Renewing professionalism: an opportunity for medicine

The Presence of Ghost Publications Among Canadian Plastic Surgery Residency Applicants: How Honest Are Canadians?

Background:

Physicians with history of unprofessional behaviour during their medical training are shown to be 3 times more likely to have board disciplinary action later in their career. One realm in which unprofessional behaviour takes place is the phenomenon of unverifiable publications or “ghost publications.” To that end, this study aims to assess the rate of ghost publications among a recent cohort of Canadian Plastic Surgery residency applicants to determine if this phenomenon is geographic in nature.

Methods:

The current study was a retrospective, cross-sectional observational study; a review of all residency applications submitted to a single Canadian Plastic Surgery residency program from 2015 to 2018 was performed and all their listed publications were verified for accuracy. The review was conducted by a third party librarian and a research coordinator blinded to the authors identifying information. “Ghost publication” was defined as any publication listed as “published,” “accepted,” or “in-press” that did not exist in the literature.

Results:

A total of 196 applications of 186 applicants were submitted over the span of 4 years. A total of 362 publications listed as peer-reviewed articles, belonging to 114 applications were extracted and reviewed. Among the 362 publications listed as peer-reviewed articles, 2 could not be found in the literature (0.55%). Additionally, 42 citations were found with 48 minor differences than what was cited.

Conclusions:

The rate of ghost publications among recent applicants to a Plastic Surgery residency program is low (less than 1%). Future studies should investigate methods to further improve and instill the value of professionalism in our future plastic surgery trainees.

Utilizing Psychodynamic Principles to Teach Professionalism to Medical Students Through an Innovative Curriculum

Professionalism is a fundamental expectation of practicing medicine and a core competency in medical education, yet the methods of how to teach and evaluate it are still experimental. Professionalism involves self-reflection, a psychodynamic understanding of the patient's and the doctor's predicament, and conflict resolution, so psychiatrists are uniquely qualified to teach it. This article describes an innovative course that utilizes psychodynamic principles to teach professionalism to medical students. The authors present a novel 2-year curriculum for teaching professionalism to first- and second-year medical students utilizing psychodynamic principles to help develop awareness of others' feelings and motivations, self-reflection, compassion, empathy, and skills in ethical conflict resolution by means of written and oral narrative exercises. Outcomes are evaluated by the student ratings about the course and the faculty, and by using the test for emotional intelligence (EI), administered as a baseline and then at the end of each year. Each subsequent year the students demonstrated a statistically significant increase in EI scores, student evaluations of the course ranked among the highest in the medical school, clerkship supervisors and residency training directors noted the high degree of professionalism of the students, and the number of student applicants to psychiatry residency were consistently higher than the national average. In addition, this course was awarded the 2018 Alpha Omega Alpha Honor Medical Society's Edward B. Harris Medical Professionalism Award for the best professionalism course of U.S. medical schools. Psychodynamic principles are fundamental for teaching medical professionalism at a medical-student level. Professionalism also serves as a way to introduce students to psychiatry early in the curriculum, and psychiatrists and other mental health professionals are uniquely qualified to teach medical professionalism.

Professional Competence and Palliative Care: An Ethical Perspective

The aim of this article is to explore an ethical view of professional competence by examining the professional competence of physicians in the context of palliative care. A discussion of the four dimensions of professional competence—knowledge, technical skills, relationships, and affective and moral attitude—leads us to the conclusion that “habits of mind” are important in every aspect of professional competence. This observation is then considered in the context of virtue ethics and ethics of care. Virtue ethics focuses on personal qualities and moral attitudes, while the ethics of care concentrates on the way these qualities are lived out in specific care relationships. Our conclusion points up the importance of education in ethics in the development of professional competence, and argues that because palliative care involves intense human interactions, integrating palliative care into the medical curriculum may improve the ethical culture of health care as a whole.

