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Academic Medicine:
doi: 10.1097/ACM.0b013e31815763d2
Professionalism

Institutional Leadership and Faculty Response: Fostering Professionalism at the University of Pennsylvania School of Medicine

Wasserstein, Alan G. MD; Brennan, Patrick J. MD; Rubenstein, Arthur H. MBBCh

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Author Information

Dr. Wasserstein is vice dean, Faculty Affairs, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.

Dr. Brennan is chief medical officer and senior vice president, University of Pennsylvania Health System, Philadelphia, Pennsylvania.

Dr. Rubenstein is dean, School of Medicine, and executive vice president, University of Pennsylvania Health System, Philadelphia, Pennsylvania.

Correspondence should be addressed to Dr. Wasserstein, Renal Electrolyte and Hypertension Division, Seventh Floor CRB, University of Pennsylvania School of Medicine, Philadelphia, PA 19104; telephone: (215) 662-2525; fax (215) 615-0349; e-mail: (alan.wasserstein@uphs.upenn.edu).

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Abstract

Fostering professionalism requires institutional leadership and faculty buy-in. At the University of Pennsylvania School of Medicine, policies and educational programs were developed to enhance professionalism in three areas: conduct of clinical trials, relations with pharmaceutical manufacturers, and the clinical and teaching environment. Responsible conduct of clinical trials has been addressed with mandatory online education and certification for clinical investigators, but some still fail to recognize conflicts of interest. Activity of pharmaceutical representatives has been strictly regulated, meals and gifts from pharmaceutical companies prohibited, and the role of the pharmaceutical industry in the formulary process and in continuing medical education curtailed. Some faculty members have resented such restrictions, particularly in regard to their opportunity to give paid lectures. Professionalism in the clinical and teaching environment has been addressed with interdisciplinary rounding, experiential learning for medical students and residents in small groups, increased recognition of role models of professionalism, and active management of disruptive physicians. Leadership has been exerted through policy development, open communications, and moral suasion and example. Faculty members have expressed both their support and their reservations. Development of communication strategies continues, including town hall meetings, small groups and critical incident narratives, and individual feedback. The understanding and endorsement of faculty, staff, and trainees are an essential element of the professionalism effort.

Despite widespread enthusiasm to restore professionalism in medicine, the meaning of professionalism and the means of advancing it are contested. Cruess et al1–3 have used the term professionalism to emphasize the medical profession’s traditional social contract: great privilege, including monopoly power over medical care and teaching, in exchange for great obligations, including altruism and social responsibility. Swick4 termed these obligations a social trust that includes the obligation to assure access to cost-effective care. In the same spirit, Miller and Brody5 have emphasized the importance of professional integrity in industry-sponsored clinical trials. In this view of professionalism, the interests of patient care, research, and teaching take precedence over the commercial interests of hospitals and health care organizations, industry, and caregivers and investigators themselves.

These principles inspired the Medical Professionalism Project, a collaborative initiative of the American Board of Internal Medicine (ABIM) Foundation, American College of Physicians (ACP)–American Society of Internal Medicine (ASIM) Foundation, and the European Federation of Internal Medicine, which published the Physician Charter in 2002.6 The charter includes three principles (patient welfare, patient autonomy, and social justice) and 10 commitments. Although the charter properly embodies the principles of professionalism, several observers have taken issue with its stance.7–10 The charter, they say, is based in rules and duties and implies that a competency in professionalism is no different in kind from other medical skills. These authors have asserted, on the contrary, that professionalism is not a competency but the moral foundation of medicine. In this vein, teaching and inculcating professionalism are defined not only as mastering a body of knowledge or skills but as moral acculturation, character development, and institutional transformation. These authors believe that academic medical centers (AMCs) must be transformed into moral communities that encompass patient-centered and relationship-centered clinical care, ethically sensitive research, and active community engagement. Promulgation of principles and policies probably could not, by itself, accomplish this moral transformation. Such a transformation requires both top-down institutional leadership and policies and grassroots participation and cultural change.

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Challenges and Strengths at the University of Pennsylvania School of Medicine

At the University of Pennsylvania School of Medicine (Penn), four key factors have converged to enhance interest in professionalism.

