics residency that may serve as a model for other programs, and discuss options for evaluating a professionalism curriculum.
OUR PROFESSIONALISM CURRICULUM
The Setting: an Interns' Retreat
Every fall for the last 25 years, the pediatrics residency program at the University of Washington and the Children's Hospital and Regional Medical Center (CHRMC) has sponsored an annual five-day retreat for interns. While the retreat has several goals, throughout the week there is an emphasis on those attributes and behaviors that contribute to the development of professionalism in medicine.22,23 There are 11 sessions during the retreat that provide the basis for this curriculum (Chart 1). The sessions address key professional issues, such as managing ethical dilemmas, evaluating and responding to child abuse, being advocates for the health of children within a specified population, and preparing oneself emotionally for the impact of working with dying patients. Empathy, open communication, respect, and collaboration are emphasized throughout these sessions. Residents are given many opportunities to explore their own biases, reactions, and values within the context of common residents' experiences and challenges. The retreat offers several approaches to foster learning and growing—from the use of videos to discussion and experiential exercises to readers' theater (described below) and more.
Below we describe how individual sessions of the retreat focus on the key components of professionalism as listed by the American Academy of Pediatrics, stated earlier: honesty/integrity, reliability/responsibility, respect for others, compassion/empathy, self-improvement, self-awareness/knowledge of limits, communication/collaboration, and altruism/advocacy (List 1). To help the reader, sessions are described under the headings as listed by the American Academy of Pediatrics above. In actuality, these sessions are dispersed throughout the intern retreat week as shown in Chart 1 and are not presented at the retreat in the order shown in the paper and in List 1.
The Eight Components
Honesty/integrity and reliability/responsibility. The session entitled Ethics (see Chart 1, Friday schedule) is held with all 24 interns who are participating in the retreat. It provides an opportunity to reflect on day-to-day issues encountered by residents and the decisions they face that require moral judgments and involve interactions with peers, families, nursing staff, attending physicians, and others. Examples of topics addressed include being asked to write a prescription for a colleague for whom one does not have a typical prescribing relationship; being asked to perform a procedure that one does not think is necessary; and responding to the situation when a nurse goes over one's head to a more senior physician. Residents are asked how they would deal with each situation, and the session leader facilitates the discussion using the following four principles of biomedical ethics: respect for autonomy, nonmaleficence, beneficence, and justice.
Smaller discussion groups provide an opportunity to discuss issues relating to honesty, integrity, reliability, and responsibility in a more intimate setting. One or two faculty members skilled in facilitating small-group discussions lead each group of eight residents. To help focus the discussions, the residents are asked to rank their comfort levels with six uncomfortable situations (see List 2). While all of the situations are intended to provoke anxiety, some residents will feel more or less prepared to deal with one or more of the situations than others. The residents discuss why they felt a particular situation was either more or less uncomfortable, the issues it raised for them, and the conflicts they felt. The exercise also highlights the diversity of values within their own peer groups. Comments and views of the residents are not perceived to be “right” or “wrong,” as the goal is to allow a free-flowing and nonjudgmental conversation among the residents. The facilitator keeps the conversations focused on residents' concerns and encourages involvement of all those attending the session.
Respect for others and compassion/empathy. To provide insight into the challenge of working with parents in a variety of stressful situations, residents watch videotaped scenarios of actors portraying parents interacting with attending faculty physicians in difficult situations. These “challenging interactions” include communicating with a parent who is hostile, dealing with a parent who has endless concerns, delivering bad news, and reporting child abuse. The scenarios are presented twice, each time with different physician interviewers. The tapes allow the residents to compare approaches and observe effective and ineffective styles. They shed light on the positive impacts of empathy, active listening, and respecting parental concerns.24
Before viewing the videos the residents are asked as a group to formulate a specific set of goals and plans for each interview. It is hoped that developing a process of explicit goal-setting will allow the interviewing physician to be more sensitive to process issues and result in improved communication and, therefore, increased satisfaction for both patient and physician. After the tape is shown, residents discuss whether the goals were met, how the physician contributed to the rapport that was established, and how both the parent and physician may have felt at the end of the interview. Special emphasis is placed on the quality of the doctor—patient relationship, physician self-awareness, and the communication process.
“Do You Know What They Said to Me?” presented by The Parent Players, is a dramatic approach to exploring the parent—physician relationship. It has proven to be an effective catalyst for candid discussion, constructive feedback, and deepening mutual respect and understanding. The script was developed by a group of parents of children with special health needs and is presented, by parents, in a readers' theater format. In readers' theater the actors simply sit in chairs and read their parts. There are no props, no costumes, just voices.
The content of the play is a composite of real events experienced by families in their interactions with residents and other physicians. There are three different scenarios, each presented twice. The first time through each scenario is presented with difficult communication that is testy and defensive. The second time through the same scenario the communication undergoes some subtle and not-so-subtle shifts. As the narrator says, “What if all parties listened a little better and respected each other more?” In these second scenarios, the communication is more respectful, productive, and supportive.
