Humphrey, Holly J. MD; Smith, Kelly MPP; Reddy, Shalini MD; Scott, Don MD; Madara, James L. MD; Arora, Vineet M. MD, MA
Since medicine assumed the mantle of a profession more than a century ago, physicians, medical educators, and scholars have grappled with its implications and have struggled to ensure that physicians embody the values of compassion and altruism and act in a responsible, ethical manner. Maxine Papadakis and colleagues'1 landmark paper in 2005 provided a compelling demonstration that professionalism problems as a medical student are predictive of unprofessional conduct as a licensed physician. Unfortunately, numerous studies point to the fact that medical students' moral and ethical reasoning actually erodes throughout their medical school education, particularly as they enter their clinical years of training.2–4 Medical training, which espouses the ideals of professionalism, essentially trains students to be unprofessional. The informal or hidden curriculum of medical training is traditionally blamed for this ethical erosion.2 The unspoken culture of medical education, specifically, day-to-day interactions with other physicians and staff in the clinical environment, often teaches medical students to do as we say, but not as we do.5–6
Until recently, most of the professionalism literature has focused on curricular interventions aimed primarily at the undergraduate level of medical education and has ignored the impact of graduate medical education and the larger environment of the academic medical center. In July 2008, all Liaison Committee for Medical Education (LCME)-accredited schools will be required to ensure that the “learning environment for medical students promotes the development of professional attributes.”7 Developing such a learning environment will require self-examination and leadership at an institutional level to encompass medical learners from every stage of the medical education spectrum, including faculty.
Conception and Design of Pritzker's Professionalism Program
In 2003, the University of Chicago Pritzker School of Medicine underwent an 18-month institutional self-study in preparation for LCME accreditation. The study revealed a need to revamp and renew our curriculum to meet the changing needs of the 21st-century physician, and to focus on issues of professionalism across both undergraduate (medical school) and graduate (residency/fellowship) medical education. To address these needs, the dean for medical education formed a curricular reform committee to reevaluate the undergraduate medical curriculum and established a Roadmap to Professionalism Steering Committee that would increase awareness of medical professionalism across the institution. Faculty with administrative responsibilities in both undergraduate and graduate medical education who were actively exploring professionalism issues were invited to participate in the steering committee. This group met regularly to design an initiative that would assess the institution's current professional learning environment and create a foundation of professionalism on which a new curriculum could be built.
Invoking the values of professionalism is not a new concept at the University of Chicago Pritzker School of Medicine. In 1990, we were one of the first medical schools in the nation to initiate the white coat ceremony, and we have long been known as an institution that fosters the “teaching of teachers.”8 The MacLean Center for Clinical Ethics was one of the first ethics centers in the country and remains one of the most highly regarded and influential. In the past, these initiatives had been considered singular achievements—lauded and celebrated but perhaps not incorporated into the overall institutional fabric of the university. Unlike other medical schools, our clinical, research, and medical education activities are centralized under one division—the Biological Sciences Division. In addition, graduate medical programs are united with undergraduate medical programs under the direction of a single dean for medical education. This centralized governance structure facilitates the support of research initiatives and curricular change across the spectrum of medical education. In developing this new professionalism initiative, we wanted to take full advantage of the existing organizational structure to integrate curricular initiatives at all levels of medical training across the medical center.
Vertically integrated structure
The steering committee modeled the initiative after Dartmouth College's vertical integration groups, which address and create curricular reform around central themes that affect all levels of learners at an institution.9 These working groups involve students and faculty in the process of integrating a core theme—in this case, professionalism—vertically throughout the medical education continuum. Using this framework as the basis of our design, the steering committee established professionalism advisory working groups that would identify the needs of the medical learner at each stage in the medical education continuum: preclinical and clinical medical students, residents, and faculty. Each advisory group is led by a member of the Roadmap to Professionalism steering committee and contains both faculty and student or trainee representation. In addition, members of the committee sit on the Pritzker undergraduate education curriculum reform committee and the graduate medical education executive committee, to translate the findings of the professionalism initiative into curricular interventions. The dean for medical education and assistant dean of curricular innovation provide oversight and guidance over the entire steering committee (see Figure 1).
