Taylor, Christine PhD; Farver, Carol MD, MS; Stoller, James K. MD, MS
Dr. Taylor is professor of medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, and director, Faculty Development, Cleveland Clinic, Cleveland, Ohio.
Dr. Farver is vice chair for education, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio.
Dr. Stoller is Jean Wall Bennett Professor of Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, and director, Physician Leadership Development, and chair, Education Institute, Cleveland Clinic, Cleveland, Ohio.
Correspondence should be addressed to Dr. Taylor, 9500 Euclid Ave./NA25, Cleveland, OH 44195; telephone: (216) 444-1299; fax: (216) 445-4471; e-mail: firstname.lastname@example.org.
First published online October 25, 2011
In changing graduate medical education (GME) accreditation standards in 1999 from documentation of rotation objectives and the number of hours spent in each rotation to a competency-based assessment system,1 the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project introduced six general competencies—patient care, medical knowledge, interpersonal and communication skills, professionalism, systems-based practice, and practice-based learning and improvement—on which residents and residency programs would be assessed. Among these six competencies, patient care and medical knowledge have seemed to be straightforward as metrics, whereas the other four—particularly professionalism—have posed greater challenges for measuring progress and for developing curricula.
In this article, we underscore the limitations of using role modeling as a primary method for teaching professionalism to physicians-in-training and propose that emotional intelligence (EI)2,3 training satisfies proposed criteria for the professionalism competency.4 We conclude by offering a curriculum design to develop EI competencies that could also develop professional behaviors in trainees.
The Challenge of Defining and Teaching Professionalism
The early scholarly response to the ACGME's launch of the professionalism competency was to invoke classical works in search of a definition. Early examination of professionalism through the lens of the social contract5–7 defined professionalism using a set of other abstract concepts (e.g., respect, altruism, compassion). As the challenge of defining professionalism continues,8–10 medical educators must determine whether professionalism is the act of behaving morally or, as intended by the authors of the Outcome Project, a competency that includes a cognitive knowledge base and a set of developmental skills.11 Huddle12 suggested that professionalism includes both a cognitive knowledge base (e.g., of medical ethics) and a moral behavior base that is gained over a lifetime rather than in the short term. Professionalism, therefore, requires not only that medical students and residents know the right thing to do (cognitive aspect) but that they actually do the right thing, even in the most challenging of circumstances (moral aspect).
Cruess and Cruess13 suggested that professionalism curricula should include explicit cognitive, experiential, and role modeling experiences. In our review of the literature, we found examples of formal didactic curricula that include medical ethics, teaching of professional principles, small-group sessions on “professional topics” guided by mentors, and opportunities for action and reflection.14–16 Doukas16 noted, however, that although formal instruction in bioethics could help residents develop their professionalism, residents are most likely to learn “virtue ethics” through the informal experience of modeling their own behavior after that of their clinical teachers. This phenomenon of learning through informal experience has been called medicine's “hidden curriculum.”17
Whereas effective role modeling is a key competency for educators,18 teaching the morality-based component of professionalism through a hidden curriculum poses challenges. The hidden curriculum relies on medical students' and residents' observing the everyday behaviors of senior physicians, analyzing the observed behaviors in the context of their own behaviors, and ultimately knowing when they should incorporate the observed behaviors into their own work. This informal role modeling lacks an associated measurable outcome and only shows the learner the mentor's actual behavior—not the mentor's internal, private analysis of the features to model. Furthermore, the mentor's internal analysis may not include all aspects of professionalism, and he or she is unlikely to communicate to the learner how to make difficult choices between competing goals, which is the essence of professionalism.
Consider the common scenario of a senior resident who, during her 29th hour of consecutive service, is at the bedside of an acutely deteriorating patient. The senior resident must choose between leaving the hospital (to remain in compliance with current duty hours rules) and staying with the patient (to provide optimal care while arranging a care transition). In role modeling this scenario for an intern, the senior resident shows the intern her final decision but not the reasoning that informed her behavior. Said differently, the intern sees the senior resident doing what the resident determines is the “right” thing to do, but he does not learn the full, professional lesson of balancing values. Another shortcoming of teaching professionalism via the hidden curriculum is that the busy intern could be absorbed in his own workload, not notice the senior resident's behaviors, and miss the learning opportunity entirely.
Another concern about depending on role modeling is that attending physicians may be hesitant to discuss professionalism—especially breaches of professionalism. In a recent qualitative study by Bryden and colleagues,19 one participant statement summed up this issue: “I don't think there is a forum where people can discuss these things [breaches in professionalism] that they don't feel judged. I don't know how you do that.” In the face of such reluctance to discuss professionalism, relying on role modeling seems inadequate. Educators must develop an alternative, better model from which to teach this critical competency.