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Professionalism as a core competency

The ACGME has required that professionalism be taught to residents as a core competency.11 Regardless of whether we teach professionalism as a set of skills, viz. a competency, or as character formation, we are obligated, like other medical schools, to teach professionalism in some form to house officers. Our residents have responded to this requirement with the opinion that faculty should get the same training. The reports of medical students, obtained from our Doctoring course (see below), have alerted us to episodes of unprofessional behavior by both faculty and residents.

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Patient safety

We have received reports of nurses intimidated by physicians and hesitant to communicate vital clinical information, such as change of patient status or abnormal laboratory results. The absence of teamwork and of mutual respect between disciplines is a threat to high-quality patient care. Tensions also exist between clinical services.

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The malpractice crisis

We have been adversely affected by high costs of malpractice insurance, and we have confirmed the observation that a practitioner’s rate of patient complaints is highly correlated with the number of malpractice actions.12 At Penn, as elsewhere, a disproportionate number of patient complaints is brought against a small fraction of the faculty. Although the precise causal link between patient complaints and malpractice actions is uncertain (e.g., alienation of patients, poor communication with colleagues or nurses), it seems that unprofessional behavior could increase malpractice costs and impair patient care.

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Conflict of interest

Conflict of interest (COI) is an issue in our clinical research, continuing medical education (CME), and relations with pharmaceutical companies and device manufacturers. Academic–industrial relationships pose potential risks to the research subject and to the integrity of the research process. Because of a tragic death during a clinical trial at our own institution,13,14 we have been motivated to introduce safeguards into our clinical research processes that we believe are models for other AMCs.

In addressing these four issues, our institution also has substantial strengths, including

▪ committed senior leadership and department chairs,

▪ a strong professionalism and humanism program for medical students,

▪ a standing COI committee and strong COI policies,

▪ an electronic system of reporting adverse clinical events, including unprofessional behavior,

▪ assessments of professionalism in measuring student performance, in faculty teaching evaluations and promotion decisions, and in patient care,

▪ resident small groups in several departments that deal with issues of professionalism, and

▪ faculty experts in professionalism, ethics, and experiential learning.

We have felt that institutional change requires the committed effort of leadership to provide effective policies, role modeling, and moral suasion. However, regulations and procedures are not enough in themselves. We also require innovative approaches to foster a culture of professionalism at the level of faculty, trainees, and staff. From these two perspectives, we will consider several key areas: COI in clinical trials and consulting arrangements, relations with pharmaceutical manufacturers, and the clinical and teaching environment for faculty and trainees.

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Professionalism in Clinical Research

In the wake of the Bayh–Dole Act, which allowed universities to claim title to intellectual property acquired with the assistance of government funding, the role of industry in academic research has greatly increased. One fourth of investigators have industry affiliations, and two thirds of AMCs have equity interest in start-up companies that sponsor research in the same institutions.15 Although these relationships have had the enormous benefit of translating useful discoveries into commercial products, they have introduced into the AMC an entrepreneurial spirit that has moral and practical risks. Study design and data analysis and publication of industry-sponsored research may be biased to achieve marketing goals. In a meta-analysis, sponsored studies were far more likely than unsponsored studies to yield results favorable to industry products (odds ratio 3.60).15 Restrictions on publication and data sharing are also more likely in industry-sponsored studies. These restrictions can have serious consequences, as has been revealed in the national media in studies of the suicide risk of antidepressants in children and of cardiovascular risk of COX-2 inhibitors. These studies exemplify risk in clinical studies not only to the research subject but risk that knowledge generated from research will be misleading. Participation in a clinical trial balances risk and reward; the reward of contributing to medical knowledge is misrepresented if the trial is biased or if negative results will not be published.5,13 A well-developed sense of professionalism should preclude investigators from participating in industry-sponsored clinical studies that are potentially biased. If that sense is absent, investigators and their institutions may bear heavy penalties, including adverse publicity, government sanctions against their clinical research enterprise, and loss of public trust in the medical profession.16