The professionalism steering committee is guided by the principles and core competencies outlined in the American Board of Internal Medicine (ABIM)/ American College of Physicians (ACP)/ European Federation of Internal Medicine's Physician Charter on Medical Professionalism.10 These principles include the primacy of patient welfare, patient autonomy, and social justice, as well as a commitment to professional competence and professional responsibilities. The steering committee is also guided by a belief that medical trainees must be involved in the assessment and development of their own professionalism curricula. In the fall of 2004, the steering committee conducted a series of focus-group discussions with students, residents, and faculty members who provided feedback that disseminating a required professionalism charter or code of behavior would be ineffective unless medical learners considered it relevant to their daily experience and were involved in the process of formulating the charter or code. Indeed, physician educators risk alienating their trainees unless they are able to redefine professionalism in contextual, even generation-appropriate terms.11 To develop effective, targeted curricular innovations, we therefore felt we needed to develop a shared vision and understanding of what the principles and competencies specified in the ABIM/ACP/European Federation of Internal Medicine's Physician Charter for Medical Professionalism mean to trainees at each level of medical education.
Naming and launching the initiative
To capture both the collaborative nature of the program's design and its focus on vertical integration, we named this initiative the Roadmap to Professionalism. This metaphor symbolizes that professionalism is part of a journey of lifelong learning which is integral to becoming a physician. The journey includes career-defining stops along way, as students, residents, and faculty members acquire and refine their professionalism skills in the context of their careers.
The Roadmap to Professionalism initiative was launched in October 2005 as a deans' distinguished lecture. All University of Chicago Medical Center faculty, staff, and students were invited to participate in an event where Drs. Christine Cassel, Maxine Papadakis, and Lawrence Smith were featured speakers. These national experts on medical professionalism presented their scholarship and insights as a context for the new initiative.1,10–11 They were specifically chosen to highlight the influence that their scholarship had on our initiative's design: the development of the ABIM/ACP/European Federation's Physician Charter for Medical Professionalism10 recognition that issues of professionalism follow students' throughout their careers,1 and the belief that professionalism must be relevant to the individual learner.11 After these presentations, the dean for medical education announced the new initiative and outlined its goals as an institution-wide initiative designed to increase awareness of professionalism at every level of medical education, integrate professionalism initiatives throughout the University of Chicago Medical Center and the Pritzker School of Medicine, and encourage professionalism scholarship in order to provide insights and guidance for future curricular innovation and reform.
In the first year and a half of the program, we have focused on increasing awareness of medical professionalism across the institution and assessing our medical learning environment. To accomplish this goal, each working group was charged with developing an interactive workshop or research initiative that engaged the medical learner in the principles and competencies outlined in the ABIM/ACP/European Federation of Internal Medicine's Physician Charter. Below is an outline of the working groups' initiatives and the effect these initiatives have had on the culture of professionalism at the University of Chicago.
Preclinical Medical Students
Despite the increasing emphasis placed on medical professionalism in undergraduate medical education, relatively little attention has been directed toward assessing the impact of the preclinical environment on students and their professional attributes. There are many reasons for this. First, the well-documented ethical erosion of student attitudes is largely believed to be a by-product of the clinical experience and less attributable to the preclinical, basic science classroom experience.12 Second, when professionalism is taught in the preclinical years, it is generally framed within a clinical context that first- and second-year medical students find difficult to relate to their day-to-day, preclinical experience, whereas medical school faculty find assessment of professionalism at this stage of training more difficult. However, Ginsburg et al13 suggest that inadequately attending to preclinical students' training in professionalism misses an opportunity to build on entering medical students' generic values of professionalism. To address these concerns, the Pre-Clinical Medical Student Advisory committee initiated a series of professionalism workshops designed to raise awareness about medical professionalism and collaborated with current students to conduct an internal assessment of the preclinical learning environment.