Teaching EI as an Alternative Approach to Teaching Professionalism
Although attending physicians' role modeling of ethical, virtuous behavior will always influence trainees' development, role modeling unavoidably resists replication or being systematically taught. Thus, we submit that teaching the abilities that constitute EI represents a useful, alternative approach in teaching professionalism. EI offers a teaching method that is explicit, is clear, and has rigor, thereby avoiding the shortcomings of the hidden curriculum of role modeling. To develop this suggestion, we first briefly review the concept of EI and then propose a model and framework for an EI curriculum that may also develop trainees' professionalism.
An overview of EI
EI2,3 is a construct that has been associated with leadership success and consists of four types of abilities: emotional self-awareness, self-management, social awareness, and relationship management (Chart 1). Simply put, if you possess characteristics of EI, you are aware of your emotions, able to manage these emotions, aware of the dynamics of relationships, and able to manage yourself in service to enhancing group effectiveness.2,3 EI is grounded in “effective performance” and leadership success20 rather than in moral right or wrong. For example, Arora and colleagues21 reported that high levels of EI positively contributed “to doctor–patient relationship, team-work and communication skills, and increased empathy.” Lobas,20 interviewing 10 chairs of academic internal medicine departments regarding the factors most associated with their professional successes and failures, identified having EI as the most important competency associated with success and lacking EI as being most closely associated with performance shortfalls. There is debate as to whether EI merely reflects fixed personality traits22 or is a mixed model of abilities and personality traits. To date, there is substantial evidence that EI measures abilities, independent of personality traits, that affect performance.23 Furthermore, EI abilities can be taught and sustained over time.24
Are EI and professionalism the same? There seems to be much overlap. As we note above, the behaviors often cited as manifestations of professionalism are the behaviors taught in EI training. Professionalism is a complex concept that includes cognitive, skill-based, and affective components. Simply, medical educators would like professionalism training to teach students and residents to do the “right” thing. On a morality-based platform, the right thing is grounded in a set of rules by which individuals are taught to live (though these rules change from culture to culture). From an EI perspective, the right thing is grounded in striving for self-awareness and social awareness and using reflections to create effective personal interactions. The outcomes may be remarkably similar even as the journey to achievement may be different.
A framework for using EI to teach professionalism
The four types of EI abilities (Chart 1)2,3 can each be divided into component skills that help learners develop and improve their EI. The two types of abilities on the left (in quadrants 1 and 2) relate to personal skills, and the two types on the right (in quadrants 3 and 4) pertain to social relationship skills. For example, through reflection, a resident may come to recognize that his emotional response to being time pressured is to become short tempered or frustrated (self-awareness, quadrant 1). Once he has identified this emotional response, the resident can learn to manage it internally or can learn skills to improve his efficiency (self-management, quadrant 2). Similarly, a resident who learns about the values and cultural background of her patient may better understand the patient's response to the disease and/or therapies (social awareness, quadrant 3). Further, the resident may use such knowledge to improve her patient's ability to both cope with the disease and comply with the therapy (relationship management, quadrant 4).
As illustrated in Chart 1's four quadrants, this model encompasses abilities that are traditionally associated with professionalism. For graduate medical educators, this model provides a framework to teach professionalism to physicians-in-training. In each quadrant in Chart 2, we propose topics that, together, would make up a professionalism curriculum. For example, an important part of managing relationships is learning how to manage and resolve conflict effectively. Thus, teaching trainees how to manage conflict (quadrant 4) would enhance their professionalism.
Although reference in the literature to training in EI abilities as part of a medical school professionalism curriculum is rare, there are scattered reports of needs analyses and task force reports of models that are either under consideration or in progress as pilot projects.25,26 In general, these models support annual or semiannual workshops, weekly or monthly seminar series, community service experiences or externships, or a combination of these components. Most important, it is clear that many academic institutions are debating how to implement a professionalism curriculum, so an EI model such as the one we propose here may offer a useful construct.
A formal EI curriculum to teach professionalism, as outlined in Chart 2, offers several advantages. First, it defines specific skills that are the basic tenets of real-world professional behavior for successful physicians. In the scenario of the resident who understands her patient's cultural background, faculty could measure the patient's compliance with therapy and clinical outcomes as a reflection of the resident's EI, invoking the principle that good doctors tend to have good patient outcomes. Second, the concepts of EI provide a nonjudgmental vocabulary that educators could use to discuss professionalism in physicians-in-training. For example, rather than focusing on changing a resident's personality, an EI-based curriculum to enhance teamwork would focus on specific behaviors that the resident could develop or enhance to promote team membership. In this way, the faculty would measure and value the final team outcome rather than the resident's emotional feelings toward the team. Finally, there are well-developed, validated instruments to assess EI, so a resident's ability to learn and use this knowledge is measurable over the course of training. Program directors have access to a suite of instruments to measure progress, including ability measures such as the Mayer–Salovey–Caruso Emotional Intelligence Test,27 self-reported measures such as the Emotional Intelligence Inventory,28 and 360-degree measures such as the Emotional Intelligence Appraisal.29
Challenges and Conclusions
Our enthusiasm for introducing EI as an alternative approach to teaching professionalism is tempered by our recognition of potential challenges. First, faculty and learners must become familiar with the concepts and vocabulary of EI. Second, training in EI requires reflection on personal responses to internal emotions and attention to the reactions of others. Sincere personal reflection and attention take time and practice as well as a safe environment in which to share and discuss reflections. Third, time is at a premium in medical school and residency, and EI training could become an ineffective addition to an already-demanding curriculum. Administrators and faculty must keep this in mind when developing and implementing a new EI curriculum. Experience with including EI training in leadership development programs for faculty has been reported30 and has since been extended to trainees, thereby providing examples of effective integration of EI training in other domains.