Guidelines and regulatory requirements have been formulated to address these issues. The National Institutes of Health (NIH) requires that academic investigators disclose potential conflicts of interest to their institutions and that conflicts be managed, that researchers involved in NIH-funded human studies research complete relevant ethics training, and that institutions that receive NIH funding for specific research training programs include training in responsible conduct of research.17 The Food and Drug Administration (FDA) requires that conflicts be disclosed to industrial sponsors, who in turn must report this information during regulatory review.13 The Association of American Medical Colleges (AAMC) suggests as a test the rebuttable presumption that individuals who have significant financial interests in human subjects research may not conduct that research unless there are compelling circumstances.18 The FDA and the International Committee of Medical Journal Editors have required, and the AAMC has endorsed, prior registration of clinical trials in a public repository.5,19 Compliance with these recommendations and requirements has been inconsistent, however. Only a small minority of AMCs prohibited investigators from holding equity, consulting agreements, or decision-making authority in companies that sponsor their research, had specific limits on research-related financial interests,15 or required disclosure to funding agencies, journals, IRBs, or research subjects.20 There is considerable variation in what AMCs require of clinical trial agreements21 or of patent holders.14 Policies that regulate or manage COI in industry-sponsored trials may not be effective in cases where the investigator is also the inventor who holds or files for patent rights.14

Penn has addressed these issues at multiple levels.

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Education program for clinical investigators

We have developed a mandatory online education program and certification for investigators who intend to do clinical research. This program includes intensive ethics and regulatory training. We have developed a COI policy for studies involving human participants22 that is modeled on AAMC guidelines.18 Our policy includes the definition of significant financial interests, including patents, the rebuttable presumption that investigators may not have such interests, and the management of such interests, when significant and unavoidable, through a conflict-of-interest subcommittee (CISC). Investigators are required to report financial interests to the CISC before IRB approval or grant submission to funding agencies. CISC must sign off on COIs before IRB approval of human participants research. Management plans include disclosure to research participants and other investigators and may include divestiture or reduction of financial interests; we have worked to make these plans consistent. We require investigators to report any change of status that could affect management plans. Our patent policy23 is one of the most stringent among AMCs, perhaps because of our experience in the Gelsinger case.14

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Development of COI database

We are instituting a unified database and online tracking of faculty disclosures of COI. Rather than being dispersed across several offices, these disclosures are grouped in a single database and easily collated and analyzed. All annual disclosures of extramural income are reviewed by a member of our office of general counsel. Consulting agreements of investigators who neglect to report these relationships are referred to the CISC.

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Relationship with sponsors

In our clinical trial agreements, we require that sponsors agree to register trials in a public database. We reserve rights to access data generated in our institution and rights to publication. (In a multicenter trial, however, we do not have access to data generated at other centers, and we may not have enough data to publish meaningful analyses. This is a problem that can be addressed not by a single institution but through institutional cooperation or national organizations.)

Significant challenges remain. We have 93 policies regarding COI at Penn that are not entirely consistent (J. Eberwine, personal communication, 2007). We need better definition of what constitutes the compelling circumstances under which an investigator may conduct research despite significant financial interest. Our most important challenge is ongoing uncertainty among our faculty as to what constitutes COI. For the most part, investigators do not fail to report financial interests in order to evade regulation. Rather, they do not understand what COI is and do not recognize when they have it; they assume naively that COI could only apply to unscrupulous individuals and therefore could not apply to them. Our challenge, then, is education. We are updating and expanding a module on COI in our mandatory online training for clinical investigators. We plan to include all faculty members (not only clinical investigators) in an education program on COI. Deming and colleagues24 have pointed out that ethical behavior is not only a matter of adhering to rules and principles but also of practical wisdom acquired through experience, self-reflection, and ongoing discussion with colleagues. As with professionalism training in the clinical setting (below), small-group discussions with faculty role models may enhance our online training. Professionalism will be a major focus of our educational effort. The best guarantor of proper conduct of clinical research is professional integrity.5

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Professionalism in Relations with Pharmaceutical Manufacturers

Penn Medicine (comprising the School of Medicine and the University of Pennsylvania Health System) views its interaction with the pharmaceutical industry as a positive but challenging relationship. Positive results of this relationship have included many productive research collaborations. Challenges have arisen from a misalignment of organizational goals (pharmaceutical sales versus patient outcomes and fiscal responsibility) and potential COI. The Hospital of the University of Pennsylvania (HUP) and the Clinical Practices of the University of Pennsylvania (CPUP) have had policies regulating the behavior of pharmaceutical industry representatives and the control of medication samples within our facilities since the 1990s. Penn believes that purchasing and prescribing decisions should be evidence-based, conflict-free, and in the patient’s best interest. Furthermore, staff should be shielded from marketing interference while doing their work. In 2003, we began a process of revising our policies that culminated in 2006 with new guidance for both professional staff and industry representatives.

