Smith, Kirk L. MD, PhD; Saavedra, Rebecca EdD; Raeke, Jennifer L.; O’Donell, Alice Anne MD
In recent decades it has become increasingly clear that the traditional U.S. academic health center (AHC), with its emphasis on scientific knowledge and clinical skill, although salutary to technical proficiency, does not fully address the competencies expected of the medical professional.1–4 Evidence of disquiet includes a warning from the American Board of Internal Medicine (ABIM) which, 15 years ago, embarked on a project to confront “changes in the health care delivery system” that “have a negative impact on the professional behavior of physicians … threatening to reduce the status of patients to commodities rather than people with an affliction.”5
That initiative, Project Professionalism, undertook to counter the threat by developing a working definition of professionalism and promulgating guidelines for its teaching and evaluation. In 2002, collaboration between the ABIM Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine produced the physician charter, which laid out three fundamental principles of professionalism: the primacy of patient welfare, respect for patient autonomy, and a commitment to social justice. While recognizing the importance of technical proficiency, the charter upholds Project Professionalism’s finding that the “core of professionalism” involves “those attitudes and behavior that serve to maintain patient interest above physician self-interest.”5 In this article, we describe the process by which the charter statement has come to define education at one AHC, the University of Texas Medical Branch at Galveston (UTMB), and inspired a campus-wide effort to transform the culture of health care training and practice.
The Journey Begins
Transformation at UTMB began in September 1997, when John Stobo, MD, was appointed university president. As chair of Project Professionalism (1992–1994), Stobo understood both the power of the concept of the initiative and the skepticism of those who thought its lofty commitments impractical. He determined to make his tenure a test ground for applying professionalism and took a further, controversial stand. Although professionalism began as an intradisciplinary effort to recall medicine to its ethical underpinning, the new president held that a fundamental concern for the patient should characterize all members of the AHC community—faculty, students, and staff—and launched a comprehensive effort to disseminate the concept throughout the institution.
Several programs were started in 1998 to introduce the topic, beginning with the establishment of the UTMB Professionalism Board, a broad-based institutional committee charged with weaving professionalism into the fabric of the university. Several recognition and education programs to raise awareness of the concept were initiated, including Professionalism and You, an annual brochure spotlighting models of professionalism at UTMB (this and other cited examples are available online at [http://www.utmb.edu/professionalism]). In addition to publicizing exemplary models of professional behavior, town meetings and monthly luncheons with the leadership were routinely held where faculty and employees were encouraged to develop ideas for making professionalism at UTMB not merely a desired state, but an expected reality. To achieve this goal, the board took a critical first step: honest appraisal of challenges.
Who is a professional?
Professionalism has been widely discussed and heterogeneously defined in contexts other than medicine and the health professions, for example, in the sociological tradition exemplified by Talcott Parsons and, more recently, in the work of the Carnegie Foundation for the Advancement of Teaching.6,7 Even within medicine’s more defined focus, the concept of professionalism has been criticized as nebulous and overreaching, encompassing everything from dress codes to abuse of power.8,9 Applicability to the real world of practice is questioned.10,11 Nonetheless, the concept has been critically important in building a common sense of pride and purpose among faculty, staff, and students at UTMB. Luncheons and workshops became occasions for reflection on the concept’s meaning for the university as a whole, and these reflections were later formalized in the deliberations of the UTMB Professionalism Board, which included students, faculty, and administrators from all four UTMB schools (medicine, nursing, allied health, and the graduate school of biomedical sciences) and every mission area. The board’s discussion renewed the campus’ understanding that what unites the research, clinical, and educational endeavors of the university is patient care, and that professionalism is everybody’s business. Professionalism at UTMB had, therefore, to be conceptualized so as to embrace all members of the UTMB community—from department chairs to groundskeepers—as their activities converge on improving patient care.
The hidden curriculum.
