1	Fostering Professionalism and Ethics in the New Generation IAMSE Webcast Audio Seminar Series: Medical Education and the Next Generation of Learners Ariel E. Hirsch, MD Assistant Professor and Director of Education Department of Radiation Oncology Boston University Medical Center Associate Radiation Oncologist Massachusetts General Hospital Harvard Radiation Oncology Program
2	Medical Students Generally well intentioned at the outset of their education All can agree that students share the high ideals of professionalism Challenge is getting them to live up to these ideals
3	Understanding Professionalism Medical knowledge Practice-based learning and improvement Patient care Systems-based practice Interpersonal and communication skills Professionalism: compassion, integrity, and respect for others; responsiveness to patient needs that supersedes self-interest; respect for patient privacy and autonomy; accountability to patients, society and the profession; and, sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.
4	Medical professionalism The keystone of the social contract between medicine and the public at large Transformation of the learning environments at academic centers and beyond the walls of academic medical centers Requirement of strong institutional leadership “Humanism provides the passion that animates authentic professionalism”
5	Ethics versus Professionalism Ethics As with the rest of the clinical curriculum, ethics is generally taught as offering students a skill, primarily cognitive: a set of conceptual tools with which to clarify and respond to moral difficulties that arise in the practice of medicine. End-of life care, organ transplantation, reproductive medicine Use of ethics to guide students to morally acceptable courses of action in difficult situations Professionalism Aspect of personal identity and character that must develop, if not already present, from a deeper commitment over time
6	Historical Perspective Assumption that physicians-in-training would acquire professional values by osmosis from mentors and role models as they progressed through their training (not unlike generations of physicians had presumably done in the past) After all, students competent in the biomedical sciences are certainly capable of learning values of the profession through the combination of clinical experience and mentoring
7	Changing (and changed) Times Major initiatives to teach professionalism and requirement of educators to measure the outcomes of their efforts In addition to ACGME core competencies - in July 2008, all LCME-accredited schools will be required to ensure that the “learning environment for medical students promotes the development of professional attributes” (www.lcme.org)
8	Why the Change? Over the past several decades, medicine has evolved considerably with many reporting an increase in physician dissatisfaction: Managed care arrangements Liability insurance and malpractice claims Increased pressure, diminished time, decreased personal well-being Business aspects of medicine Disappearance of physician independence Loss of physician autonomy
9	…Leading to Change in Medical Student Perceptions In the process of becoming medical professionals themselves, our students learn powerfully from the systems in which we work and what they see us do (the ‘hidden’ and ‘informal’ curriculum), not only from what they hear us say (the formal curriculum): leads to cynicism and thought that cynicism is intrinsic to medicine Despite addition of dedicated coursework (didactics) in many institutions, may not be sufficient. It is critical that students see change in our behaviors, our institutions, and ourselves
10	Teaching and Evaluation Clinical teacher versus moral teacher Didactic knowledge through examinations and on-the-job competence via observation, preferable of behaviors that can be assessed objectively (not subjectively) Artificial situations (OSCEs) less useful as assessment of moral attitudes different then assessment of interpersonal skills
11	“Experiential Apprenticeship” in Medical Education Allowing learners to acquire the knowledge base of medicine and the capacity to think like a competent physician Allowing learners to acquire the skills necessary for the practice of one of the disciplines of medicine Allowing learners to acquire an understanding of the ethical standards, social roles and responsibilities of the profession so that they grasp the meaning of the profession’s fundamental purpose
12	Enhancing education for professionalism in medicine: Action Agenda Options Enhance the recognition of the relevance of professionalism to key institutional roles and accountabilities Vertically integrated emphasis on professionalism in accreditation Deans, Chairs, Chief Residents: placement of professionalism, exemplary behaviors, improvement and feedback on the organizational agenda Make explicit the role of professionalism in organizational performance and management Integration of professional norms into institutional missions Organization-community dialogue Mechanisms for reviewing and taking action and disseminate summary information for discussion