Before 2006, Penn’s policies required that pharmaceutical industry detail staff register in the pharmacy department on arrival in our facility. Industry representatives were permitted to market approved medications only in nonpatient care areas and only after making an appointment with a staff member. In practice, these requirements were routinely breached. Our prior policies were silent on the issues of gifts and meals. For reasons of patient safety, we did not permit sample medications at HUP or CPUP practices on the HUP campus.

Despite these policies, we became increasingly concerned about the effects of marketing efforts on practice and staff behaviors. The need for review and revision of existing policies grew out of observations of the activities and behavior of industry representatives and our own professional staff. Our organization became the focus of intense marketing and sales activity. On-site and after-hours meals were regularly served to professional and nonprofessional staff as a means of gaining access to prescribers. Industry staff sometimes engaged in marketing practices in clinical areas of the hospital. Two major pharmaceutical manufacturers had each assigned nearly 20 representatives to our 658 bed acute-care AMC to detail various product lines. Other companies assigned multiple representatives as well. We were not alone in these observations. Evidence emerged that even small gifts confer obligation and influence behavior, even when physicians deny that they are so influenced.25–28 Clinicians are thus induced to prescribe new and more expensive alternative medications that are no better and, in some cases, inferior to older, off-patent drugs. The industry sales force, in a sort of pharmaceutical equivalent of the arms race, grew to nearly 100,000 representatives calling on the nation’s doctors and hospitals while the industry spent upwards of $10 billion annually on marketing endeavors.26 Industry presence in large numbers, the ubiquitous use of meals and small gifts as a means to gain access, and the potential for untoward effects on staff decision-makers were all cause for concern.

Discussions to update Penn’s policies on industry–professional interactions began as early as 2002 after revisions to the Pharmaceutical Research and Manufacturers of America (PhRMA) code. The code is an industry standard that characterizes appropriate behavior, including limits on meals and gifts, to reduce COIs in the selection and prescription of their products.29 Although the code provided explicit guidance on industry behaviors, particularly on the size and nature of gifts and meals, Penn’s view was that it did not go far enough. We recognized at the same time that any revision to our own policies must address not only industry behavior but professional staff behavior as well.

In July 2003, our Medical Board leadership began more determined efforts to revise Penn’s policies. The Medical Board is our medical staff-governing body and comprises department chairs and elected members. The leadership team began to speak of remodeling its relationship with the pharmaceutical industry, retaining those aspects that functioned well, such as evidence-based medicine (EBM), research, and education, while eliminating those aspects that had become problematic.

The process of revision moved forward in 2003 in a very deliberate manner after vetting and approval of the need for action on this subject by the dean and CEO of the health system. The personal and institutional ethic of those involved in these policy revisions was to avoid demonizing any of the stakeholders in the relationship. In October 2004, we held the first of two symposia on the relationship of the pharmaceutical industry to AMCs. The symposium, held on the Penn campus, was open to the public and was heavily subscribed by industry staff. In a series of presentations by faculty and industry leaders, the industry–academic relationship was alternately described as conflicted and fueled by gifts and meals (by academics) or useful and informative (by industry). Industry representatives expressed significant concerns over the characterization of their work and the failure to represent the many important and charitable activities of the pharmaceutical industry. Faculty in turn described the distractions and cost of industry marketing efforts in terms of excess pharmaceutical use as well as apparent COIs.

In the year after the symposium, internal discussions at Penn occurred among stakeholders and included dialogue with industry partners. We conceived and implemented a Center for Evidence-Based Practice to better inform the organization on pharmaceutical, device, and clinical decision making and to serve as a conflict-free, transparent forum for EBM. In the center, all participants are required to actively disclose relationships with industry for every review in which they participate, and conflicted parties are not permitted to participate as decision makers.