Admissions criteria assume that health care professionals enter the healing arts motivated at least in part by a service ideal. Unfortunately, factors intrinsic to the training process can erode that commitment. Operating through informal clinical and social interactions, a hidden curriculum12 informs a professional identity shadowed by cynicism, particularly as teachers attempt to enlighten students about certain so-called “realities” of health care. No one should discount the problems encumbering the health care system; however, imbuing students with a foregone sense of futility, especially with respect to the commodification of care, guarantees a generation of health care providers less likely to confront those problems. As Association of American Medical Colleges president emeritus Jordan Cohen13 notes, “Unless we convert our learning environments from crucibles of cynicism into cradles of professionalism, no amount of effort in the admission arena is going to suffice.”
Conduct unbecoming a professional.
Professional identity is concentrated in the behavior and beliefs of role models.14 These mainly operate for the good and reinforce the profession’s millennial respect for the patient’s interest. However, beneficence cannot be assumed. The salience of role models is counterproductive if mentors evince behaviors contrary to service and express beliefs skeptical of the provider’s primary duty to the patient. As the institutions responsible for inculcating values in those newly entered into the art of health care delivery, AHCs are guardians of professionalism. There is a clear responsibility to identify and reprove unprofessional behavior in students.15 However, UTMB also acknowledges the institution’s duty to address unprofessional behavior in faculty, elucidating the connection between student misconduct and mistreatment by teachers in order to remediate the training environment.
The training environment reflects the culture of the institution. Parsing the relationship between faculty role models and student behavior committed UTMB to consider other relationships as well, thus resulting in an examination of the values permeating the campus-at-large. That examination began with recommitment to the healing environment. Novelty lay in confronting the entitlement mentality of campus members who put self-interest (i.e., that the university exists to serve them) above the needs of those who come to UTMB for care and education. Absent a regulative ideal of service, institutional inertia prevails, permitting a culture that avoids responsibility for maintaining standards, holds unspecified “others” accountable for failure, tolerates subordination of patient well-being to self-interest, and presumes professionalism on the basis of superior education or institutional status, rather than dedication to the patient. Dispelling such assumptions is a necessary part of UTMB’s journey toward a truly collegial and patient-centered environment.
Finding a Way
In defining professionalism, the conclusions of the UTMB Professionalism Board approximate those of Project Professionalism and other published definitions. Collectively, they find inspiration in the health professional’s traditional commitment to the patient’s best interest. Starting in 2000, the board began a series of exercises aimed at raising awareness of professionalism. These include Going the Extra Mile, a program that calls on staff, students, and volunteers to identify outstanding professional qualities in colleagues; inauguration of the John P. McGovern Academy of Oslerian Medicine, which endows School of Medicine (SOM) faculty who exemplify ideals of professionalism and humanism; You Count, an employee survey used to solicit perceptions of the UTMB work environment; and the UTMB Honor Pledge, which was initiated by the Student Honor Education Council but extended campus-wide as a unifying statement of professionalism:
On my honor, as a member of the UTMB community, I pledge to act with integrity, compassion, and respect in all my academic and professional endeavors.
As momentum for the initiative gathered, attention turned to codifying guidelines around which professional behavior at UTMB would cohere. The effort gained traction with the simultaneous 2002 publication of the physician charter in the Annals of Internal Medicine16 and Lancet,17 which described three guiding principles of professionalism and 10 corollary commitments: patient welfare, autonomy, and social justice are exhibited in commitments to competence, honesty, confidentiality, propriety, quality, access, justice, knowledge, trust, and self-regulation. The relevance of the charter to the university’s professionalism initiative was recognized immediately, and the board began exploring its application to the university, catalyzed by grant support from the ABIM Foundation as part of the Professionalism Charter Project (Putting the Charter into Practice). The result is the UTMB Professionalism Charter, which extends the themes beyond a physician focus and makes professionalism “the standard of conduct for everyone at UTMB”—faculty, staff, and students.18
The university’s position is controversial because the physician charter is consistent with a view that confines professionalism to vocations with a fiduciary tradition, that is, medicine, law, and the clergy. (One of the authors is sympathetic to this view and makes this distinction: those outside the traditional professions aspire to the fiduciary standard; for physicians, it is sine qua non.) UTMB enlarges that vision to encompass the campus as a whole, arguing that all members of the AHC community share responsibility for professional commitments, from the clinician who ensures quality care, to the staff member who ensures confidentiality of patient records. Many physicians were uncomfortable with including staff and other health care providers in the discussion and holding them to the same standards as clinicians. However, UTMB is committed to an environment in which all community members share values that support its charter commitments.