Our preclinical medical students begin their first year with the traditional white coat ceremony, symbolically marking the beginning of their weeklong orientation as well as their initiation to medical school. To reinforce the values espoused during the white coat ceremony, the preclinical advisory group developed a series of professionalism workshops highlighting the concepts of medical professionalism as defined by the ABIM/ACP/European Federation of Internal Medicine's Physician Charter for Medical Professionalism. This included a half-day workshop presented during orientation and biannual workshops on professionalism at symposia and orientations, which are held quarterly throughout the first and second years. In addition, students receive training and evaluation on communication skills, self- and social awareness, and other core professionalism competencies through the following courses: Clinical Skills 1, Social Context of Medicine, and the Doctor–Patient Relationship (Medical Ethics).
To enhance the effectiveness of these workshops, the course directors of the fall-quarter, first-year Clinical Skills 1 course devoted part of their curriculum to discussing professionalism and what it means to be a medical professional as a preclinical medical student. Small-group sessions were held to define and discuss the elements of medical student professionalism, and then the results of these discussions were brought to the class as a whole for discussion. A summary of these discussions and students' written responses are shown in Table 1. These sessions were powerful and enlightening for faculty as well as students, and this experience was instrumental in developing the preclinical advisory group's approach to the professionalism curriculum. Through these class sessions, we learned that preclinical students enter medical school with strong grounding in generic principles of professionalism, but they have wide ranging beliefs and opinions about what the concept means in a medical setting. The experience also taught us that first-year students quickly grow weary of being talked to about professionalism; instead they want to have an active collaborative role in defining and designing the professionalism curricula.
Pritzker student subcommittee on professionalism
As a result of these course discussions, a group of students formed a subcommittee on professionalism within the student government to help guide the development and assessment of the medical school's professionalism curriculum. The student committee provides feedback on the school's professionalism programming initiatives, brings to our attention new and emerging professionalism issues that they witness in the preclinical and clinical environments, and assists the steering committee with its ongoing professionalism research initiatives. Most recently, the student subcommittee helped to revamp our educational workshops at the orientation to the Clinical Biennium to focus on a more case-based approach, and the subcommittee is currently working with the professionalism steering committee to address the appropriate use of Internet and other media in the learning environment. The main focus of the student subcommittee is to help the steering committee conduct student assessments of the professionalism learning environment.
Preclinical medical student survey
The formation of the committee was largely driven by students' reactions to the classroom discussions about professionalism and by their perceptions of unprofessional behavior on the part of some students and faculty. To determine whether this behavior was the result of the medical school learning environment, in 2005 the student subcommittee conducted an electronic survey of first-year medical students to assess how students' behaviors and attitudes toward professionalism change within the first six months of medical school. Students were asked to identify, through a series of yes–no questions, whether they considered a list of specific behaviors unprofessional. The subcommittee created the list of specific behaviors on the basis of what they believed was most pertinent to the first two years of medical school. These behaviors were reviewed by faculty members on the steering committee for content and relevance to professionalism. Specific behaviors included cheating, leaving lectures early, and surfing the Internet during class. The electronic surveys were administered just before matriculation and then six months thereafter. Sixty-seven percent of the first-year class responded to the survey just before matriculation, and approximately 60% of the class responded six months later. Selected results of this survey were presented at the 2005 Society of General Internal Medicine Midwest Regional Meeting14 and are summarized in Table 2. An analysis of the pre and post data shows that behaviors students previously considered unprofessional became increasingly more acceptable to them after only six months in medical school, with one notable exception. Taking food from a lecture that one was not attending was considered increasingly unprofessional. Placing an enhanced value on incentives to attend a meeting or activity, as opposed to all other behaviors, is especially interesting because pharmaceutical representatives often use food and other inducements to encourage the use of their products within academic medical centers. Although this study clearly has limitations, several conclusions can be drawn. First, the findings support other studies suggesting that students enter medical school with established opinions about what constitutes professional behavior. Second, the data suggest that the ethical erosion normally attributed to the clinical years may actually begin during students' preclinical years in the basic science classroom. The survey results suggest that within the first six months of medical school, preclinical students find it increasingly difficult to engage in professional self-regulation, such as holding their peers accountable for dishonesty, fraud, and impairment. In addition, behaviors that were once deemed unacceptable become increasingly more acceptable during the six-month period.