These potential challenges notwithstanding, we maintain that the concept of EI has value for teaching professionalism to physicians-in-training. The abilities that constitute EI can help define specific curricula which, when successfully taught to and learned by physicians-in-training, would allow professionalism to be recognized and measured in ways that are not currently possible in existing hidden curricula. Our hope is that colleagues who develop policies regarding professionalism and who train physicians will find this construct helpful and will consider learning more about EI and incorporating EI training into curricula for professionalism.
2 Mayer JD, Salovey P. The intelligence of emotional intelligence. Intelligence. 1993;17:433–442.
3 Goleman D, Boyatzis R, McKee A. Primal Leadership: Learning to Lead With Emotional Intelligence. Boston, Mass: Harvard Business School Press; 2004.
4 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.
5 Benson JA. Professionalism: Reviving or redrawing the social contract? Ann Allergy Asthma Immunol. 2002;89:114–117.
6 Cruess SR, Cruess RL. Professionalism: A contract between medicine and society. Can Med Assoc J. 2000;162:668–669.
7 Latham SR. Medical professionalism: A Parsonian view. Mt Sinai J Med. 2002;69:363–369.
8 Archer R, Elder W, Hustedde C, Milam A, Joyce J. The theory of planned behavior in medical education: A model for integrating professional training. Med Educ. 2008;42:771–777.
9 van Mook WN, van Luijk SJ, O'Sullivan H, et al. The concepts of professionalism and professional behavior: Conflicts in both definition and learning outcomes. Eur J Intern Med. 2009;20:e85–e89.
10 Borrero S, McGinnis KA, McNeil M, Frank J, Conigliaro RL. Professionalism in residency training: Is there a generation gap? Teach Learn Med. 2008;20:11–17.
11 Leach DC. Professionalism: The formation of physicians. Am J Bioeth. 2004;4:11–12.
13 Cruess SR, Cruess RL. Teaching professionalism: General principles. Med Teach. 2006;28:205–208.
14 Elliott DD, May W, Schaff PB, et al. Shaping professionalism in pre-clinical medical students: Professionalism and the practice of medicine. Med Teach. 2009;31:e295–e302.
16 Doukas DJ. Where is the virtue in professionalism? Camb Q Healthc Ethics. 2003;12:147–154.
18 Kouzes JM, Posner BZ. The Leadership Challenge. 4th ed. San Francisco, Calif: Jossey-Bass; 2008.
20 Lobas JG. Leadership in academic medicine: Capabilities and conditions for organizational success. Am J Med. 2006;19:617–621.
21 Arora S, Ashrafian H, Davis R, Athanasiou T, Darzi A, Sevdalis N. Emotional intelligence in medicine: A systematic review through the context of the ACGME competencies. Med Educ. 2010;44:749–764.
22 Cherniss C, Extein M, Goleman D, Weissberg RP. Emotional intelligence: What does the research really indicate? Educ Psychol. 2006;41:239–245.
23 Boyatzis RE. Emotional and social intelligence competencies. In: Ashkanasy NM, Cooper CL, eds. Research Companion to Emotion in Organizations. Northampton, Mass: Edward Elgar; 2008:226–244.
25 O'Connell MT, Pascoe JM. Undergraduate medical education for the 21st century: Leadership and teamwork. Fam Med. 2004;36(suppl):S51–S56.
26 Varkey P, Peloquin J, Reed D, Lindor K, Harris I. Leadership curriculum in undergraduate medical education: A study of student and faculty perspectives. Med Teach. 2009;31:244–250.
27 Mayer JD, Salovey P, Caruso DR, Sitarenios G. Measuring emotional intelligence with the MSCEIT V20. Emotion. 2003;3:97–105.
28 Tapia M, Marsh GE 2nd. A validation of the emotional intelligence inventory. Psicothema. 2006;18(suppl):55–58.
29 TalentSmart. Emotional Intelligence Appraisal, Multi-Rater Edition (360°). San Diego, Calif: TalentSmart; 2011.
30 Stoller JK, Berkowitz E, Bailin P. Physician management and leadership education at the Cleveland Clinic Foundation: Program impact and experience over 14 years. J Med Pract Manage. 2007;22:237–242.