A Professionalism Curricular Model to Promote Transformative Learning Among Residents

BACKGROUND

Using the frameworks of transformational learning and situated learning theory, we developed a technology-enhanced professionalism curricular model to build a learning community aimed at promoting residents' self-reflection and self-awareness. The RAPR model had 4 components: (1) Recognize: elicit awareness; (2) Appreciate: question assumptions and take multiple perspectives; (3) Practice: try new/changed perspectives; and (4) Reflect: articulate implications of transformed views on future actions.

OBJECTIVE

The authors explored the acceptability and practicality of the RAPR model in teaching professionalism in a residency setting, including how residents and faculty perceive the model, how well residents carry out the curricular activities, and whether these activities support transformational learning.

METHODS

A convenience sample of 52 postgraduate years 1 through 3 internal medicine residents participated in the 10-hour curriculum over 4 weeks. A constructivist approach guided the thematic analysis of residents' written reflections, which were a required curricular task.

RESULTS

A total of 94% (49 of 52) of residents participated in 2 implementation periods (January and March 2015). Findings suggested that RAPR has the potential to foster professionalism transformation in 3 domains: (1) attitudinal, with participants reporting they viewed professionalism in a more positive light and felt more empathetic toward patients; (2) behavioral, with residents indicating their ability to listen to patients increased; and (3) cognitive, with residents indicating the discussions improved their ability to reflect, and this helped them create meaning from experiences.

CONCLUSIONS

Our findings suggest that RAPR offers an acceptable and practical strategy to teach professionalism to residents.

Nationwide study of publication misrepresentation in applicants to residency

OBJECTIVES

This study was conducted to assess the prevalence of research publication misrepresentation amongst Canadian Resident Matching Service (CaRMS) applicants to a single surgical subspecialty residency as a potential means of assessing professional behaviour.

METHODS

The authors reviewed CaRMS application forms to Canadian otolaryngology residency programmes over a 3-year period (2006-2008) for peer-reviewed publications reported as 'published', 'accepted' and 'in press'. Citations were verified by searching PubMed, Google Scholar and electronic journals. Misrepresentation was defined as any of: (i) falsely claimed authorship of an existing article; (ii) claimed authorship of a non-existing article, and (iii) improper ordering of authorship. Outcomes included descriptive statistics, as well as sub-analyses pertaining to age, gender, affiliated medical school and academic degree, and number of publications per applicant.

RESULTS

A total of 427 peer-reviewed publications were reported by 124 of 182 applicants (68% of applicants reported at least one publication). Of the 385 verifiable publications, 47 (12% of articles) were misrepresented by 29 applicants (23% of applicants claiming publication) self-reporting at least one publication. Age, gender, location of medical training, prior academic degree and number of citations per applicant did not relate to likelihood of misrepresentation (p > 0.05).

CONCLUSIONS

This study documents the nationwide prevalence of publication misrepresentation amongst applicants to Canadian otolaryngology residency programmes. The high rate of misrepresentation aligns with data reported in the literature and highlights the need to institute measures to dissuade graduates from this form of unprofessional behaviour.

Teaching and Assessing Professionalism in Ophthalmology Residency Training Programs

The Accreditation Council for Graduate Medical Education (ACGME) has mandated that all residency training programs teach and assess new competencies including professionalism. This article reviews the literature on medical professionalism, describes good practices gleaned from published works, and proposes an implementation matrix of specific tools for teaching and assessing professionalism in ophthalmology residency. Professionalism requirements have been defined by the ACGME, subspecialty organizations, and other certifying and credentialing organizations. Teaching, role modeling, and assessing the competency of professionalism are important tasks in managing the ACGME mandate. Future work should focus on the field testing of tools for validity, reliability, feasibility, and cost-effectiveness.

Core competencies in dermatopathology

Medical education has traditionally focused on imparting medical knowledge, delivering quality patient care, and teaching research methodology. Various measures of success, including standardized testing, have been developed to assess the achievement of those goals. These measures then served as documentation of the effectiveness of individual training programs. However, in 1999, the Accreditation Council for Graduate Medical Education (ACGME) changed the way we measure the success of medical education. They developed six core competencies for medical education and assigned the task of enforcing them to the individual Residency Review Committees. By July 2006, all accredited programs, including dermatopathology fellowships, must use measurable, competency-based objectives, and assess achievement of those objectives. Programs should also be documenting ways they are improving the evaluation process. They must be in full compliance with implementation, measurement, and assessment of the six core competencies for accreditation. The next phase required by the ACGME involves developing curriculum based on competencies as well as using resident, fellow, or graduate competency performance to assess success in preparing trainees for the practice of medicine. This manuscript discusses measurable objectives to address the core competencies for dermatopathology fellowship training as well as dermatopathology rotations in dermatology and pathology residency training.