This erosion may be occurring for a number of reasons. Prior research demonstrates that medical students involved in the preclerkship, classroom experience approach their educators and other health professionals believing that the world is situated to accommodate their learning needs.13 This sense of classroom entitlement may translate into their views of what constitutes professional behavior. Also, students may not be able to recognize how the attributes of professionalism that are discussed in orientation sessions and at the white coat ceremony apply to their basic science classroom experience. As educators, we may need to be more explicit in communicating how the principles of professionalism translate into the preclinical basic science classroom experience. That is, medical students should be expected to treat their basic classroom experience and classmates with the same level of professional courtesy with which they would treat their colleagues in the medical center. This includes issues such as arriving to class on time and maintaining academic integrity. The professionalism steering committee, in collaboration with the Pritzker student subcommittee on professionalism, is continuing to collect longitudinal data to understand these changes more fully.
Through the preclinical medical student survey, not only have we gained a clearer understanding of preclinical medical students' views toward professionalism, but we now also have a behavior-specific context from which we can further assess and evaluate our preclinical learning environment.
Clinical Medical Students
Building on the initiatives of the preclinical medical student advisory group, the clinical medical student advisory group engaged clinical medical students in a series of professionalism workshops designed to prepare them for the moral and ethical dilemmas of the clinical years, and conducted an assessment of the clinical learning environment.
Our students' clinical training begins during a required two-day Introduction to the Clinical Biennium, which takes place immediately before the commencement of clerkship experiences. All rising third-year students are required to attend an interactive workshop session entitled Student Treatment and Mistreatment. During this session, students are divided into small groups to review, under the guidance of experienced Pritzker faculty, brief descriptions of case-based scenarios, prewritten skits and videos that illustrate how faculty, residents, and peers may behave unprofessionally during their clinical rotations. Students are then asked to identify whether a range of behaviors might be examples of student mistreatment or unprofessional behavior. Students discuss potential approaches to handling these situations and review the resources available to them if they feel they have experienced a case of student mistreatment or unprofessional behavior. Throughout the remainder of the third year, students may participate in monthly debriefing sessions as part of the Schwartz Center Rounds,15 an interactive forum for physicians, students, and staff to discuss and reflect on their experiences with patients. In addition, during a symposium held each autumn, third-year students have the option of participating in a confidential debriefing forum to discuss their own patient interactions and any questionable situations they have encountered with physicians, nurses, and other health care workers while on rounds. This session is facilitated by two senior faculty members with expertise in the area of medical ethics.
Clinical medical student professionalism survey
Despite these efforts to prepare our students for the moral and ethical dilemmas associated with clinical clerkships, we anecdotally observed an erosion in professional behaviors in medical students during their clinical years. Although our observations were consistent with national data supporting a longitudinal decline in behaviors and attitudes toward ethical and social issues in medicine,16 we wanted to assess the validity of our observations.
