Presenter: Carrie Tibbles, M.D., Director of Graduate Medical Education, Designated Institutional Officer Beth Israel Deaconess Medical Center Boston, MA
[The following blog was generated by Susan Ely and Doug McKell]
Teaching Professionalism: Strategies for the Frontline
The Learning Objectives for the second Spring 2024 IAMSE Webinar series on Teaching and
Learning in Medical and Health Professions Education include the following: First, define
professionalism and the process of integrating professional values. Second, review real-time
strategies to address episodes of unprofessional behavior. Third, identify struggling learners
and strategies for remediation and intervention. Fourth, develop a systematic approach to
interventions for learners with academic difficulties and professional or behavioral issues.
Dr. Tibbles began her presentation by focusing on improving learning environments and
hospitals to train the next generation of doctors. She highlighted trends in the last decade that
have impacted clinical learning environments by transmitting professional values to the next
generation, especially those relevant to medical students and residents’ professional identity
formation. She reviewed some good and not-so-good behaviors that could be impacted during
a medical student’s preclinical years to foster more positive attitudes. Dr. Tibbles posed the
following questions as central to understanding professional identity and professional
development, specifically asking attendees to ask themselves and their colleagues: How am I
instilling curiosity? How am I instilling a love of learning? How am I instilling reliability and excitement for this field early on, and how am I helping medical students take those values into
the clinical learning space? Dr. Tibbles contends that how we think about professionalism in the
clinical space needs to be revised. Instead, she suggests a focus on professional values
integration, not simply managing someone’s behavior but helping them tie their behaviors to
the values that will support them throughout their career.
Dr. Tibbles presented information about her group’s work at Beth Israel Deaconess Medical
Center and with other researchers in professional identity formation. She began by providing
two definitions: First, medical professionalism signifies a set of values, behaviors, and
relationships that underpin the public’s trust in doctors. Second, professionalism in medicine
requires the physician to serve the interests of the patient (and community) above his or
her self–interest. Dr. Tibbles pointed out that some enduring characteristics of professionalism,
such as reliability, commitment to lifelong learning, curiosity, altruism, humility, cultural
humility, competence, and compassionate communication skills, are at the core of
professionalism and professional identity. Simultaneously, however, medical education is
evolving and interfacing with emerging tools such as AI. These developments will introduce a
new set of questions on professionalism and what it means to take good care of patients as the
tools, technology, and environment change.
Dr. Tibbles continued her presentation by discussing the concept of wellness in medicine. She
believes that we need to improve the ability of faculty to help students find meaning, purpose,
and joy in their work while incorporating self-care and balance in their lives. The goal is to help
students flourish so they are physically, emotionally, psychologically, and intellectually
prepared to care for others. She stated that this needs to begin early in medical school because
wellness interventions in residency are too late and too little to truly affect the needed
behavior changes. In her view, this is because we aren’t doing enough to truly understand what
makes people well in the workplace and what makes people well in medicine, so it is an area
that we all should be focusing on earlier in a physician’s career path.
Dr. Tibbles shifted her focus to strengthening professionalism and professional identity
formation during the transition from undergraduate to graduate medical education. For faculty
supervising medical students or residents, the question of paramount importance is how
learners view themselves. Are medical students focused on getting good grades, or are they
now concentrating on learning to be the best possible patient caregiver? l Once this transition
occurs, they will be less anxious and more ready to thrive in practice. This transition pertains to
the classroom, where physician skills, attitudes, competencies, and disciplines are discussed.
She further points out that a vital aspect of this transition is discovering that some students are
uncomfortable in the clinical space, especially when they don’t know something. Similarly,
students struggle with the discomfort of training. Unfortunately, some students and residents
confuse some of this discomfort with mistreatment. This is not to say that there isn’t
mistreatment, which certainly warrants attention. Sometimes, however, students need more
time to prepare for the discomfort of clinical training and the unpredictability of providing
direct patient care.
Dr. Tibbles shifted her focus to how the process of caring for patients can put an added burden
on professionalism and professional identity formation. When medical students enter the
clinical environment, they want to behave ethically toward their patients and may feel that the
environment does not support that desire. For example, in a dermatology clinic, a patient needs
an expensive medication, but the provider may not be able to get the patient the medicine they
need. Another example is an environment with healthcare disparities, where different patients
appear to receive different care. These situations are challenging to navigate, especially when
the required actions differ from their personal values. Students experience moral distress when
they feel powerless to change those circumstances. There may also be a culture of silence
around this problem. That leads to moral injury when students ask, “Can I even do this job
anymore?” Dr. Tibbles pointed out that what we want to achieve through our training programs
in medical school and residency are physicians who have enduring values and resilience to
sustain ethical integrity in response to morally complex or distressing situations. She
recommended increasing opportunities for discussion with students about these professional
challenges and how medical systems and structures can be adjusted to make a difference. She
listed five conditions for effectively confronting these problems: authentic role experiences,
longitudinal relationships, intact teams, interdepartmental learning, and safe spaces for
intentional reflection.
Dr. Tibbles described the expectations of professional training by pointing out that we don’t
need perfection – we need reliability, authenticity, honesty, and respectful behavior. The most
challenging problem is dealing with a student who needs better self-awareness, is not sensitive
to others, requires more insight into their behavior, and is resistant to feedback. Suppose pre-
clinical faculty have a student who’s struggling with feedback. In that case, it is essential to
work on it immediately because it later becomes extremely difficult to address it in the fast
pace of residency. She asked us to think about our department’s professionalism challenges.
First, if you are witnessing unprofessional behavior, how long will it be before it’s detected?
Immediately, relatively soon, it takes a while, or never. Ask yourself if unprofessional behavior
slips under the radar in your department because everybody knows each other. Then, ask
yourself the second question: If there is unprofessional behavior in your department, how long
will it take before it’s effectively addressed? Immediately, relatively soon, it takes a while, or
never. The answers to these questions may well expose a gap between how effective our
processes and procedures are in dealing with a trainee or student with issues. Are we getting to
things early? Are we good at early intervention? Or does a pattern develop before something
happens? Or, in some ways, do we let some things go, assuming they’ll get taken care of down
the road?
Dr. Tibbles concluded her presentation by emphasizing the role of faculty as expert teachers,
mentors, coaches, and interprofessional learning examples for students. She recommended
using the R2C2 Facilitated Feedback Model as an excellent tool for faculty to adopt, specifically
the 4 phases of faculty-student relationships: Phase 1: Rapport and Relationship Building,
Phase 2: Exploring Reactions to Feedback – “What do you think?”, Phase 3: Exploring Feedback
Content – “Do they get it?”, and Phase 4: Coaching for Change. This effort is to help medical
students, and residents integrate assisting patients while training for an essential job where patients will rely on them daily. These approaches target the process of increasing professional
responsibility while acquiring the professional identity of our calling and recognizing why our
job is so meaningful.
References:
Rosenbaum, L. (2024). Being Well while Doing Well – Distinguishing Necessary from
Unnecessary Discomfort in Training. N Engl J Med 2024; 390:568-572
DOI: 10.1056/NEJMms2308228
https://www.nejm.org/doi/full/10.1056/NEJMms2308228
Mak-van der Vossen M, van Mook W, van der Burgt S, Kors J, Ket JCF, Croiset G, Kusurkar R.
Descriptors for unprofessional behaviours of medical students: a systematic review and
categorisation. BMC Med Educ. 2017 Sep 15;17(1):164. doi: 10.1186/s12909-017-0997-x. PMID:
28915870; PMCID: PMC5603020.
https://pubmed.ncbi.nlm.nih.gov/28915870/