The dialogue that follows the presentation is as important as, if not more important than, the play itself. Residents share their reactions, ask questions, discuss their own frustrations, and present situations for feedback. Parents field the questions based on their personal experiences and give examples of how residents have had positive impacts on their hospital experiences. Typically, it is a time of honest sharing that results in a deepening of their appreciation for one another. This section of the retreat concludes with the parents' continuing their conversations with the residents in smaller groups over lunch.
The session on talking with teens is facilitated by faculty from the Division of Adolescent Medicine and the Department of Psychiatry. Residents are provided with scenarios in which teenagers are presenting complex issues (e.g., pregnancy; parental concern about drug use). The residents take turns playing the roles of the physician and the patient and help each other when they get stuck. This session combines practical tips and supportive guidance from the faculty. There is active involvement of those who participate in the role-play as well as those who observe. Issues related to confidentiality are discussed, as well as ways to enhance open communication with this unique group of patients.
Self-improvement. The session on residents as teachers provides a framework for residents to discuss their role as teachers of colleagues and medical students. Residents are encouraged to explore those situations where they are at their best as teachers and those situations where they find teaching frustrating and difficult. As one approach to increasing their self-awareness, the group grapples with a roleplaying scenario that presents some of the stereotypic frustrations residents encounter when teaching a medical student. The follow-up discussion results in concrete strategies for effectively addressing these challenges. Tools and resources are provided to help the residents enhance their skills as educators.
Self-awareness/knowledge of limits. A session on ethical issues in neonatology begins with the presentation of a recent clinical situation from the neonatal intensive care unit with which many but not all of the residents are familiar. The leaders (neonatologists) simplify the medical facts to the bare minimum needed to illustrate the ethical challenges. The presentation is interrupted at points where an ethical decision is required: Should the distressed fetus at 23 weeks be delivered by C-section? Should the extremely premature newborn be resuscitated? Should care be withdrawn upon the discovery of a severe intracranial hemorrhage or upon the development of chronic ventilator dependence? Residents are encouraged to ask for clarification of the patient's medical situation, family preferences, etc., and to discuss and debate the ethical issues as well as explore their personal reactions and perspectives. The case is used to illustrate how physicians' decision making can be influenced by their lack of ability to predict an outcome and how other factors must influence decision making. The issues of beneficence, non-maleficence, autonomy, and justice are discussed.
The other discussion group focuses on “Internship Values.” The residents are given a list of value-based statements (see List 3) and asked to indicate the levels of their agreement or disagreement with the statements. They are told not to labor over any one statement, but instead to go with their first reaction. Before breaking into small groups, the entire group gathers together. The residents are asked to physically position themselves on a continuum that reflects their responses to particular questions. In this process, it becomes apparent that there are issues on which there is widespread consistency among the residents, but others on which there is considerable inconsistency. Differences are honored. There is no attempt to achieve consensus. The residents then break up into small groups of about eight per group, with one or two facilitators to lead a discussion at a deeper level. This provides residents with the opportunity to think about what issues are most important to them and provide a supportive environment to explore them more fully.
Communication/collaboration. The first afternoon of the retreat is spent outdoors at a local park doing adventure-based team building. Through a series of group exercises that are posed as problems to be solved, residents are encouraged to reflect on their interaction as members of a team, and on how the group works together to solve the challenges presented. Retreat faculty believe training that incorporates not only cognitive but also physical challenges has a strong impact and produces learning insights in a more dynamic fashion than do traditional approaches. These experiences provide an enjoyable and active way to get to know one's self and others as well as a way to promote trust and respect among the group of residents.
Residents face simulated challenges such as evacuating their group from a earthquake-damaged building that is dripping with downed electrical wires, and rescuing an eagle's nest from atop a snag without breaking the eggs (water balloons) inside. There is no one answer to these problems. However, none of the solutions can be executed without teamwork and good communication. The key to a successful training such as this is helping the participants transfer the learning “to the real world.” While the specific exercises may be contrived, the specific and individual behaviors manifested in the exercises are as real as they are in any teaming situation. Residents learn the value and exhilaration of working together.
Equally non-traditional in its approach to teaching communication and collaboration is the session called “Advanced Group Dynamics.” This session has two specific components: The first is a scavenger hunt and the second, the assignment of preparing a meal for everyone the last night of the retreat.
For the scavenger hunt the class is divided into groups of four. Each group is given clues that take them all over the city and a disposable camera to capture their discoveries. For the second assignment, the entire group of residents is given an appropriate amount of money with instructions to plan, prepare, and serve dinner for themselves, their spouses, partners, and the faculty. To accomplish this, they engage in lively debate about the menu and actively work together to organize the event.