Proto-professionalism and the dissecting laboratory

This essay argues for medical students' dissection of cadavers because this activity offers medical students opportunities to have certain experiences and reflect on them in ways facilitating their development of mature medical professionalism at the time they enter clinical practice. Issues central to professionalism as we envision it are (1) cognitive abilities identified as reflective judgment and principled ethical reasoning as they are exercised in four practice domains and (2) learning to learn in medical settings. We argue further that a key feature of such setting is practitioners' having to deal with ill-structured problems, and so we identify their features and relate their management to the sophisticated cognitive and learning abilities required of medical professionals.

Professionalism and team care in the clinical setting

The introduction of an 80-hr work week mandates frequent sign-out or transfer of patient information sessions among training physicians. At the same time, patients are increasingly more complex and cared for by teams employing technologically driven interventions. In order for team care to work, residents and medical students must master the elements of professionalism, upon which solid leadership and clear communication rests. Early instruction should include topics, such as clarity of language, cultural sensitivity, a subordination of self-interest to the needs of the patient, and a dedication to lifelong learning of cognitive and motor skills. This exposure to professionalism may begin in the dissection room and continue seamlessly through residency and into practice.

Patient Evaluations of Pharmacist Performance with Variations in Attire and Communication Levels

OBJECTIVE

To determine whether the attire of a pharmacist has any effect on how he is evaluated when a patient also considers the pharmacist's performance and to assess whether attire and performance interact to influence patients' evaluations.

DESIGN

Randomized, cross-sectional, three-factor design.

SETTING

Community pharmacy settings were portrayed.

PARTICIPANTS

179 university staff members.

INTERVENTIONS

Videos of pharmacist-patient interactions were encoded and placed on a Web site to be viewed by participants.

MAIN OUTCOME MEASURES

Service encounter satisfaction, perceptions of overall service quality, trust in the service provider, and behavioral intentions based on two levels of pharmacist communication performance (high or adequate), three levels of dress style (casual, business casual, formal), and two levels of white coat (wearing or not).

RESULTS

Of the three independent variables, only communication performance was found to significantly influence the dependent variables. High communication performance resulted in higher satisfaction scores, higher perceptions of quality, higher levels of trust, and behavioral intention scores that reflected a greater willingness to use and recommend the pharmacist.

CONCLUSION

Style of dress or whether the pharmacist was wearing a white coat did not significantly influence participants' evaluations of the pharmacist in this study. Rather, the level of the pharmacist's communication performance was the most important cue used by participants in their ratings of service encounter satisfaction, perceptions of overall service quality, and trust in the service provider.

Proto-professionalism: how professionalisation occurs across the continuum of medical education

INTRODUCTION

Professionalism and its assessment across the medical education continuum have become prominent topics in recent years. We consider the nature of professionalism and how it emerges and relates to the work carried out by doctors and doctors-in-training.

THESIS AND DISCUSSION

We suggest 6 domains in which evidence of professionalism can be expected: ethical practice; reflection/self-awareness; responsibility for actions; respect for patients; teamwork, and social responsibility. Furthermore, we propose that a defining characteristic is encapsulated by the Greek term phronesis, or practical wisdom. Phronesis is acquired only after a prolonged period of experience (and reflection on experience) occurring in concert with the professional's evolving knowledge and skills base. The prior period we have termed as one of 'proto-professionalism'. Influences on proto-professionalism are considered in terms of moral and psychosocial development and reflective judgement.

CONCLUSION

Curricula that develop meta-skills will foster the acquisition and maintenance of professionalism. Adverse environmental conditions in the hidden curriculum may have powerful attritional effects.

