Fryer-Edwards, Kelly PhD; Van Eaton, Erik MD; Goldstein, Erika A. MD; Kimball, Harry R. MD; Veith, Richard C. MD; Pellegrini, Carlos A. MD; Ramsey, Paul G. MD
At the University of Washington School of Medicine (UW Medicine), we are in the midst of an emerging ecology of professionalism.1 Our prior institutional work—outlined by Goldstein and colleagues2 in 2006—focused on enhancing and promoting professionalism among one constituency: the students. Building on this effort, we were ready to move toward the complete integration of a culture of professionalism within the full spectrum of our community at UW Medicine: staff, faculty, residents, and students. Our intent is to address professionalism as institutional culture rather than isolating each developmental stage of training or sectors of the workforce. The platform for initiating organizational development is the Committee on Continuous Professionalism Improvement, established in November 2006.
In 2004, the UW School of Medicine conducted an internal review process regarding professionalism within our institution and among our members. During this process, two appointed committees completed an environmental scan involving interviews with faculty, residents, students, and other peer institutions and systematically reviewed institutional documents and guidelines affecting hiring, disciplinary action, and promotion. Through this process, we learned that although a high level of professionalism is common among our members, faculty and trainees have occasionally witnessed unprofessional or questionable behaviors. Further, there were systems-level questions, such as services for uninsured patients and policies toward pharmaceutical company involvement in education, that were thought to be a matter of community-level discussion. There was wide agreement that an institutional effort to strengthen professionalism would be beneficial. Our review also identified some gaps in formal procedural guidelines, such as between the faculty code, annual review criteria, and promotions processes, which we determined would benefit from consistency in articulating what we valued and what was rewarded within the institution.
The final report from the review process recommended forming an institution-wide standing committee to provide connections for the many professionalism activities that were ongoing, and to initiate new programs as needed. This decision was based on the following assumptions: (1) professionalism is a dynamic and evolving process that benefits from regular and systematic attention, (2) separate activities are good, and linking them into a coherent whole is better, (3) cynicism can take root quickly—it should be identified and acted on to keep the institutional climate healthy, and (4) all members of the institution must be enlisted in this process, because we all influence and are influenced by it.
Why Continuous Professionalism Improvement?
The term continuous professionalism improvement was introduced by the UW Medicine dean to emphasize the use of Continuous Process Improvement (CPI) theory. Popularized by Toyota and introduced into the health care system by Berwick3 in 1989, the theory proposes that every system can be improved and that further improvements can be developed constantly. The CPI theory focuses on systems; it requires engagement of the entire organization and concentrates its effort on delivering a quality product to the consumer. Although centered on improvement of the system, the theory relies substantially on the creative nature of the individuals who compose the organization. The theory appealed to us as a basic method or guiding principle because we intended to engage all our constituencies, to introduce change in an iterative (cyclic) fashion, and to measure the results of the change to guide new improvements. Through these iterative changes, we intended to improve professional practices within the entire organization. We felt that although our focus was on professionalism, as opposed to quality as with the original theory, this method provided the closest ideal to what we intended to accomplish.
Another benefit the CPI process brings to professionalism is the way it mirrors what we know about how people progress from novice to experts.4 Unlike the majority of early trainees, experts in a given field are characterized by continually reflecting on their actions and improving them. A commitment to continuous improvement moves beyond competence to expertise. Medical educators have derived this concept largely from the Dreyfus Model of Knowledge Development, embraced by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties during development and deployment of the general competencies.5 This model has been widely used for framing clinical skill development, and we found it appropriate for professionalism as well. Consider a common example from the Dreyfus model: competent automobile drivers learn to drive correctly by fitting all driving situations to a set of conscious rules. New situations are often dealt with incorrectly if no rules have been learned to handle them. Through continuous driving, they become experts; mindful exposure to new situations compounds the richness of their driving experience to the point where they seem to respond intuitively to new situations with correct maneuvers, even if they have never encountered the situation before.6
In medical education, the traditional progress of clinical skill acquisition from medical school, through residency, to junior and senior clinician, follows the Dreyfus model closely.7 In many ways, however, the current training model has not supported the same kind of progression from novice to expert within professionalism. Attention to cultivating a mindful exposure to new situations in professionalism often is distracted by other clinical and research priorities, and many practitioners do not progress beyond the advanced beginner or competent stage. These practitioners understand professionalism and can describe examples of professional and unprofessional behavior, yet they may deal with new situations inappropriately. They have not made the transition to proficiency or expert stages where they continuously think about and interpret professional behaviors in a way that permits them to act correctly and intuitively in unfamiliar situations. In the same way in which mindfulness in clinical practice improves the clinician’s focus and enhances care,8 mindfulness in this domain enhances development of professionalism.9
By focusing on continuous professionalism improvement, we recognize that professionalism must involve fostering habitual behaviors that shift with the context of daily medical interactions. Furthermore, the mere idea of improvement implicitly recognizes that a certain level of professionalism already exists among all our constituencies and focuses the attention on its enhancement.10 Lastly, we consider professionalism to be a progressive institutional and individual trait, rather than an end point, and it is best approached using proven techniques for continuous improvement.
