Professionalism in Medical Education: An Institutional Challenge : Academic Medicine

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University of Washington

Professionalism in Medical Education: An Institutional Challenge

Goldstein, Erika A. MD, MPH; Maestas, Ramoncita R. MD; Fryer-Edwards, Kelly PhD; Wenrich, Marjorie D. MPH; Oelschlager, Anne-Marie Amies MD; Baernstein, Amy MD; Kimball, Harry R. MD

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doi: 10.1097/01.ACM.0000238199.37217.68
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Abstract

Medical education has long focused on teaching professionalism to medical students and, less often, to residents. Curricula are frequently didactic and center on rules, skills, and behaviors. Teaching professionalism typically is divorced from the clinical setting, eliminating the complexity and motivations of real patient care.1–3 Educational discussions may center on concepts like respect and integrity—essential qualities of a good physician, but difficult to assimilate out of the clinical context.4,5

Medical professionalism appears to be entering a period in which educators are asking hard questions, and answers don’t come easily. Will professionalism be addressed at meaningful levels? Will discussions focus only on students or on all members of the institution? Without involving the entire institution, is there value to addressing professionalism in the medical school curriculum? Any institution that addresses professionalism must hold itself up to a mirror and answer these difficult questions.

In 2002, the University of Washington School of Medicine (UWSOM) initiated a curricular innovation known as the Colleges program.6 In this model, 30 outstanding, carefully chosen faculty–clinicians work with small groups of students to develop their basic clinical skills and professionalism. The faculty–clinicians teach and model clinical skills at the bedside during the students’ second year, and continue to follow and mentor the students until their graduation.

Development of the Colleges’ professionalism curriculum has opened the window on professionalism at our medical school and led to awareness of an “ecology of professionalism.” In his report titled “A Flag in the Wind,” Inui referred briefly to the “complex and highly interconnected organizational ecology of the academic medical center.”7 The ecology of professionalism that we describe here is characterized by institutional interdependence, in which addressing professionalism at one level of an institution influences or opens up the need to address it at other levels. This article describes our understanding of the “ecology of professionalism” and what that means for the future of our educational programs and institutional culture.

Early Approaches to Professionalism at the UWSOM

Few medical schools have implemented comprehensive, institution-wide programs that address professionalism at all levels. The University of Texas Medical Branch8,9 and Virginia Commonwealth University10,11 are two notable examples of institutions that have done so, and others are following suit.12 Prior to the Colleges curriculum at the UWSOM and into its early stages, as in most institutions, formal professionalism programs have focused primarily on medical students; residents have received less attention, and faculty even less than residents. With the evolution of the Colleges approach, professionalism training at our institution has begun to be more all-inclusive, which we discuss in a later section.

Medical students’ training

Prior to 2001, the professionalism curriculum at the UWSOM consisted of regular but limited lectures and discussions in the first- and second-year Introduction to Clinical Medicine course and in clerkships, and an orientation session for first-year students on the physician’s oath. The advent of the Colleges presented an opportunity to redesign curricula for teaching clinical skills and professionalism.

Students often articulate values and service ideals consistent with the principles of medical professionalism when they enter medical school, but these often decline over the course of their medical education.13–15 Colleges faculty held extensive discussions about how to maintain students’ ideals and created an explicit professionalism curriculum to achieve this outcome. Along with developing benchmarks for faculty and students in teaching and learning clinical skills, the Colleges faculty developed professionalism benchmarks for preclinical students.6 These outline the knowledge and behaviors expected for the principles of altruism, honor and integrity, compassion, communication, respect, accountability and responsibility, scholarship, excellence, and leadership. In addition, ethics benchmarks define the knowledge base related to ethics and reasoning skills that students are expected to master.

Throughout their first and second years in the Colleges curriculum, students learn about issues of professionalism and ethics. Traditional teaching formats include lectures, small-group discussions, and required written reflections. Topics include communication skills, ethical principles and reasoning, cultural diversity, human sexuality, substance abuse, physicians’ uncertainty and mistakes, patients’ life-threatening and terminal illness, and issues of “physicianhood.” Students are required to complete written reflections to help them recognize and articulate the personal feelings and reactions they bring to potential interactions with patients. In small groups, students can examine their own perspectives and biases, shape their ideas, and frame their actions in a patient-centered fashion.