Building on the work of the preclinical medical student group, we charged the student subcommittee on professionalism with examining the changes in medical students' perceptions and behaviors before and after the start of their clinical clerkships. Third-year medical students were electronically surveyed regarding their perception of and participation in unprofessional behaviors immediately before starting their clerkships and five months after beginning their clinical rotations. Students received a 27-item list of behaviors and were asked to report yes or no as to whether they (a) observed, (b) participated in, and (c) considered the behavior unprofessional. Sixty-two percent of the third-year class responded. Results from the surveys demonstrate that students' unprofessional behavior increases after participating in clerkships. Examples of these unprofessional behaviors ranged from minor offenses (late to rounds) to more serious offenses (making derogatory remarks about patients), and those that are somewhat open to question (accepting a pen from a pharmaceutical representative). More alarmingly, students have an increased likelihood of considering previously identified unprofessional behaviors as acceptable only five months after starting clinical training. In addition to the quantitative data, students provided comments regarding their views on professionalism on the postsurvey by answering the open-ended question, What are the most important issues of professionalism at Pritzker? Representative comments and identified subthemes are shown in Table 3. Qualitative analysis of the comments confirmed that students participate in and witness professionalism breaches (poor student/role model behavior, lack of patient-care focus, and disregard for student needs) throughout their clinical experience. In addition, students display an overt hostility towards professionalism education (e.g., “I feel harassed by all of this professionalism talk”) and regard its effectiveness with skepticism (e.g., “we trivialize the term [professionalism]”). A full analysis of this study was recently published.17
The results of this survey provided an important baseline assessment of the clinical learning environment at the University of Chicago and demonstrated a need for a more comprehensive assessment of the learning environment. To gain a better understanding of the clinical context in which these ethical erosions are taking place, we will be expanding our assessment initiatives to include residents and faculty in 2008. By getting a full picture of the clinical learning environment through the perspective of students, residents, and faculty, we will be able to more accurately and effectively target curricular interventions.
On the basis of the results of this survey, we are already instituting changes to our current professionalism curriculum. We are exploring the development and use of online portfolios to promote self-reflection during students' clinical experiences. These online portfolios will serve two purposes. First, they will provide us with day-to-day data that document when, where, and how breaches of professionalism take place, so that we can target future interventions more effectively. Second, they will enable students to process the ethical and professional dilemmas that arise on their daily rounds in a more immediate, contextual way.
Students' strong negative reactions to the term professionalism suggest that they misunderstand the term and mistakenly attribute it to codes of professional etiquette, rather than identifying it as a core aspect of being a physician. By introducing the online portfolios into our curriculum, we hope to move students toward a more narrative-based approach to professionalism, in which they may incorporate the values and beliefs of medical professionalism into their own personal narrative,18 thus allowing them to better resolve the dilemmas that arise throughout their clinical experience.
The crux of professionalism literature focuses on assessing and evaluating clinical medical student professionalism and offers recommendations for ways to improve faculty's and residents' interactions with medical students. Much less attention has been focused on the professional ethics of residents, faculty, practicing physicians, and the structure of organized medicine. Recent reports have called attention to this discrepancy and have appealed to academic medical centers to address issues of professionalism beyond the classroom.19,20 Therefore, a key aim of our Roadmap to Professionalism was to develop initiatives that would educate residents and faculty about issues relevant to their day-to-day activities within the hospital. Our program directors stressed that residents would not want to be “talked to” about professionalism; instead, the residents would need to be engaged in interactive educational modules that highlight professionalism behavior in the context of specific resident activities. On the basis of this feedback, we chose to promote two interactive workshops for residency program directors that have been highlighted as professionalism challenges for residents: interactions with the pharmaceutical industry,21 and the emergence of a resident “shift-work mentality” in the wake of restricted duty hours.22 Patients' assessment of residents is another component of fostering residents' professionalism that we are currently implementing.
The first workshop presented to residency program directors was an interactive, video-based workshop addressing resident interaction with the pharmaceutical industry. The original workshop was developed by internal medicine residents in 2002 to educate their colleagues about routine interactions with the pharmaceutical industry.23 The workshop has since been evaluated in a longitudinal study of internal medicine residents and was found to be effective in improving residents' awareness of what constitutes an inappropriate gift.24 The video scenarios were designed to depict three routine resident interactions with pharmaceutical representatives (1) receiving free gifts, ranging from a pen, to travel, to a national conference, (2) debating whether to attend a pharmaceutical-company-sponsored off-site dinner at an upscale restaurant, and (3) attending a pharmaceutical-company-sponsored noontime journal club. After viewing each scenario, residents were asked to discuss the scenario using a matrix of professional guidelines and ethical domains. The professionalism steering committee is continuing to present the workshop at resident orientations and campus-wide events on professionalism, including our most recent Medical Education Day.