Confronting the hidden curriculum
UTMB hosts an annual summit on the pedagogy of professionalism. In 2004, Maxine Papadakis, MD, spoke on the association between unprofessional behavior among medical students and subsequent disciplinary action by a state medical board.19 The presentation discussed conduct which AHCs have long addressed through formal disciplinary processes. However, because students typically take their cue from role models, the summit also sparked a dialogue on faculty behavior and the informal, sometimes deleterious mechanisms by which students are indoctrinated in the ways of the profession.20 The resident who disparages patients and the faculty member who verbally assaults residents are not signaling service. Students who observe a teacher mistreating patients learn professionalism is a sham. Too often, a code of silence and fear of retribution leave witnesses reluctant to protest such behavior.
In 2004, UTMB introduced an online mechanism for reporting unprofessional behavior. The reporting link is prominently displayed on the UTMB Web site, allowing users to contact the university ombudsman to initiate investigation by neutral third parties. As of April, 2007, the professionalism button, as it is known, had elicited 60 reports: 19 concerned unprofessional behavior by faculty and 18 by residents or employees, 13 reports addressed student peer issues, and another 10 concerned the institution in general. Thirty of the reports were filed by medical students, 14 by residents or employees, 11 by nursing students, 3 by graduate students, and 2 by allied health students. Types of concerns included verbal abuse, belittlement, and inappropriate language by faculty; inappropriate patient care and rudeness by staff; and cheating, inappropriate remarks or dress, and discourtesy in the classroom by students. The tool’s purpose is not to police the institution or ferret out misconduct but, rather, to safeguard vulnerable members of the academic community who speak out in defense of professionalism and engage those who act unprofessionally in a crucial conversation aimed at remediation. The intention is that the subject emerges with a sense of renewed obligation, both to patient care and to the edification of the campus community. Such intervention is critical, especially when the alternative is a trickle-down effect that coarsens newcomers to the art.
Various mechanisms have been introduced at UTMB to edify conduct. These include the Early Concern Note, which provides a means of informal, confidential intervention with students for whom a member of the faculty has a professionalism-related concern; the Student Professional Development Plan, which allows a student to work with faculty to identify and correct behavioral weaknesses; and the inclusion of professionalism as a core measure in the student, resident, and employee evaluation process. These innovations involve different processes, but each requires personal involvement by faculty in guiding students toward positive traits of professionalism; moreover, in embracing the role of mentor, faculty must inquire of themselves what traits constitute professionalism. That inquiry is facilitated by the presence at UTMB of the John P. McGovern Academy of Oslerian Medicine. The Osler Scholars are a group of practicing faculty physicians who are selected for their devotion to the art of compassionate care and for excelling as role models for students and other physicians. Candidates may be nominated to the academy by any member of the UTMB community; each year, one scholar is elected to a five-year term by current holders of the distinction. The scholars are a highly visible presence on campus that bears witness to ideals of professionalism: exemplary clinical ability and dedication to patient care. The influence of such models and conscious emulation by others has markedly affected the learning environment at UTMB, informing the hidden curriculum with faculty–student interactions consciously attuned to professional values.