During their second-year clinical tutorials, students are mentored at the bedside through weekly half-day sessions with faculty and small groups of students. Since faculty work with students at patients’ bedsides, learning opportunities to discuss professional values, behaviors, and ethical principles arise frequently. Faculty mentors, chosen through a careful selection process by Colleges leaders for their teaching and clinical skills and role modeling abilities,6 model professional behavior, observe students’ interactions with patients, and provide immediate feedback. Identifying and using teachable moments permits the mentor to connect the clinical experience to professional values or ethical principles. In this way, students find that the lessons taught at the bedside are more personally relevant and salient than more abstract instruction. Students also complete an ethics write-up aimed at demonstrating competence in identifying and resolving an ethical dilemma arising from their actual clinical experiences.

Professionalism curricula and benchmarks are being developed for the third- and fourth-year clerkships by clerkship faculty with assistance from Colleges faculty. Benchmarks for the third-year family medicine and neurology clerkships are being implemented, while benchmarks for the remainder of clerkships are in varying stages of development. The goals for integrating professionalism into the clinical curriculum are the same as those for preclinical students: defining developmental needs, developing curricular materials, providing and using opportunities for instruction, and identifying specific targeted behaviors expected of students.

Residency training

The UWSOM Department of Pediatrics has made a notable effort to implement a graduate medical education professionalism curriculum.16 For over 25 years, the department has held an annual five-day retreat for interns, with 11 mandatory sessions devoted to key professionalism issues. Teaching techniques include discussion groups, videotaped clinical scenarios, observing a play, role-playing, and simulations. Following the retreat, topics are revisited at noon conferences throughout the residents’ training, and two Grand Rounds each year focus on professionalism. %A Web- or CD-based professionalism curriculum for use across multiple departmental residency programs is in early stages of development.17

Most clinical departments now evaluate residents on their professionalism through inclusion of at least one item on routine evaluation forms. Several departments (obstetrics–gynecology, surgery, and urology) use 360-degree evaluations that incorporate professionalism, and obstetrics–gynecology uses a separate evaluation related to professionalism.

Faculty training

The Colleges faculty has been the primary faculty group to undertake faculty development about professionalism. Their goals have focused on helping their own faculty gain expertise in teaching and addressing professionalism with preclinical students. Topics for workshops and Colleges faculty meetings have included how to facilitate student sessions where professionalism expectations are discussed, leading case-based discussions, debriefing ethics cases, providing one-on-one mentoring through clinical tutorials, giving formative and summative feedback, and teaching about cultural diversity and disparities. A professionalism working group, consisting of a subgroup of Colleges faculty and faculty from outside the Colleges, leads these activities.

Outside the Colleges, the University of Washington Teaching Scholars program has been active in professionalism faculty development. This one-year program trains faculty from a variety of specialties and health professions to assume leadership roles in medical education, conduct research related to educational endeavors, and develop and disseminate educational innovations.18,19 The 2004–2005 cohort addressed medical professionalism as a group project and has continued to promote professionalism institution-wide by giving professionalism-specific Grand Rounds and workshops. In many departments, faculty professionalism is evaluated in a manner similar to how residents are evaluated.

The Evolving Consensus on Professionalism

Developing and introducing the preclinical professionalism curriculum has not been a smooth process with universal appeal. Results from annual interviews initiated in 2003 with second- and fourth-year medical students for evaluation purposes highlight several challenging aspects of the Colleges’ professionalism program.

A substantial number of second-year medical students complained in 2004 and 2005 about the professionalism curriculum, especially about overuse of the word “professionalism” itself. Some students viewed the curriculum as a collection of excessive directives, lectures, rules, and moral pronouncements that they found repetitive and patronizing. Our anecdotal conversations with faculty from other medical school disclosed similar experiences. The problem facing the Colleges faculty was to determine whether these criticisms were reasonable, were the result of an incomplete understanding of the curriculum among some students, or emanated more broadly from the generational perspectives of current students.

Through self-evaluation, discussion, and reflection, the faculty began to understand that a “rule-based” approach to professionalism does not address the core of professionalism; neither does an approach based strictly in discussions about medical ethics, nor one focused strictly on teaching professionalism “skills” and behaviors. Coulehan noted that, for learning to be meaningful, trainees must experience professionalism as contemporary narratives, either observed through role-model physicians or indirectly through stories and film.1 By themselves, rules, behaviors, and didactic lessons provide a limited narrative perspective and little opportunity for context-based understanding. Although in the Colleges’ initial approach we used a case-based approach to highlight values, we did not connect the cases sufficiently to real life for the students.