While both of these components of the retreat are light-hearted and fun-spirited, they provide a welcomed balance to the more serious, intense conversations that fill up the remainder of the retreat. They are highly valued by the residents and faculty as creative ways to get to know one another better and promote teamwork. They confirm that “good old-fashioned fun” can result in a deeper level of trust and collaboration.
Altruism/advocacy. For many residents, dealing with the dying child brings up issues of helplessness and insecurity. To illustrate a patient's perspective on death and how physicians are able to help, a video is shown of an adolescent patient with cystic fibrosis several weeks before his death. This session is designed to allow each resident to identify his or her own level of comfort and discuss how to best care for the patients and families affected as well as for themselves. A parent whose child has died and the physician who cared for the child and her family are present for part of this session. Both share their perspectives in personal and candid ways. A specialist in death and dying, who is comfortable with the issues and with supporting differing ways of coping, facilitates a discussion that explores residents' concerns and reactions. Residents reflect on how they can provide care that is in the best interest of the patient while also dealing with their own feelings related to death and dying.
Evaluation of the Retreat
To maintain interest and relevancy, the interns evaluate each session of the retreat each year. The evaluations are reviewed by the faculty team responsible for the retreat, the residency program director, and the department chair. These evaluations have guided the evolution of the intern retreat. Below are a few excerpts from residents' comments in recent years, keyed to the retreat topics or activities.
Parent Players: “It brings me back to feel those parents' feelings—feel their fear, discomfort, and frustration.” “They gave me tremendous insight into how I should speak.”
Ethical issues in neonatology: “Interesting ethical discussion. I would also have liked more guidance on ways to approach end-of-life discussions.”
Discussion group: “Good way to safely discuss our attitudes and beliefs about work ethic and life priorities.”
Revisiting the Retreat Topics during the Residency
Following the pediatrics interns' retreat, many of the retreat's topics are revisited in noon conferences throughout their three-year residency experience. One example is the monthly ethics discussion that is presented by a member of the retreat faculty and is designed for pediatrics residents. These sessions provide residents longitudinal exposure to ethical dilemmas, and offer opportunity to deepen their self-awareness, enhance their self-understanding, and remember the critical importance of maintaining professional behavior and of being committed to the core professional values that guide their practices.
THOUGHTS ON TEACHING AND EVALUATING PROFESSIONALISM
The sessions described above can be incorporated into a retreat or integrated throughout the year. There are benefits and problems with both. Making these sessions mandatory is important to assure that residents are exposed to this curriculum. The retreat format allows the entire group of interns to attend and interact during all sessions, something that would be difficult to attain at several sessions during the year. Perhaps more important, a retreat facilitates the establishment of a reflective, contemplative environment that is difficult to create in the midst of a busy clinical day. Many of these issues are difficult to approach in a one-hour conference and require the development of a sense of trust within the group.
Despite some of the difficulties in implementation, an intermittent format may be a better fit within the constraints of many programs. If used in an intermittent format, it would be necessary to provide each session several times during the year. This would assure that all residents were able to participate in each of the sessions. A sign-in sheet could be used to record attendance, with attendance at every session necessary for graduation from the program.
We are currently developing measures to better assess professionalism at our program. A number of options are being promoted nationally. Jordan Cohen, MD, president of the AAMC, suggests the use of peer evaluations, where fellow residents/students measure their colleagues as a supplement to faculty evaluations.25 Tenets of professionalism can be added to the evaluation form for residents after each of their rotations. This would allow residents to address issues related to professionalism throughout their residency. The American Academy of Pediatrics has published a one-page evaluation form for professionalism (List 1). It encompasses the eight components of professionalism described earlier in this article. Use of this form by programs may be most useful on an annual or twice-yearly basis, as opposed to a single time at the completion of residency.
Clearly, professionalism should be taught during medical school and residency. How to go about this is not as clear. Wear and Catellani discussed the importance of specific curriculum content and described their vision of professional understanding beginning with the medical school admission process.26,27 Markakis et al. reviewed the past ten years of their primary care internal medicine residency program. Their program includes communication-skills training, challenging case conferences, home visits with patients, a residents' support group, and mentoring.28
While there are many opportunities for teaching about professionalism in residency, in our institution, we present these sessions during the five-day retreat described earlier, in a relaxed, nonjudgmental setting where there is time for individual views and opinions to be aired. We prefer a retreat to an intermittent format to avoid attendance issues, but more importantly because it enables the full internship group to participate utilizing a discussion rather than lecture format and allows the group to grapple with these issues at a pace they find comfortable away from the pressures of residency. Many programs will not have the means to provide a severalday retreat for residents. We believe that programs that are unable to provide a retreat could present this curriculum, in part or in its entirety, through intermittent sessions over the course of a residency. Regardless of its format, continuing to emphasize professionalism as an integral component of residency training is essential. Developing compelling and relevant approaches that engage the resident in the issue remains a worthy endeavor.
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