Becoming a professional
In citing role models, it is important to celebrate the part students have played in the evolution of professionalism at the university. The school enjoys a legacy of student activism in fulfillment of UTMB’s motto: Here for the Health of Texas. Examples include a student-run free clinic serving Galveston’s working poor and Frontera de Salud, a student-led organization serving impoverished communities near the Texas/Mexico border. UTMB is now augmenting the developmental opportunities implicit in these activities with formal course work to inculcate professional values. For example, the School of Allied Health Sciences gives course credit for participation in these activities with the requirement that students write up their experience as a reflection on professionalism, the School of Nursing has added classes on ethical practice and cultural sensitivity, and the Graduate School of Biomedical Sciences convenes an annual seminar on the ethics of scientific research under the auspices of UTMB’s Institute for the Medical Humanities. The SOM has undertaken an ambitious project to engrain professionalism throughout the four years of medical schooling. Introduced in 2005 as a pilot project funded by the Arnold P. Gold Foundation and now fully funded by UTMB, the professionalism curriculum is based on Accreditation Council for Graduate Medical Education (ACGME) guidelines for professionalism: altruism, ethically sound practice, and sensitivity to culture, age, gender, and disability.21
The curriculum begins in Year I with an all-class orientation to the ACGME guidelines, followed by facilitated discussion on what it means to be altruistic, ethical, and sensitive. Subsequent small-group sessions take up oaths and codes, the fiduciary compact, truth telling, shared decision making, distributive justice, and avoiding conflicts of interest, and are capped by an essay assignment in which students articulate their comprehension of professionalism. Year II starts with an all-class review of the professionalism guidelines, followed by eight weeks of small-group sessions that use readings and case studies to ground the students’ understanding of the concept, with topics that include a patient’s right to die, medicine as a caring profession, the experience of illness, empathy in clinical practice, patient autonomy, and the goals of medicine. In Year III, course work continues with discussions on decision-making power, truth telling, rationing health care, medical mistakes, and the impaired colleague. In the clerkship year, discussion turns to the students’ increasing familiarity with clinical practice, asking them, for example, to discriminate their professional and civic roles in respect of health care rationing. The curriculum culminates in Year IV with monthlong rotations emphasizing professionalism in practice with, for example, a case-based selective that teaches advocacy skills and others involving indigent care. By graduation, all members of the SOM class of 2010 will have completed course work designed to instill specific skills of professionalism; approximately 15% will have deployed those skills in intensive rotations. (For the general scheme and specific priorities of the SOM strategic plan, see Figure 1.)
Motivating the institution
Moving the university toward a campus-wide culture of professionalism has required executive leadership, especially in overcoming resistance. Some at the institution take exception to the egalitarian approach (e.g., adherents to hierarchical traditions that privilege the physician). Others view the initiative as a passing fad. Early in the journey, the Professionalism Board adopted a social movement approach to the initiative, abandoning the logic of a hierarchy whose rules, roles, and relationships emphasize the status quo in favor of a more informal process of dialogue and consensus.22 Participants in this network of colleagues were challenged to think across disciplinary and bureaucratic boundaries, embracing views and opinions outside their own school or specialization. This nonhierarchical approach dove-tailed with the leadership’s desire to foster a “productive community” at UTMB in which “members share a common purpose and each works for the benefit of all. Where people in higher positions see themselves as servants to those in lower positions.”23
Concurrent with the committee’s activities, a mandatory training program was implemented for all members of the UTMB community. Starting at the executive level and working its way throughout the institution, the Principles of Service program sought to align the campus in a common purpose, educating the community at all levels of responsibility in the values of professionalism, teamwork, and quality improvement.
Because UTMB undertook its professionalism initiative on an institutional scale directed at every sector of the university, the endeavor has necessarily involved multiple approaches. Different programs adapted to the circumstances of various departments and service areas have been implemented. Consequently, it is imperative that the initiative not lose focus by becoming too particularized and heterogeneous. The charter serves a crucial function in maintaining institutional focus so that these manifold programs evolve in synergistic fashion. Whatever form the initiative takes, however adapted to local operations and needs, the core commitments to patient interests and professional conduct remain invariant. Constant review by the professionalism committee and regular program updates keep the endeavor, in all its variety, on track and ultimately directed to the charter’s unifying theme of service excellence.