We began to recognize that the Colleges faculty, who are role-model physicians working directly with students in patient care, had the best possible opportunities to enhance professionalism by focusing on the “teachable moment” within clinical settings. Although we had known this previously, its central importance became clearer over time. Classroom work, benchmarks, and reflections must be secondary to and supportive of actual clinical experiences. The professionalism program must be both organic and evolutionary, capitalizing on the lived experience of the clinical setting and the narratives that build from that. This creates the best opportunity for students to understand professionalism in a meaningful way—thinking about what is right for patients, struggling with immediate clinical situations with the assistance and guidance of faculty mentors, and reflecting with mentors and small groups on real patients confronting real illnesses.

Accordingly, we brought students directly into the dialogue about how professionalism should be addressed. Formed in 2005, a Professionalism Student Advisory Group has provided substantial feedback and direction. These students are members of the Medical Student Association who are elected by their peers to represent them in a variety of issues at the medical school. In the fall quarter of 2005, a subgroup of faculty who form the professionalism working group met with these students to better inform our approach to teaching professionalism. Two subsequent meetings were held in winter and spring 2006. Students told Colleges faculty that despite hearing the words “professionalism” and “cultural competency” many times, they had no real idea what these words meant, and that teaching must be specific, clinically relevant, and challenging. Examples of students’ comments are:

The best teaching has happened with the College mentor at the bedside, just watching her work with patients. A good approach would be to hear from the expert clinicians about what went well and also what they tried that backfired. Hearing from them that “this is important and that’s why” really helps.

Use cases from our mentors—real-life situations where they were stuck or challenged. Talk with us about what is effective and what is not effective.

Just throw us in the situation. Challenge us: “What would you do?” Then take a step back and learn.

One of the products of student advisory input was preparation by the Colleges faculty of 60 case vignettes, based on their own training or clinical experiences, that reflect ethical, professional, cultural, or communication issues. When the student advisory group was asked to select five of these vignettes for an upcoming case-discussion activity, the students responded that all the vignettes should be required reading, and pointed especially to the value of reading case examples from their mentors.

As a result of discussions and reflections, Colleges faculty shifted the emphasis of the professionalism curriculum in 2005. Basic professional expectations concerning dress and timeliness, for instance, are now presented in a straightforward manner without lectures. The use of the word “professionalism,” which carries some negative overtones for students, has been replaced with discussions of professional values. Other aspects of professionalism are treated both more and less explicitly—more explicitly through distribution and discussion of supportive benchmarks and less explicitly by minimizing use of the lecture format to convey professionalism issues.

Since 2004, during program evaluation interviews, samples of second- and fourth-year students are asked to define professionalism, comment on their own professional growth and what has influenced it, and provide examples of professional and unprofessional behaviors they have observed or experienced. Students at the end of their second year typically provide minor examples of unprofessional behavior, often classroom behaviors of fellow students. In contrast, students at the end of their fourth year frequently describe observing unprofessional behaviors in clinical settings. Although students stressed that these instances were relatively rare, all students provided examples of questionable behaviors, often by residents or faculty. This is in keeping with data from other clinical training settings nationally and points to the need to focus attention on the professionalism of medical residents and faculty in addition to medical students.12,20–22 We believe that students should also be trained in how to respond to the unprofessional behaviors that they are likely to encounter in their careers. The Colleges faculty have led discussions with students, based on the written vignettes described above portraying actual unprofessional behaviors observed or experienced, on how to respond to such behaviors.

The Colleges’ focus on professionalism and our initial findings from student interviews with second- and fourth-year students highlight that our institution gives uneven attention to professionalism at different levels. Introducing professionalism in a meaningful way in the preclinical years can be negated by trainees’ subsequent experience with unprofessional behaviors in the clinical years, especially when acknowledgement, reflection, remediation, and/or addressing the consequences of unprofessional actions are absent. This hidden curriculum23 has great power to contradict the lessons we aim to teach at any point; therefore, consistency is essential across all institutional levels. This means that professionalism must specifically be addressed widely, through teaching, sensitization activities, professionalism awards and incentives, and evaluation, with faculty, residents and staff, as well as with medical students.