Moving from Theory to Practice
The UW Medicine Committee on Continuous Professionalism Improvement currently has 23 members and can be expanded as needed on the basis of expertise and representation. Among the members are four department chairs, two medical directors, three advisors to the dean, two residents, two medical students, and faculty from both clinical and basic science departments and three teaching hospitals. The committee charge for 2007 is to (1) review and assess recommendations produced by earlier ad hoc committees that laid the groundwork for the standing committee on professionalism, (2) complete an environmental scan of professionalism activities at UW Medicine, (3) initiate and augment current activities as needed, and (4) oversee and promote professionalism activities throughout the medical school. Additional working groups will be charged by the committee to conduct specific activities. These additional working groups will draw on a large number of other individuals with specific areas of expertise. The Committee on Continuous Professionalism Improvement will serve as a coordinating and promoting body of such efforts, to address the institution-wide needs and to identify interrelationships between projects. The committee is to focus on process, to introduce approaches for integrating professionalism into further aspects of our institutional culture and practices, leaving the actual innovations to those with particular investments in specific areas (e.g., residency education, research, clinical practice, faculty promotions). The committee chair is appointed by and reports directly to the dean. Given the broad nature of the charge, the chair and other committee members give frequent progress reports to the dean, to the medical school executive committee, and UW Medicine faculty and staff, with a formal report to the dean expected annually.
When the committee received its charge, we knew success would depend on a carefully designed process that involved the entire UW Medicine community. We started by identifying existing champions and areas that needed attention rather than dictating particular actions—an approach that might create substantial resistance. Indeed, other colleagues had struggled with professionalism initiatives at other institutions (as we have at our own) when the initiatives were perceived as threatening or pedantic. We knew we would have to address common pitfalls faced during organizational innovation: burnout, cynicism, loss of a champion, limited time for leadership, “top-down” implementation, and lack of resources.11 Furthermore, some professionalism efforts, including our own early attempts, have suffered from being too idealized and not sufficiently grounded in the reality of the complexity of clinical practice and multiple, diverse educational and training programs.
To overcome such obstacles, we considered a variety of models and strategies. Although our continuous professionalism improvement approach is inspired primarily by CPI theory as described above, we knew there were other models of organizational change and development that could inform our efforts. We reviewed several in search of features that would best fit the context of an academic medical institution.12 Three such approaches caught our attention and are highlighted below. Table 1 summarizes features that are under consideration by our committee.
A number of models for organizational development have been extensively studied: Continuous Quality Improvement, Total Quality Management, 4A Model, Six Sigma, etc.13,14 Some of the features addressed by these models are relevant for educational institutions committed to fostering medical professionalism, such as identifying and articulating clear expectations, maintaining a focus on mission, developing a responsive feedback process, and realizing value from all new efforts.