Influenced by the publication of Brennan and colleagues,30 the Penn process began to move towards closure and release of our new policies in early 2006. Recognition of the reciprocity engendered by the provision of even small gifts and meals led to an internal consensus that meals and gifts must be eliminated entirely. This position is more stringent than that of the PhRMA Code, which permits small meals and small gifts of medical value. The Penn position on meals and gifts has been characterized by industry and others as missing the point. It has been abundantly clear to us that meals are critical to creating access to prescribers and familiarity with industry personnel and, consequently, that these tokens are keys to influence on the decision-making process. The extent to which meals had become part of our culture was evident in the anticipated disruption that elimination of industry-supported meals would create. Some even characterized the meals as an employee benefit, albeit one granted by an organization other than their employer.

A new policy, Guidelines for Interactions Between Health care Professionals and Industry,31 and a revised Pharmaceutical Industry Representative Activity policy32 were brought forward to the Medical Board in January 2006. These policies were discussed monthly between January and April 2006 before a vote at the April meeting established the documents as institutional policy. Both policies passed without dissenting votes, although there were three abstentions to each policy. Other institutions have announced similar policies, including the University of Michigan Medical School, Yale University School of Medicine,33 University of California–Davis School of Medicine, and Stanford University School of Medicine.

The purpose of these policies is to define appropriate interactions for staff and industry and to minimize undue influence in product selection and prescription. Department chairs, division chiefs, and program directors are charged with implementation of these policies, which apply to all professionals in our organization who deliver patient care. The policies contained four important reaffirmations:

1. Marketing is a privilege authorized by Penn. As such, industry may continue to market only institutionally approved products within our guidelines so long as it remains compliant with institutional policies.

2. Pharmaceutical industry representatives must register in the pharmacy department on arrival and must have an appointment to see a staff member.

3. Marketing is prohibited in all clinical areas including conferences rooms on clinical units.

4. Sample medications are not permitted in any practice site. (This resulted in an extension of the policy to CPUP sites off the main campus as well as to the other hospitals in our health system.)

The critical new elements of the Penn policies included the following:

1. Gifts and meals of any size are prohibited.

2. Unrestricted support for non-CME education is permitted, but grants must be made only through chairs and chiefs and may be disbursed at their discretion.

3. Active disclosure of conflicts of interest is required for all participants in the pharmaceutical formulary process and conflicted parties are not permitted to be decision makers for that product.

4. Professional staff should not participate in industry marketing activities.

5. Industry attendance at conferences and meetings is not permitted.

6. Departmental training curricula will include discussion and reflection on industry encounters.

After adoption of these policies, town hall meetings were held to address faculty concerns on their specifics. A second public symposium held in May 2006 publicly announced the policies and invited faculty and industry reaction. Since approval, several points of resistance have emerged consistently in town hall meetings:

1. Faculty and staff have in some instance resented the proscription against meals and asserted that the provision of food is a trivial issue. As with reports in the literature, most faculty members believe that their decision making is not influenced by meals and gifts. Some saw the policy as the elimination of an employee benefit.

2. Faculty members were resistant to the statement in the policy that professional staff should not participate in industry marketing activity. Opposition, expressed by a small but vocal minority of the faculty, was particularly acute on the issue of paid lectures.

3. Some faculty members were opposed to expansion of the policy to eliminate sample medications on the grounds that indigent patients would be adversely affected.

In every setting in which resistance to the policies was expressed, vocal support was offered as well. In the year since approval of the policies, pharmaceutical industry meals have been nearly eliminated, conflicts and conflicted parties are removed from decision-making roles, and Penn Medicine is working to develop new initiatives that remodel its relationship with the pharmaceutical industry in the areas of EBM, research, and education.

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Professionalism in Clinical Faculty and Trainees

There is no widely accepted and tested curriculum to teach professionalism effectively in the clinical setting (List 1). Cruess et al1–3 have argued that professionalism constitutes a discrete body of knowledge and can be taught in analogy to other topics in the medical school curriculum. Coulehan9 has suggested that the teaching of professionalism, with the goal of achieving professional character formation, should be pursued through four approaches: self-reflection, role modeling, narrative, and community service. One way to cultivate self-reflection and emotional engagement is through small discussion groups in which physicians share their experiences with colleagues. Such group meetings have fostered physician and trainee well-being, reinforced professional identity, and enhanced the effectiveness of clinical care.34–38 Narratives further enhance self-awareness in small groups.39,40 The sharing of critical incident narratives in a group setting is a particularly powerful means of addressing learners’ deeply held values and attitudes and fostering reflection.35,37,39–42 In these groups, faculty and residents can reflect on their own emotional responses to clinical encounters. The concept that physicians must attend to themselves as they care for patients constitutes what has been called relationship-centered care.43 We believe that physicians find this approach more satisfying in the long run than an insistence on altruistic self-sacrifice, which risks emotional disengagement and burnout.