Closing Loops: An Unexpected Benefit

Issues of professionalism and institutional responsibility arose in two additional areas at the UWSOM as a result of the Colleges program: ensuring that students are ready to advance to clerkships or graduation, and ensuring students’ understanding of respect for patients. Because Colleges faculty have frequent close contact with students, they commonly identify students with academic, professionalism, and/or personal problems earlier than in the past. As the faculty develop confidence in identifying and handling such problems, they identify students who might previously have “flown under the radar,” progressing to clinical work and graduation without the requisite skills, maturity, and/or professionalism. Now these students are being brought to the attention of the school’s Student Progress Committee, which oversees students’ academic progress. The Colleges faculty work with these students on an individual basis, providing feedback to improve their clinical skills and professionalism and developing and implementing remedial action and consequences for failure to remediate. All medical schools have graduated students who were not ready for the next level of training. For the first time, a mechanism is in place at the UWSOM to correct or slow this problem.

Second, the opportunity to provide our students with an understanding of the full meaning of respect for patients has been a very important outcome of the Colleges’ approach to teaching skills and values. Patients at academic medical centers have always been an essential part of students’ training, yet they are rarely acknowledged for the valuable service they perform. Within the Colleges structure, patients must give their permission for students to interview them, perform a physical exam, and present an oral case presentation to their mentor and fellow students at the bedside. At the end of each tutorial session, most Colleges mentors ask patients to offer the students advice for their future performance as physicians. The patients invariably appreciate being asked this question, often telling students to always listen carefully to their patients. These are often touching moments, for students, mentors, and patients alike.

To further encourage respect for and acknowledgement of patients, several Colleges faculty initiated a project, called “Patients as Teachers,” in which some patients seen by second-year medical students discuss how the students performed in terms of clinical skills and professionalism, how students might improve, how it feels to be a patient in a teaching setting, what might improve the experience for them as patients, and whether they experience themselves as teachers. Data collection for this project is in its second year. The process has introduced a new level of professionalism and respect for patients into the teaching experience.

Closing these two loops—requiring that students have the requisite skills and professionalism to advance in their training, and requiring that patients are treated with respect as patients and as teachers—holds students, teachers, and the institution accountable. In the first instance, students must demonstrate the skills necessary to progress as physicians, and the UWSOM is responsible for ensuring that students who advance are ready to do so. Faculty and the institution are also held responsible for giving students every chance to succeed in a “safe” environment that watches out for and works to correct deficiencies. In the second instance, students are held responsible for the care they provide to patients, and the UWSOM is held responsible for ensuring that the patients in teaching settings are treated with respect and sensitivity. Closing these two loops is an indication of how the Colleges system has created an environment that increases incorporation of professionalism at multiple levels

The Ecology of Professionalism

Our experience, which began with a new clinical skills and professionalism curriculum for medical students, has taught us that the academic medical center structure operates within a delicate ecological balance. Professionalism at each level of the institution is dependent on professionalism at all other levels. Implementing a professionalism curriculum, receiving student feedback about our curriculum, and hearing about observations and experiences of unprofessional behavior in various medical school settings has revealed that attention to resident and faculty professionalism is also essential. Professionalism is an institution-wide responsibility. Medical students will not truly learn professionalism unless they see frequent examples that reinforce and reaffirm the tenets and behaviors of professionalism throughout their education—from and to residents, fellows, faculty, and staff.

Within the “ecology of professionalism,” one major change sets in motion a series of other changes, and all of these influence the whole. The Colleges initiated changes to the professionalism curriculum for medical students that, in turn, set in motion responses from students and led to additional changes, which resulted in a relatively fluid and organic, if sometimes uneven, process. If the Colleges faculty had taken a static approach to the professionalism curriculum, a chance to make meaningful changes would have been lost. Curricular improvements resulted from listening to the students, thinking reflectively about their reactions, and considering the value of different approaches to teaching professionalism. New awareness of the influence of the hidden curriculum that resulted from medical students’ observations about residents and faculty during clinical rotations led to our recognition of the need to address professionalism more broadly throughout the institution.23 These components are crucial to the success of teaching professionalism at the UWSOM.