One feature that seemed useful for our process is the practice of establishing clear expectations for both successful and sanctioned behaviors within that organization. Such expectations need to be behavioral, observable, understandable, and open to evaluation. For professionalism, this means shifting from an I know it when I see it mentality to clearly articulating which behaviors are laudable and which are unacceptable within the institution. In our system, this will mean developing behavioral benchmarks for students and residents, as well as for faculty and staff within the annual review and promotion mechanisms. The annual review process offers a unique opportunity for a private discussion between a division chief or department chair and the faculty member on specific behaviors. Traditionally, annual reviews, as well as the promotion process itself, have emphasized clinical work, teaching effectiveness, research accomplishment, and administrative leadership as the key determinants for advancement. Simply adding professionalism as a category for appraisal creates an opportunity for a conversation and reinforces this domain as a valued measure of academic merit and professional growth. Identifying specific behaviors to reward or rectify is a process, one accomplished through community engagement and participation. One approach frequently used in professionalism workshops is to ask various stakeholder groups, who do you respect, and why? Institutional members at every level can participate in identifying students with whom they enjoy working and colleagues and staff they admire, with the goal of articulating specific behaviors that are desirable. A similar process can identify behaviors that the community finds unacceptable and, therefore, open to sanction. Through a process of community dialogues, we can develop behavioral expectations at every developmental level that can be incorporated into formal evaluation and feedback mechanisms. This approach of community-based reflection weaves together two threads within the literature on medical professionalism previously thought to be contradictory, but which we find highly complimentary. In our experience, we need both concrete definitions and explicit expectations as well as reflection and discussion of the complex, real-time experience of practice.15,16
A second important feature of organizational development models is that they help to keep front and center the mission-driven purpose for highlighting certain behaviors and restricting others. For medicine, it becomes a test of asking, how does this behavior contribute to (or hinder) quality patient care? Does a specific behavior promote the best standards in our profession? In an era where public trust in medicine and science is declining, fostering trustworthiness should be a high priority within academic medical institutions. Thus, we should ask ourselves, what do I feel especially proud of? What would the general public think of this behavior? What could I do to remedy a misstep I have made? What have I learned from this experience that helps me develop expertise in professionalism? How can I teach this to others?
Third, if professional development is understood as an evolving, lifelong process, then it follows that the systems in place to foster development would need to be similarly responsive and ongoing (hence, continuous). Clear expectations that are frequently disseminated can help the assessment process become nearly instinctual. Annual reviews or end-of-rotation evaluations are logical times to incorporate ongoing self-assessment as well as external feedback. This practice can be substantially enhanced by more frequent and periodic discussions centered on events that have been observed or reported. Incorporating professional behavior into a regular review process allows the person to focus on a specific behavior, results in immediate feedback, and allows the supervisor to determine whether the feedback process resulted in the desired changes. By including specific behavioral expectations in a review process, students and faculty can self-identify problem behavior and begin a dialogue about which corrections or improvements are possible. Developing a routine, mission-driven, and behaviorally anchored feedback system solves a major dilemma in evaluating professionalism—we are not as comfortable giving feedback on professional behaviors as we are on more concrete clinical skills and knowledge.
Moving closer to an organizational approach that had already been used at our institution,17 we further examined the lessons learned from the systems-based thinking that characterizes the safety culture. When faced with unacceptable levels of medical error, health care looked to other industries, particularly aviation, to learn about error reduction.18,19 A few key themes from this set of practices are pertinent to professionalism.
For a safety culture to work, it must be proactive, involve everyone, and have mechanisms for safe reporting. These three features are tightly linked. For potential problems to be explored and prevented, everyone on the team must be involved and feel safe to report and discuss observations. Intrinsic to the safety culture adopted by industry is the concept that human failure is inevitable, and, thus, problems and issues will always arise. This relatively simple concept makes the reporting of events a more natural phenomenon. The organizational culture must espouse a blame-free environment, recognizing that systems should be designed to manage the inevitability of human failure. If blame and punishment accompany human error, then workers hide mistakes, unsafe systems persist, and ongoing attention to safety is lost. By eliminating blame, rewarding error reporting, and focusing on the system, the personal aspect is removed from the equation, and a safety culture can thrive.
Certain mechanisms have developed, such as critical incident reporting, so that errors and near-misses can be reported and reviewed centrally within a clinical setting.20 The review, in turn, focuses on patterns or systems issues that can be rectified to prevent future problems from occurring. It is generally a blame-free process, with everyone committed to a common goal: promotion of patient safety. Some institutions have started similar reporting systems for professionalism concerns, either through anonymous Web sites21 or as part of student evaluations of residents and faculty (M. Papadakis, personal communication, 2006). What these systems have in common is that feedback flows to a central location (usually leadership) that can look for patterns of behavior. For professionalism, unlike patient safety lapses, a single incident or unfortunate interaction may not warrant follow-up, but a pattern of behavior will.