13	Action Agenda Options cont’d Make explicit the role of professionalism in trainee/physician/program performance within the organization Focus on candidate’s history of meaningful service to others Inclusion of professional quality assessment in dean’s assessment letter Ceremonial events marking milestones in professional development Enhance resources for continued learning and professional development in the hidden curriculum Model positive professional behavior in the teacher/learner relationship M&M conferences without shame/humiliation Promote resources that make explicit the link between personal and professional growth and development Teaching the importance of uncertainty and open-mindedness in medicine Teaching the importance (and limits) of evidence-based medicine, as well as the continuing need for natural science of health care Case studies for problem-based learning curricula that include threats to asserting positive professional qualities
14	Fostering Professionalism: A Four-Pronged Approach 1. Professionalism Role-Modeling Increase in number of physicians who are able to role-model professional virtue at every stage of medical education Full-time faculty members who exemplify virtue in their interactions with patients, staff, trainees, and the community at large Implication of major new financing for medical education (monetary and academic)
15	Fostering Professionalism: A Four-Pronged Approach 2. Self-awareness Providing a safe venue for students and residents to share their experiences and enhance their personal awareness Small-group meetings to discuss difficulties with patients and their personal reactions to practice Understandable that physicians experience frustration, anger, helplessness when dealing with ill patients Change coping mechanism from suppression or rationalization to developing self-awareness beneficial for entire team and improve ability to connect with and ultimately respond to patients’ experiences
16	Fostering Professionalism: A Four-Pronged Approach 3. Narrative Competence Students learn to conceptualize patients in terms of flow sheets rather than personal stories Little time to listen to and lacking skill to experience themselves as characters in the larger narrative The trainee’s own life experience, molded by positive role-modeling and reflective practice, serves as the basic material from which narrative competence may develop Medical school entrance essay – consider addition of exit essay Medical student thesis – experiential as well as scientific
17	Fostering Professionalism: A Four-Pronged Approach 4. Community Service Inclusion of socially relevant service-oriented learning Many different geographic and social levels: locally, regionally, nationally, internationally Clinical care: working in free clinics or third-world countries Public health: stop smoking campaigns Health education: HIV education in high schools Community service: volunteering with groups that provide assistance to third-world countries Political action on health and welfare issues Whatever the specific tasks involved, the minimal required “dose” of community service must be sufficiently large for students to view it as integral to the culture of medical education, rather than an unconnected add-on
18	Fostering Professionalism: A Four-Pronged Approach Each component of the approach: role-modeling, self-awareness, narrative competence, and community service, overlaps with and reinforces the others Each lends itself to longitudinal evaluative processes, such as the creation of narrative-based portfolios Does not discount the experiences of allied health care teams (nursing, social work, chaplaincy, etc)
19	Institutional Approaches University of North Dakota: patient-centered learning (PCL) curriculum University of Texas – Galveston: Project Professionalism – campus-wide charter Vanderbilt University – Professional behavior commitment/addressing unprofessional behaviors University of Pennsylvania – institutional leadership advancement/faculty requirements
20	Scheme for the four-year professionalism-humanism curriculum strategic plan UTMB
21	Evaluation and Grading of Professionalism Professionalism in the eye of the beholder regardless of written definitions Only trainees are subjected to grading based on their behavior (little accountability for faculty) Students have learned that best answer may not be the right answer Students have learned how to avoid trouble, rather than how to exemplify virtues of professionals
22	What Faculty can do Professionalism education to involve consistent education, clear standards, and fair assessment Medical educators must lead by example Professionalism education and evaluation must be top down, starting with the most senior physicians, administrators and staff Faculty need to be trained in evaluation of professionalism Medical educators need hold themselves accountable for any unprofessional behavior
23	Current State of Affairs Reality is that many of the elements for this development are already present, but in most medical schools dispersed too thinly and/or integrated too sparsely to produce a significant impact on the culture of medical education
24	Future directions Cultural change can happen if a relatively small number of well-placed faculty members, curricula, faculty development programs, and institutional supports are brought together Can “reverse” the symptoms of ailing professional culture Already by creating sessions like these, culture is changing for the positive
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