List 1
List 1
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Our teaching of professionalism is best established at the medical student level. In September, 2004 we named an associate dean for professionalism and humanism, who reports to the vice dean for education. The associate dean has designed and directs a well-established, professionalism-related course for medical students, entitled Doctoring, that was formally introduced into the curriculum in 1997.44 This course begins in the spring semester of the first year and continues as a requirement for a total of two and one-half years. Each Doctoring small group consists of 12 to 14 students and three faculty facilitators (preceptors). Classes use multiple teaching pedagogies with a primary emphasis on learning through discussion. Topics include empathy, end-of-life care, confidentiality, choosing a career in medicine, student–teacher boundaries, breaking bad news, disclosing medical errors, physician–patient boundaries, and the impaired physician. Group members are encouraged to share experiences that have occurred since their previous class. These often take the form of oral narratives that relate to professional and unprofessional behaviors encountered in the students’ first year of clinical training and provide a window on the informal curriculum. The trust that has developed during the first year of classes is important and facilitates group members’ sharing emotionally difficult experiences in patient care. The faculty members who teach this course are enthusiastic and inspired by it; a large proportion volunteer to teach multiple times.

Through this course, we have become aware of unprofessional behavior by residents and faculty members and of the disparity between idealizations of medical practice and the reality of a very busy patient-care environment challenged by COIs, market forces, stress and burnout, and less-than-optimal personal behavior. In an effort to enhance professionalism among faculty and residents, we have taken the following steps.

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Extramural speakers.

We organized the Professionalism Symposium in the spring of 2006 that included Drs. Richard Cooper, Richard and Sylvia Cruess, and Jack Coulehan. This symposium had the hoped for benefit of stimulating schoolwide discussion. It elicited a proposal from one of our departments (OB-GYN) to develop a housestaff curriculum that has grown into a wider effort (below).

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Oversight committee.

We formed the Physician Professionalism Committee that includes the vice deans for faculty affairs and for education, the associate deans for professionalism and humanism and for graduate medical education, the chief medical officer, several department chairs, the director of faculty affairs, an attorney, and faculty members with expertise in professionalism. Discussion in this committee focused on two broad themes: building a culture of professionalism and remediating disruptive physician behavior. This committee spawned several subcommittees (below) and continues to meet quarterly to oversee professionalism initiatives.

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Interdisciplinary rounding initiative.

We organized the Interdisciplinary Rounding Initiative across our health system. This effort was facilitated by a consulting group experienced in group dynamics and culture change. It began with focus groups and other interactive formats involving all disciplines and all three hospitals in our system. These groups developed practices that could foster team building in diverse clinical units. These practices have included joint nurse-physician rounds, easy identification of all personnel in the unit, improved introduction and acclimatization of new personnel, joint leadership by nurse managers and lead physicians, and others. We are now rolling these practices out in selected clinical units. These proposals face formidable scheduling obstacles and some resistance from physicians. Use of advanced communications technology, such as video conferencing, may prove helpful.

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Feedback for patient complaints.

We have initiated a program of identifying physicians with disproportionate numbers of patient complaints, with the assistance of Dr. Gerald Hickson at Vanderbilt University.12 These physicians receive feedback from trained physician messengers, and we hope for improvement of unprofessional behavior as a result of this feedback. We may include incidents reported by faculty, trainees, and nurses in this feedback program.

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Manual of resources for disruptive physicians.

We are developing a manual for department chairs to deal with disruptive behavior of their faculty, including resources in the Employees Assistance Program (anger management, substance abuse, etc.), 360 evaluations by coworkers, and other resources.

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Resident professionalism curriculum.