A second mechanism familiar to medicine provides another potential process to debrief and learn from professionalism “incidents”: the morbidity and mortality conference (M&M). Within this process, it is understood that undesirable outcomes will happen during the course of clinical practice, just as unfortunate missteps occur with professional behavior between colleagues or mentor–trainees. The M&M provides an opportunity to learn from mistakes. A professionalism M&M would allow collective discussion around seminal events that can foster cynicism if left unaddressed. Our committee had the opportunity to identify one such issue of communication between teaching hospitals during a town hall meeting. The ability of the staff to discuss the origins of the problem, their own expectations, and the immediate action taken by the leadership were all aimed at preventing the development of cynicism engendered by such events. The Committee on Continuous Professionalism Improvement has used existing venues, such as town halls and staff meetings, to extend UW Medicine community conversations into areas of professionalism, and to identify community needs for further attention and development. One such staff meeting recently focused on a discussion of issue of access for the uninsured, on the concern of making sure that our hospital remained committed to their care, on the ways physicians deal with lack of beds in the institution, and so on. These topics were elicited by members of our committee who surveyed staff about professionalism issues they face and that warrant attention.
Community-level discussions can focus on systems-level concerns that affect the entire institution, such as those described above. They can also provide opportunity for everyone to learn from an event that may originally have involved only a few individuals. It also prevents rumors from developing and taking on a life of their own. Broad discussion permits exploration of the kinds of judgment and trade-offs that are inevitably needed. Various stakeholders might see a problem or potential solution differently, and how we learn as an institution to respond to mistakes or differences in judgment or action will be a large measure of our professionalism. The correlation between response to error and meaningful growth has already been shown at the personal level in medicine. Residents who embraced errors and were aware of the emotional impact make more constructive changes to their practice when compared with residents who dealt with mistakes by escape or avoidance.22 Like the investment we make with medical knowledge and patient care, our practice of professionalism requires a personal, emotional commitment beyond just understanding the concepts and possessing the desire to follow them. Experiencing the impact of professionalism must take place on a personal level, and through broad discussion, we endeavor to experience it at the institutional level as well.
It was apparent from our original environmental scan that there are many individuals in the UW Medicine community who are considered role models of professionalism. We felt it was important to build on the strengths of these positive role models, even while we aim at learning from our mistakes. Appreciative inquiry (AI), in keeping with other solution-focused approaches, fosters organizational development through attention to strengths.23 At the core of AI is a shift in focus from problems to possibilities. The basic idea is that if we can do more good things, then the good in the system will gain momentum and build enthusiasm, eventually leaving little room for the bad. Simply holding up examples of professional behaviors and choices helps provide others within the institution with alternatives when faced with their own professional dilemmas.
Several mechanisms can help keep our strengths at the forefront. By including professionalism in evaluations and faculty reviews, we not only identify and remedy undesirable behavior, but we are able to reward exemplars and good citizens. Periodic panels of students, residents, faculty, and staff who talk about aspects of their work that highlight professionalism help to model the kind of practices of which we all want to be a part. A recent panel featured seven of our community members (from student to faculty level) speaking about their experiences, both locally and abroad, of providing service to those in need. We routinely recognize excellence in our research and teaching programs through quarterly lectures presenting innovative work going on within our institution.
The Committee on Continuous Professionalism Improvement will work toward more structured opportunities for reflection and assessment to be built into the educational system at UW. Likewise, an annual award for institutional members who are exemplars for specific aspects of professionalism (humanism, excellence, altruism, accountability24) offers another opportunity for community reflection on the behaviors we admire and to which we aspire.
Continuous Professionalism Improvement: Where Do We Go from Here?
Our institution is engaged in an ongoing, community-based process of professionalism development. We began by centering our work on the idea of CPI. This theory alone is not sufficient to allow us to reach our goals, and in some instances it does not provide an ideal working environment. To achieve an advanced culture of professionalism within our institution, we borrow practices and guidelines from successful models from other organizations and industries to give us a diverse set of tools with which to work.