Death rates of medical school class presidents

Medical professionals often face many competing demands to contribute both to the clinical care of patients and to the public health of society. We studied the long-term survival of doctors graduating from one medical school over one century (n = 1521), comparing those who were presidents of their class to those who appeared alphabetically before or alphabetically after the president in the graduating class photograph. Statistics on long-term mortality were obtained from licensing authorities, medical obituaries, professional associations, alumni records, and national physician directories (follow-up 94% complete, median follow-up duration = 38 years, total deaths = 220). We found that most graduates were male (88%), white (93%), and younger than 30 years at time of graduation (93%). Presidents more frequently made contributions to society than their classmates, as recognized by professional alumni notices (21.9% vs. 13.3%, P < 0.001) and Who's Who directory listings (7% vs. 0.5%, P < 0.001). Nonetheless, survival after medical school was 2.4 years shorter for presidents than their classmates (49.0 vs. 51.4, P = 0.036). The decrease in life-expectancy was unrelated to medical school marks or early career mortality and was accentuated after adjustments for birth year, gender, race, and specialization (P = 0.001 ). We suggest that the type of medical professional who sacrifices themselves for this type of professional prestige may also be the type who fails to look after their health or is otherwise prone to early mortality.

Cardiac anesthesiology, professionalism and ethics: a microcosm of anesthesiology and medicine

The granting of professional status to medicine by society at large entails obligations by physicians. Those physicians in the young subspecialty of cardiac anesthesiology have fulfilled these obligations by developing a body of scientific and clinical knowledge and the technical bases to increase survival and decrease morbidity of patients with heart disease undergoing either cardiac or noncardiac surgery. Furthermore, they have contributed effectively to the broad practice of medicine. However, a strong argument can be made that these contributions, though benefiting many individual patients, do not by themselves completely fulfill our obligations. The concept of Civic Professionalism states that our moral responsibilities as physicians must be expanded beyond our immediate patients. Physicians have the obligation to use their knowledge and influence to promote the common good. The Universal Declaration of Human Rights includes access to health care as a basic tenet. The present health care system of the United States excludes many people. Thus, cardiac anesthesiologists have a moral obligation to actively advocate for universal access to health care until it is achieved. Doing so will make the specialty of cardiac anesthesiology an example to the entire profession of medicine.

IMPLICATIONS

Cardiac anesthesiologists have contributed to enhanced survival and decreased morbidity of patients with heart disease undergoing surgery. These achievements do not by themselves fulfill the moral obligations incurred by the concept of Civic Professionalism, however. Cardiac anesthesiologists, in common with all physicians, must share the obligation to advocate for the human right of universal access to health care.

"Profession": a working definition for medical educators

PURPOSE

To provide a working definition of professionalism for medical educators.

SUMMARY

Thus far, the literature has not provided a concise and inclusive definition of the word profession. There appears to be a need for one as a basis for teaching the cognitive aspects of the subject and for evaluating behaviors characteristic of professionals. Furthermore, a knowledge of the meaning of the word is important as it serves as the basis of the contract between medicine and society, and hence, of the obligations required of medicine to sustain the contract. A definition is proposed based on the Oxford English Dictionary and the literature on the subject. It is suggested that this can be useful to medical educators with responsibilities for teaching about the professions, professional responsibilities, and professional behavior.

CONCLUSIONS

The proposed definition is as follows: Profession: An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.

Linking health and ecology in the medical curriculum

Human health vulnerabilities to ecosystem degradation are well documented. Destabilization of natural ecosystems and the biosphere have posed an entirely new set of risks to human health and preclude any simple extrapolations from the past. Newly emerging diseases, increasing prevalence of many vector borne diseases, increased exposure to harmful UV radiation and a number of other transformations in the natural environment, have decidedly negative implications for the sustainability of human health. Curricula in medical schools are responding to these new realities by exposing the connections between health and ecology. The program in Ecosystem Health at the University of Western Ontario serves as one model for connecting these disciplines. This program has resulted in a perceptible shift in values and professional responsibilities of emerging physicians.