The second workshop addresses residents' and faculty's concerns that a shift-work mentality is threatening residents' ability to be professional. This question arose with the institution of duty hours limits.25 Two of our faculty members developed a 90-minute interactive workshop, Hand-off Clinic, to help individual residency programs that take in-house call on inpatient services to better understand and improve hand-offs during shift changes. Loss of professionalism occurs in hand-offs when patients are treated as someone else's job instead of as humans needing continuity of care, which improved hand-offs would alleviate. We worked with residents to develop a standard protocol for the hand-off, using process-mapping methodology. One of the major themes that emerged from our multiple meetings with nine residency programs was that the hand-off represented more than just a transfer of content; it was also a transfer of professional responsibility.26
Patient assessment: FACE™ cards
In addition to developing curricular content for residents, we wanted to enhance our evaluation of their professionalism, and we began piloting programs where patients assessed residents. With funding from the Graduate Medical Education Committee, the University of Chicago Internal Medicine residency program is in the midst of implementing an innovative new tool that focuses on collecting and validating patients' evaluations of residents' professionalism. The FACE™ (Feedback and Care Evaluation) tool facilitates formal introductions of resident teams and their roles to hospitalized inpatients. The front of the card identifies each resident, and the reverse side includes a detachable evaluation form for patients to rate the residents on a scale of 0 (worst possible) to 100 (best possible) using questions corresponding to domains of professionalism derived from the ABIM/ACP/European Federation for Internal Medicine's Physician Charter for Medical Professionalism (communication, compassion, respect, and responsibility) (see Figure 2). During attending physician bedside rounds for new patients, the team members explain the project to the patient, asking the patient to use the cards to rate their physicians. At discharge, nurses remind patients to fill out evaluations, collect the evaluations, and deposit envelopes into a locked collection box. Evaluations are compiled into reports that residents view during their quarterly feedback sessions with the program director. This project has been well received by physicians and patients, and discussions are underway to expand this innovation into other residency programs.
The Faculty Challenge
Residents and program directors are quite responsive to our emphasis on educating residents about issues of professionalism. Addressing issues of medical professionalism among faculty members has proved to be our biggest challenge in the first year and a half of the Roadmap to Professionalism. Educators have the authority to command residents' and students' attention about this important issue. Faculty members, however, tend to view professionalism as a medical education or even student issue. To address this problem, we held focus groups with an interdisciplinary group of faculty leaders to better understand how to involve faculty in the initiative and to find out which professionalism topics are most relevant to faculty. The major consensus from these groups is the need for institutional leadership to require professionalism education, similar to yearly mandated seminars on patient safety. However, even this suggestion has been met with skepticism about its effectiveness in terms of changing attitudes or behaviors. While the Roadmap to Professionalism steering committee debates its next steps, we have started instituting ongoing faculty discussions through a series of workshops and lectures on medical education initiatives. In 2006, the dean for medical education gave grand rounds lectures on the state of medical education at the University of Chicago to each of the clinical departments with required medical student clerkships. The lecture highlighted professionalism initiatives, drew faculty attention to student mistreatment problem areas, and revealed the most recent results of our preclinical and clinical medical student assessment surveys. Monthly research and innovation in medical education conferences also regularly highlight professionalism initiatives. In the future, the faculty advisory committee plans to host faculty development workshops to provide appropriate student feedback and guidance on assessing and evaluating professionalism.
Promoting Professionalism across the Medical Education Spectrum
As the Roadmap to Professionalism steering committee continues to debate how best to engage the faculty on a more targeted, individual basis, we are making a concerted effort to raise awareness about the importance of professionalism throughout the medical school and university in a series of high-profile events and initiatives that span the medical education spectrum. Although many of these efforts have occurred through the direct intervention and input of the steering committee, others have evolved indirectly. All have contributed significantly to promoting a culture of professionalism at the University of Chicago.