We are developing the Resident Professionalism Curriculum based in self-reflection as well as competency training. Residents are a natural target for professionalism training for several reasons: They are in a formative stage that is amenable to intervention; they are an important vector of the informal curriculum and a major influence on the socialization of medical students; and the training of residents allows us to engage the faculty as their teachers, so enhancing faculty professionalism in a collegial and unpatronizing way (R. Cruess, personal communication). Our hope is that with self-reflective exercises, such as small groups and critical incident narratives, we can restore emotional connection; inculcate satisfaction in the physician–patient relationship and in relations with coworkers; build teamwork and prevent burnout; and develop professionalism that is grounded in inward and self-sustaining experiences rather than rule-based behaviors. We are organizing residents into intradepartmental small groups in six departments. Later we plan to include residents of other medical services and nurses in these groups. Faculty have objected that time is a serious constraint. In such cases, small groups are conducted during scheduled conference time, whereas in other cases groups may be conducted after hours and off campus. We are attempting to achieve mandatory attendance and so are competing with other teaching and clinical duties as well as reservations about the utility of these groups. It is essential, therefore, that small groups provide emotional rewards, such as overcoming professional isolation, from the outset. Faculty and residents in some departments object that they have difficulty writing critical incident narratives. In these cases we are considering alternative means of facilitating small groups, including case discussions and role play.

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Faculty role models.

An essential condition of this curriculum is training a cadre of faculty members who will be role models of professionalism. We plan to give them a background in the cognitive content of professionalism, to teach them how to lead small groups with narrative medicine techniques and to precept and model humanism in clinical settings, and train them to teach and exemplify conflict resolution skills. This training can occur intramurally. We are fortunate to have local experts in narrative medicine techniques,39 group dynamics, and communication skills in clinical practice.45 An important challenge is how we will compensate participating faculty. Our Doctoring course (above) is a model in this regard: some effort will be voluntary, whereas other effort may serve to discharge teaching responsibilities or earn relative value units.

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Community service.

We offer faculty trainees several regional and international community medicine experiences, including working with migrant farm workers in Chester County, Pennsylvania, in Botswana and Central America, and in urban West Philadelphia, and we plan to introduce an explicit professionalism component into these settings.

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Recognition of professionalism.

This recognition is accomplished on a schoolwide basis with the Tow Humanism Award, sponsored by the Gold Humanism Honor Society.46 Individual departments are encouraged to give analogous recognition to faculty and residents. Our obstetrics– gynecology department has established a Professionalism Award in Women’s Health, and our department of medicine has established a Humanism and Professionalism in Medicine award.

Assessment of professionalism is being pursued in multiple venues: (1) critical incident narratives generated in small groups, (2) nurses’ evaluation of attending physician and resident professionalism, (3) patient assessment of attending physicians in aspects of humanistic patient care (courtesy, answering questions, etc.) through Press Ganey surveys, (4) teaching and clinical performance evaluations of faculty and trainees, and (5) a faculty climate survey including questions related to professionalism. Some faculty members have objected that nurses are not capable of evaluating their clinical skills in any regard, including their professionalism. We regard this attitude as an example of the problem we are trying to address and are working to educate these faculty members.

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The Ongoing Pursuit of Professionalism

We have outlined initiatives at Penn to enhance professionalism in the conduct of clinical trials, in relations with pharmaceutical companies, and in the clinical and teaching environments. We believe that we have instituted sound policies to address issues such as COI, teamwork, and mutual respect, but some resistance to these initiatives remains. Market forces, financial rewards, clinician stress and burnout, a narrowly technical worldview, declining federal research support, and other factors are obstacles to the professionalism we wish to foster. Professionalism requires not only policies and rules but also deeply held beliefs.47 We are committed to the creation of a moral community or culture of professionalism, and the faculty in general strongly supports this effort. But it is too early in our initiatives to say whether we have made progress in changing attitudes. We hope that continued communication throughout our institution, in lecture halls and in small groups, in policy announcements and in one-to-one feedback, will develop in faculty members and trainees a professional ethos to anchor them in complex times.

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Acknowledgments

The authors gratefully acknowledge advice and review provided by Kelly Curran, James Eberwine, PhD, Paul Lanken, MD, and Victoria Mulhern, and the thoughtful efforts of our professionalism committees.

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© 2007 Association of American Medical Colleges

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