Part of the “ecology of professionalism” at the UWSOM must involve creating a “safe” educational environment for students in at least the following ways. First, students must feel free to provide valid feedback and reactions to faculty about the program. By creating a student advisory group to give feedback and provide input into the professionalism curriculum, Colleges faculty implemented a safe environment.

Second, a safe environment means ensuring that an aspirational approach to professionalism is addressed throughout the entire institutional culture. In addition, when students or others observe or experience unprofessional behaviors in the institutional setting, there must be effective mechanisms for bringing these to institutional attention. Such mechanisms must ensure action, accountability, and confidentiality.

Third, students must be held accountable for their performance in professionalism, as well as their clinical skills. Students who do not meet acceptable educational standards must receive remedial instruction from faculty they trust. In turn, the institution must give these students every chance to receive help. If students are unable to achieve these standards, the institution must ensure that they do not advance to the next stage of training. These difficult actions require a high degree of professionalism from students, faculty, and the institution.

Finally, a safe environment means that faculty and residents must visibly and consistently demonstrate respect for patients, through role modeling, establishing expectations, and providing mechanisms that promote respect. Again, this requires a high degree of professionalism from students, residents, educators, other faculty, and the institution. Each is dependent on the other; if one element fails to assume responsibility, the entire system may fail.

A strong lesson from this process has been the need to simultaneously strive for perfection and yet to acknowledge imperfection. One way to think of this is as continuous professionalism improvement (CPI). Akin to the concept of continuous quality improvement, CPI recognizes the aspirational, developmental, and lifelong nature of professionalism. Students, residents, and faculty achieve a richer understanding of professionalism when they are encouraged to think continuously about professional values and the existence of, reasons for, and alternatives to unprofessional behaviors observed or experienced. This approach provides an environment in which mistakes are acknowledged and improvement is encouraged.

The Future of Medical Professionalism at the UWSOM

In summer 2006, the UWSOM dean convened a steering committee to examine the need for professionalism activities at all institutional levels. He cited the following reasons for this action: (1) to ensure that the institution is keeping medical professionalism current and relevant; and (2) to build upon the strong start made in instilling medical professionalism in medical student programs and in some residency training programs by considering how to promote professionalism at all levels and in all activities. The dean asked his senior advisor, a national expert on professionalism, to select members and lead the steering committee. Committee members were chosen from a variety of departments and educational roles for their commitment to professionalism and diverse viewpoints.

After extensive discussion, completion of a limited environmental scan for professionalism, and review of institutional efforts elsewhere, the steering committee offered the dean a series of recommendations. Chief among these was the appointment of a standing advisory committee on medical professionalism to develop, implement, monitor, and coordinate an institution-wide professionalism initiative.

It is with great hope that we consider the future of professionalism at the University of Washington School of Medicine. Our medical school has areas of weakness, individuals who at times display unprofessional behaviors, and educational endeavors that do not always provide the greatest protection or opportunities for trainees, faculty, and the profession. We are not unique in that regard. Trainees and physicians in all training and practice settings at times display unprofessional behaviors, including those designated as role-models. Professionalism is neither easy to understand nor to master and should be continually under development throughout a physician’s career. It is essential to set standards, discuss and reflect on professionalism in contextually relevant settings, acknowledge and discuss mistakes, and work continuously to achieve high individual and institutional professional standards. The ability to engage in continuous professionalism improvement as an aspiration of an entire academic medical center is an opportunity for all community members to acknowledge and recommit to what is best about the profession.

Our experiences with the evolution of the undergraduate medical professionalism curriculum have taught us about the profound interdependence of all aspects of the medical school in truly modeling and promoting professionalism and in helping trainees achieve a genuine and lasting professional perspective on medicine. The University of Washington School of Medicine now has the opportunity and challenge to build upon this understanding to improve training, patient care, and collaborative, collegial relationships throughout our institution.

Acknowledgments

The authors are indebted to Paul G. Ramsey, MD, dean of the University of Washington School of Medicine, for his careful critique of this manuscript and for his development of the concept of “continuous professionalism improvement,” which is used in this paper with his permission. The authors are also indebted to Carol MacLaren, PhD, associate dean for student affairs at the University of Washington School of Medicine, for her careful critique of the manuscript.

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© 2006 Association of American Medical Colleges