The Dean's Distinguished Lecture Series on Medical Professionalism was followed in the spring of 2005 with the establishment of a Gold Humanism Honor Society chapter to honor fourth-year medical students, residents, faculty members, and other exemplars for their humanistic qualities. Each year, Pritzker faculty, residents, and students gather together a total of four times to recite the Hippocratic oath and honor faculty members, students, and residents who most exemplify the virtues of medical humanism and professionalism. This occurs at the white coat ceremony, Gold Humanism Honor Society induction ceremony, student clinician ceremony, and convocation. Through these ceremonies, students, residents, and faculty reaffirm the beliefs and values that have been inherent to the profession for thousands of years. By highlighting these qualities at key transitions in students' medical education, we hope to demonstrate that medical professionalism is a principal orienting value of the institution and an important aspect of their own identity as physicians.
In 2005, the Pritzker School of Medicine Academy of Distinguished Medical Educators and the University of Chicago Graduate Medical Education Committee began funding a series of grants to support scholarship in undergraduate and graduate medical education, with professionalism as a specific area of focus. This support spawned numerous research initiatives in the areas of professionalism and supported the efforts of the professionalism working groups outlined above. Recent grantees have received awards to pursue topics such as improving the teaching of professionalism in surgery, fostering residents' professionalism, and evaluating professionalism in the emergency room. By demonstrating to faculty that professionalism is a research priority within the medical center, these grants have served to increase the awareness of medical professionalism and the need to improve the learning environment.
In his seminal report on professionalism, Thomas Inui27 stated that because of the interconnected ecology of the academic health center, changing one niche of institutional activity has the potential to enable change in a variety of other areas. In the first year and a half of the Roadmap to Professionalism, we have sought to initiate change by involving medical trainees in a series of research initiatives, experiential workshops, and events aimed at making the ideals espoused in the ABIM/ACP/European Federation of Internal Medicine's Physician Charter for Medical Professionalism relevant and contextual to each trainee's daily experience. These initiatives have included assessments of medical students' professional behavior and how their perceptions and behaviors change during their medical school careers.
As we look to the future, we plan to expand our assessments of the institutional learning environment to include faculty and residents so that we may begin to translate our findings into targeted interventions. We also hope to develop a stronger approach to reaching faculty members. The findings and experience of the Roadmap to Professionalism steering committee will continue to inform our curriculum reform process, to ensure that our new curriculum, which will be unveiled in the coming years, is built on a foundation of professionalism.
Through this experience, we have learned several lessons about developing an institution-wide initiative to address professionalism. First, medical learners can offer valuable insights regarding the development of effective professionalism curricular interventions and programs. Involving students and residents in the development of their own professionalism curricula reduces the potential for developing an us (medical trainee) versus them (medical educators) mentality, and it improves program effectiveness.
Second, developing institution-specific assessments of the learning environment is an important first step in developing effective curricular interventions. As a result of the preclinical and clinical medical student surveys, we are now better able to explain and understand the professional and unprofessional behaviors that are specific to trainees' particular learning environment, and we can articulate the points at which students' behaviors and perceptions begin to change. This provides an important baseline from which we can target specific evaluation and curriculum-assessment efforts. In addition, administrators, faculty, and staff can now point to institution-specific data to stress the importance of improving the institution's learning environment. Establishing this level of credibility is a crucial first step toward getting faculty and administrator support for larger systemic changes, and it provides credibility for the initiative as a whole.
Third, establishing institution-wide ceremonies and professionalism-focused research grant programs demonstrates that professionalism is a core aspect of being a physician that can and should be celebrated, recognized, studied, and understood. As we work to develop targeted plans for interventions that address the curriculum at all levels, it is helpful to hold high-profile lectures, seminars, and ceremonies to formally send the message that professionalism is a principal orienting value of our institution. Finally, academic medical centers should develop a professionalism initiative that is tailored to the history, structure, and resources of one's institutional environment. The Roadmap to Professionalism has been effective because it is aligned with the values of the institution, is fully supported by key leaders, has taken advantage of the organizational structure in place at the University of Chicago, and has built on the school's existing traditions of interdisciplinary scholarship.