Sustaining the Journey
UTMB is now 10 years into its professionalism journey. The campus has five years’ experience putting its charter into practice. The result is a university whose professional commitments have come to define the institution’s mission and identity, incumbent on every member of the campus community and affecting every facet of university operations. Three factors have emerged as critical in this transformation.
First, from the start, the initiative’s goals were consistent with UTMB’s self-identity. The university’s legacy of caring for the state’s most vulnerable populations has conditioned a service culture mindful of patient welfare and impatient of impediments to care. The initiative’s goal of professionalizing the campus in commitment to care respects that legacy, easing removal of institutional impediments. It is fair to note at UTMB a special hospitality to the notion that creating a healing environment depends as much on the hospital administrator and admissions clerk as on the doctor and nurse.
Second, professionalism has been woven into the fabric of the organization in a way that will endure administrative perturbation and changes of personnel. Training programs and annual events, the Oslerian Academy, the online professionalism reporting link, faculty evaluations, and student development plans are now campus fixtures. Professionalism’s prominence in the curricula of the four schools is typical: from the heart of the academic enterprise to poster displays of the UTMB charter in campus hallways, professionalism permeates the university. It has become the culture of the institution.
To integrate professional ideals vertically, the university recently began offering competitive grants to workgroups throughout the institution to create projects that implement UTMB charter commitments. The initiative was undertaken in conscious imitation of the ABIM Foundation’s Professionalism Charter Project of 2002. Putting the Charter into Practice sought to sustain professionalism on a national basis by providing grants to select AHCs to inculcate these core commitments. Likewise, UTMB is looking to the future of its charter. The Professionalism Awards project provides an annual opportunity for stakeholders to share responsibility for professionalism on their home campus. Announced in October 2006, the first seven grantees have one year to complete their projects for presentation at the annual Professionalism Summit in the fall of 2007, where the best will receive the President’s Professionalism Award. This year’s submissions range from the pediatric residency directors’ Web-based curriculum for tracking ACGME competence in professionalism to an Educational Affairs program to increase reflection by employees on the charter’s significance to their department’s educational mission to a student project to raise awareness of the pharmaceutical industry’s influence on medical research and education. This widespread response to the Professionalism Awards indicates a campus firmly committed to the charter.
Third, detailed attention is given to assessing the progress of UTMB’s professionalism journey. Every member of the community is assessed by clearly stated criteria for professional behavior. For example, executive leadership and SOM faculty are subject to 360-degree evaluations assessing their performance of UTMB charter commitments; faculty, residents, and students are scored for professionalism in all clerkship evaluations; and at all levels professional evaluations are correlated with patient satisfaction surveys to further individual accountability. Because assessment is more difficult when the goal is to address relationships, competence, and ethical development, evaluation also takes into account peer and supervisor/supervisee relationships. Most important, when unprofessional conduct is revealed, expeditious action is taken. Likewise, superlative behavior is acknowledged and rewarded, as in the annual faculty and resident teaching awards and induction of faculty into the Oslerian Academy. Significantly, the recognition process is not limited to teachers. Acknowledging the key role students play in supporting professionalism, a student cohort of the Osler Scholars was established in 2005, providing scholarships to twelve rising second-, third-, and fourth-year medical students; that same year, the university inaugurated a chapter of the Gold Honor Humanism Society (GHHS). Election to the Osler Student Scholars and the GHHS recognizes students who evince outstanding compassion and integrity and honors their commitment to the cause of professionalism. This recognition is crucial. Only in measuring change, enforcing accountability, and honoring achievement can progress occur.