Teaching professionalism to residents

The need to teach professionalism during residency has been affirmed by the Accreditation Council for Graduate Medical Education, which will require documentation of education and evaluation of professionalism by 2007. Recently the American Academy of Pediatrics has proposed the following components of professionalism be taught and measured: honesty/integrity, reliability/responsibility, respect for others, compassion/empathy, self-improvement, self-awareness/knowledge of limits, communication/collaboration, and altruism/advocacy. The authors describe a curriculum for introducing the above principles of professionalism into a pediatrics residency that could serve as a model for other programs. The curriculum is taught at an annual five-day retreat for interns, with 11 mandatory sessions devoted to addressing key professionalism issues. The authors also explain how the retreat is evaluated and how the retreat's topics are revisited during the residency, and discuss general issues of teaching and evaluating professionalism.

Professionalism for medicine: opportunities and obligations

Physicians' dual roles - as healer and professional - are linked by codes of ethics governing behaviour and are empowered by science. Being part of a profession entails a societal contract. The profession is granted a monopoly over the use of a body of knowledge and the privilege of self-regulation and, in return, guarantees society professional competence, integrity and the provision of altruistic service. Societal attitudes to professionalism have changed from supportive to increasingly critical - with physicians being criticised for pursuing their own financial interests, and failing to self-regulate in a way that guarantees competence. Professional values are also threatened by many other factors. The most important are the changes in healthcare delivery in the developed world, with control shifting from the profession to the State and/or the corporate sector. For the ideal of professionalism to survive, physicians must understand it and its role in the social contract. They must meet the obligations necessary to sustain professionalism and ensure that healthcare systems support, rather than subvert, behaviour that is compatible with professionalism's values.

Ethical and professional issues in pathology: a survey of current issues and educational efforts

Professionalism, including ethics, has assumed greater importance in residency education, and the Accreditation Council for Graduate Medical Education now requires its incorporation into residency training. Insight into current ethics education, as well as those ethical issues important to pathology, would be efficacious. A mail survey was sent to all members of the Association of Pathology Chairs that asked for specific information related to pathology resident education in ethics and identification of important ethical issues in the current practice of pathology. A total of 148 surveys were mailed, and 53 (35.8%) were returned. Formal instruction in ethics is provided by approximately 62% of pathology residency training programs, and 94% provide informal ethics education. However, 84% of programs believed that ethical issues were underrecognized, and 38% believed that current ethics training was inadequate. Issues regarding the use of tissue for research, confidentiality and privacy, and professionalism were identified as the most important ethical issues currently encountered in pathology.

Assessing professional behavior: yesterday, today, and tomorrow

PURPOSE

The author interprets the state of the art of assessing professional behavior. She defines the concept of professionalism, reviews the psychometric properties of key approaches to assessing professionalism, conveys major findings that these approaches produced, and discusses recommendations to improve the assessment of professionalism.

METHOD

The author reviewed professionalism literature from the last 30 years that had been identified through database searches; included in conference proceedings, bibliographies, and reference lists; and suggested by experts. The cited literature largely came from peer-reviewed journals, represented themes or novel approaches, reported qualitative or quantitative data about measurement instruments, or described pragmatic or theoretical approaches to assessing professionalism.

RESULTS

A circumscribed concept of professionalism is available to serve as a foundation for next steps in assessing professional behavior. The current array of assessment tools is rich. However, their measurement properties should be strengthened. Accordingly, future research should explore rigorous qualitative techniques; refine quantitative assessments of competence, for example, through OSCEs; and evaluate separate elements of professionalism. It should test the hypothesis that assessment tools will be better if they define professionalism as behaviors expressive of value conflicts, investigate the resolution of these conflicts, and recognize the contextual nature of professional behaviors. Whether measurement tools should be tailored to the stage of a medical career and how the environment can support or sabotage the assessment of professional behavior are central issues. FINAL THOUGHT: Without solid assessment tools, questions about the efficacy of approaches to educating learners about professional behavior will not be effectively answered.