The authors wish to thank Drs. Halina Brukner, Michael Simon, Jeanne Farnan, Mark Siegler, John Schumann, Mindy Schwartz, John Schneider, Bill Borden, John Yoon, Jim Woodruff, and David Meltzer, as well as Julie Johnson, Sandy Cook, and Dana Levinson. In addition, the authors would also like to thank the following members of the Student Task Force on Professionalism: Megan Collins, Troy Leo, Gaurav Upadhyay, Adam Kern, Griffin Myers, and Catherine Roberts.
1 Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by medical school boards and prior behavior in medical school. N Engl J Med. 2005;353:2673–2682.
2 Feudtner C, Christakis D, Christakis N. Do clinical clerks suffer ethical erosion? Students' perceptions of their ethical environment and personal development. Acad Med. 1994;69:670–679.
3 Satterwhite RC, Satterwhite WM, Enarson C. An ethical paradox: the effect of unethical conduct on medical students' values. J Med Ethics. 2000;26:462–465.
4 Patenade J, Niyonsenga T, Fafard D. Changes in the components of moral reasoning during students' medical education: a pilot study. Med. Educ. 2003;37:822–829.
5 Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69:11: 861–871.
6 Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med. 1998;73:403–407.
8 Association of American Medical Colleges (AAMC) Medical School Profile System Institutional Goals Ranking Report: 2000.
9 Nierenberg DW. The use of “vertical integration groups” to help define and update course/clerkship content. Acad Med. 1998;73:1068–1071.
10 ABIM Foundation. American Board of Internal Medicine; ACP–ASIM Foundation. American College of Physicians–American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136:243–246.
11 Smith LG. Medical professionalism and the generation gap. Am J Med. 2005;118:439–442.
12 Ludmerer K. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. New York, NY: Oxford University Press; 1999.
13 Ginsburg S, Kachan N, Lingard L. Before the white coat: perceptions of professional lapses in the pre-clerkship. Med Educ. 2005;39:12–19.
14 Leo T, Dmochowska K, Kern A, Myers G, Scott DW. 1st and 2nd year medical students' perceptions of professional behaviors. Paper presented at: 2005 SGIM Midwest Regional Meeting; September 30–October 1, 2005; Chicago, Ill.
16 Woloschuk W, Harasym PH, Temple W. Attitude change during medical school: a cohort study. Med Educ. 2004;38:522–534.
17 Reddy S, Farnan J, Yoon J, et al. Third year medical students and unprofessional behaviors. Acad Med. 2007; 82 (10 suppl):535–539.
18 Coulehan J. Viewpoint: today's professionalism: engaging the mind but not the heart. Acad Med. 2005;80:892–898.
19 Whitcomb M. Medical professionalism: can it be taught? Acad Med. 2005; 80:883–884.
20 Hafferty FW. The elephant in medical professionalism's kitchen. Acad Med. 2006;81:906–914.
21 McKinney WP, Schiedermayer DL, Lurie N, Simpson DE, Goodman JL, Rich EC. Attitudes of internal medicine faculty and residents toward professional interaction with pharmaceutical sales representatives. JAMA. 1990;264:1693–1697.
22 Van Eaton EG, Horvath KD, Pellegrini CA. Professionalism and the shift mentality: how to reconcile patient ownership with limited work hours. Arch Surg. 2005;140:230–235.
23 Arora V, Schneider JA, Borden WB, Humphrey HJ. Approach to routine interactions with industry: a primer for residents. Semin Med Pract. 2005;8:55–63.
24 Schneider JA, Arora V, Kasza K, Van Harrison R, Humphrey H. Residents' perceptions over time of pharmaceutical industry interactions and gifts and the effect of an educational intervention. Acad Med. 2006;81:595–602.
25 Ratanawongsa N, Bolen S, Howell EE, et al. Residents' perceptions of training and practice: barriers, promoters, and duty hour requirements. J Gen Intern Med. 2006;21:758–763.
26 Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf. 2006;32:646–655.
27 Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003.