Like many institutions engaged in this work, we have a number of professionalism activities already underway within medical student education, graduate medical education, faculty development, and research training. Where we go from here will be substantially influenced by our community members (students, trainees, faculty, staff). As we continue to seek input and identify opportunities by active listening and elicitation, we will keep in mind the lessons from other organizational development efforts; that is, this will be a continuous process in which we build on concrete expectations, use mechanisms to learn from our individual and collective missteps, and draw on our strengths. Throughout all our specific activities, we explicitly take a two-pronged approach to cultivating a culture of professionalism: celebration of excellence and attention to accountability. The key now is to keep the momentum generated by the creation of this committee and the involvement of all of our UW Medicine members so that as we build this culture, we do so on a solid platform.
The authors thank their colleagues who are members of the Committee on Continuous Professionalism Improvement, the University of Washington College Faculty, and also those members of UW School of Medicine who are engaged in this work. This work has benefited from their ideas, efforts, and energy in support of this project.
1 Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: American Association of Medical Colleges; 2003.
2 Goldstein E, Maestas RR, Fryer-Edwards K, et al. Professionalism in medical education: an institutional challenge. Acad Med. 2006;81:871–876.
3 Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med. 1989;320:53–56.
4 Sawyer RK.The Cambridge Handbook of the Learning Sciences. New York, NY: Cambridge University Press; 2006.
5 Batalden P, Leach D, Swing S, Dreyfus H, Dreyfus S. General competencies and accreditation in graduate medical education. Health Aff (Millwood). 2002; 21:103–111.
6 Dreyfus H, Dreyfus S. Mind over Machine. New York, NY: Free Press; 1986.
7 Ogrinc G, Headrick LA, Mutha S, Coleman MT, O’Donnell J, Miles PV. A framework for teaching medical students and residents about practice-based learning and improvement, synthesized from a literature review. Acad Med. 2003;78: 748–756.
8 Epstein R. Mindful practice. JAMA. 1999; 282:833–839.
9 Dobie S. Viewpoint: reflections on a well-traveled path: self-awareness, mindful practice, and relationship-centered care as foundations for medical education. Acad Med. 2007;82:422–427.
10 Brennan TA. Physicians’ professional responsibility to improve the quality of care. Acad Med. 2002;77:973–980.
11 Kotter J. Leading change: why transformation efforts fail. Harvard Bus Rev. 1995; 73:59–67.
12 Grol RP, Bosch MC, Hulscher MEJL, Eccles MP, Wensing M. Planning and studying improvement in patient care: the use of theoretical perspectives. Milbank Q. 2007;85:93–138.
13 Essex L, Kusy M. Fast Forward Leadership: How to Exchange Outmoded Leadership Practices for Forward-Looking Leadership Today. Lafayette, Colo: Moonlight Publishing; 2004.
14 Tennant G. Six Sigma: SPC and TQM in Manufacturing and Services. Burlington, Mass: Gower Publishing Co.; 2001.
15 Huddle TS. Teaching professionalism: is medical morality a competency? Acad Med. 2005;80:885–891.
16 Cruess RL, Cruess SR. Teaching professionalism: general principles. Med Teach. 2006;28:205–208.
17 Larson EB. Measuring, monitoring, and reducing medical harm from a systems perspective: a medical director’s personal reflections. Acad Med. 2002;77:993–1000.
18 Hudson P. Applying the lessons from high risk industry to healthcare. Qual Saf Health Care. 2003;12 (suppl 1):i7–i12.
19 Reason J. Human error: models and management. BMJ. 2000;320:768–770.
20 Helmreich RL. On error management: lessons from aviation. BMJ. 2000;320:781–785.
21 Suchman AL, Williamson PR, Litzelman DL, et al. Towards an informal curriculum that teaches professionalism: transforming the social environment of a medical school. J Gen Intern Med. 2004;19:501–504.
22 Wu AW, Folkman S, McPhee SJ, Lo B. How house officers cope with their mistakes. West J Med. 1993;159:565–569.
23 Watkins JM, Mohr BJ. Appreciative Inquiry: Change at the Speed of Imagination. San Francisco, Calif: Jossey-Bass; 2001.
24 Stern DT, ed. Measuring Medical Professionalism. New York, NY: Oxford University Press; 2006.