Finally, with respect to assessment, it is proper to acknowledge the aura of abstractness that envelops professionalism. The academic community favors programs to encourage professionalism. But is there reason to believe that they make a difference in terms of the quality and event rate of desired behaviors? Are teams stronger, individuals better prepared to prioritize the needs of others? The assessment tools enumerated above reflect UTMB’s effort to measure the impact of the professionalism initiative and substantiate improvement. Although that effort is far from complete, data from an annual survey of student, faculty, and staff reactions to professionalism suggest the initiative is bearing fruit. For example, in 2002, 92% of students from all four schools reported that professionalism is a priority at UTMB; by 2007, that number had risen to 96%. In 2002, 86% of students reported that they had been treated with courtesy and respect by faculty; in 2007, the rate rose to 93%. The trend is similar among faculty and staff. In 2002, 52% rated their immediate supervisor as compassionate; in 2007, 75% responded in the positive. The same holds true for treats me with respect (2002: 59%; 2007: 78%) and exhibits integrity (2002: 54%; 2007: 73%). Undoubtedly, there is room for improvement, but the numbers indicate significant progress. As more sophisticated metrics are deployed (particularly measures drawn from the ACGME Toolbox of Assessment Methods to gauge the impact of the professionalism curriculum), the university looks forward to sharing further results of its professionalism journey with the academic medicine community.
No magic wand, pledge, or mere charter statement will make professionalism a reality. The initiative requires honest appraisal of challenges and a plan for implementing clearly stated priorities. It requires executive leadership prepared to share responsibility as the campus-at-large takes ownership of the initiative. As John Kotter24,25 notes in his seminal work on leading change, which anticipates many of the lessons noted below, “In the final analysis, change sticks when it becomes ‘the way we do things around here,’ when it seeps into the bloodstream of the corporate body.” A decade into its journey, UTMB offers eight lessons on making professionalism “stick”:
1. Change does not happen overnight. It would have been easy to declare victory once the UTMB charter was codified and adopted by the campus, but in reality that only marked the beginning. Each month, opportunities to renew the initiative are identified and endeavors to refresh professional values begun. The culture needs constant tending.
2. Transformation is not achieved solely by a top-down approach. A productive community embracing all areas of the campus must be mobilized around the initiative and community members at all levels of responsibility engaged.
3. Professionalism must be built into the basic structure of the institution. Leadership must be committed to changes that will survive its own transition. Stakeholders should feel that the effort is meaningful and that diverse constituencies can share the vision in ways tangible to their respective departments and missions.
4. The effort needs to be creative and use a collegial process. Often missing in the discussion of professionalism is an acknowledgement of the importance of civility and respect to other members of the health care team. Effective innovations should be embraced whatever their provenance, whether from administration, faculty, students, or staff.
5. Progress must be assessed. Specifying professional behaviors in performance evaluations and satisfaction surveys reminds the community that professionalism counts. Personal and systemic impediments to professionalism must be identified and data accrued to effect change. In short, measure what matters and act on what you measure.
6. The issue is one of hearts and minds rather than dollars and cents. Resources are needed to establish the infrastructure for change but this is not financially burdensome. The UTMB Professionalism Charter project began with an external grant of $10,000 and yielded research, training materials, and a Web site module. The UTMB Professionalism Award seed grants required $35,000 and resulted in seven high-impact projects.
7. Individuals must be held accountable for their behavior regardless of their status within the organization, especially those in positions of trust. Vulnerable constituencies, particularly patients and students, must be protected from conduct harmful to healing and learning. Specific mechanisms must be in place to identify and encourage professional behavior and remedy misconduct.
8. It is important to recognize and reward exemplary behavior. Students come to the profession prepared to serve. Staff and administrators expect to serve the goals of the university. It is critical that faculty and key personnel provide appropriate models of service and inspire each other to act with compassion and humane respect. Role models must be identified, cultivated, and valued.
A decade of leadership focused on professionalism has shaped a culture of shared values and interdisciplinary collaboration at UTMB. Stobo has secured a legacy attentive to the university’s century of service to the state’s most marginalized and vulnerable people. That tradition is one that all members of the campus community value and one to which the professionalism initiative has given renewed coherence. The president’s words make a fitting conclusion: “When the culture is respectful of others and the environment is positive, our patients, students, and colleagues all benefit.”