"Once when i was on call...," theory versus reality in training for professionalism

A modified Delphi approach to nurturing professionalism in postgraduate medical education in Singapore

INTRODUCTION

Nurturing professional identities instils behavioural standards of physicians, and this in turn facilitates consistent professional attitudes, practice and patient care. Identities are socioculturally constructed efforts; therefore, we must account for the social, cultural and local healthcare factors that shape physicians' roles, responsibilities and expectations. This study aimed to forward a programme to nurture professionalism among physicians in Singapore.

METHODS

A three-phase, evidenced-based approach was used. First, a systematic scoping review (SSR) was conducted to identify professionalism elements. Second, a questionnaire was created based on the findings of the SSR. Third, a modified Delphi approach, which involved local experts to identify socioculturally appropriate elements to nurture professionalism, was used.

RESULTS

A total of 124 articles were identified from the SSR; these articles revealed definitions, knowledge, skills and approaches to nurturing professionalism. Through the modified Delphi approach, we identified professional traits, virtues, communication, ethical, self-care, teaching and assessment methods, and support mechanisms.

CONCLUSION

The results of this study formed the basis for a holistic and longitudinal programme focused on instilling professional traits and competencies over time through personalised and holistic support of physicians. The findings will be of interest to medical communities in the region and beyond.

Professionalism: A Core Competency, but What Does it Mean? A Survey of Surgery Residents

OBJECTIVE

Professionalism is 1 of the 6 core competencies of the Accreditation Council of Graduate Medical Education. Despite its obvious importance, it is poorly defined in the literature and an understanding of its meaning has not been evaluated on surgical trainees. The American College of Surgeons (ACS) has previously published tenets of surgical professionalism. However, surgery residents may not share similar views on professionalism as those of the ACS.

DESIGN

Surgical residents of all levels at 2 surgery residencies located in the same city were interviewed regarding their personal definitions, thoughts, and experiences regarding professionalism during their training. They were then queried regarding 20 points of professionalism as outlined by the ACS tenets of professionalism.

SETTING

The study utilized the surgery residencies at William Beaumont Army Medical Center and Texas Tech University Health Science Center in El Paso, Texas.

PARTICIPANTS

All general surgery residents at each program were invited to participate in the study. Eighteen residents volunteered to take the survey and be interviewed.

RESULTS

The definitions of professionalism centered on clinical competence. Surgery residents conveyed experiences with both professional and unprofessional behavior. Seven of the 20 ACS tenets of professionalism were unanimously agreed upon. There were key differences between resident definitions and those as outlined by the ACS. The least agreed upon ACS tenets of professionalism include professionalism education, public education, and public health.

CONCLUSIONS

Surgical trainees express personal experiences in both professional and unprofessional behavior. Their definitions of professionalism are not as expansive as those of the ACS and seem to focus on patient and colleague interaction. Due to the lack of congruency, a tailored curriculum for professionalism based upon ACS tenets appears warranted.

Emergency Medicine Resident Perceptions of Medical Professionalism

INTRODUCTION

Medical professionalism is a core competency for emergency medicine (EM) trainees; but defining professionalism remains challenging, leading to difficulties creating objectives and performing assessment. Because professionalism is dynamic, culture-specific, and often taught by modeling, an exploration of trainees' perceptions can highlight their educational baseline and elucidate the importance they place on general conventional professionalism domains. To this end, our objective was to assess the relative value EM residents place on traditional components of professionalism.

METHODS

We performed a cross-sectional, multi-institutional survey of incoming and graduating EM residents at four programs. The survey was developed using the American Board of Internal Medicine's "Project Professionalism" and the Accreditation Council of Graduate Medical Education definition of professionalism competency. We identified 27 attributes within seven domains: clinical excellence, humanism, accountability, altruism, duty and service, honor and integrity, and respect for others. Residents were asked to rate each attribute on a 10-point scale. We analyzed data to assess variance across attributes as well as differences between residents at different training levels or different institutions.

RESULTS

Of the 114 residents eligible, 100 (88%) completed the survey. The relative value assigned to different professional attributes varied considerably, with those in the altruism domain valued significantly lower and those in the "respect for others" and "honor and integrity" valued significantly higher (p<0.001). Significant differences were found between interns and seniors for five attributes primarily in the "duty and service" domain (p<0.05). Among different residencies, significant differences were found with attributes within the "altruism" and "duty and service" domains (p<0.05).

CONCLUSION

Residents perceive differences in the relative importance of traditionally defined professional attributes and this may be useful to educators. Explanations for these differences are hypothesized, as are the potential implications for professionalism education. Because teaching professional behavior is taught most effectively via behavior modeling, faculty awareness of resident values and faculty development to address potential gaps may improve professionalism education.

Medical professional values and education: a survey on italian students of the medical doctor school in medicine and surgery

Background:

The values such as participation/empathy, communication/sharing, self-awareness, moral integrity, sensitivity/trustfulness, commitment to ongoing professional development, and sense of duty linked to the practice of the medical professionalism were defined by various professional oaths.

Aims:

The aim of this study was to evaluate how these values are considered by the students of the degree course of medicine.

Materials and Methods:

Four hundred twenty three students (254 females, 169 males) taking part of the first, fourth, and fifth years of the degree course in medicine were asked to answer seven questions. Pearson's Chi-square, Wilcoxon rank sum test, and Kruskal–Wallis test were used for the statistical analysis.

Results:

The survey showed a high level of knowledge and self-awareness about the values and skills of medical profession. In particular, the respect, accountability, and the professional skills of competence were considered fundamental in clinical practice. However, the students considered that these values not sufficiently present in their educational experience.

Conclusions:

Teaching methods should be harmonized with the contents and with the educational needs to ensure a more complex patient-based approach and the classical lectures of teachers should be more integrated with learning through experience methods.

In the eye of the beholder: student perspectives on professional roles in practice

CONTEXT

Learning about professional roles in clinical settings is confounded by the gap between espoused theory and the professional practice of the workplace. Workplace learning is grounded in that which is afforded to learners and individuals' engagement with those affordances. The meaning students make of the real-world performance of professional roles and how this relates to formal professionalism frameworks remain unclear. Construal of experience is individual. Professional roles are enacted in the eye of the beholder. In their reflections, student subjectivities, intentionalities and engagement with workplace affordances are revealed. Our research question was: How do students' perspectives of professional roles in practice, revealed through written reflections, relate to the formal professionalism curriculum?

METHODS

Year 3 students (n = 108) wrote reflections during hospital and community placements. Thematic content analysis was performed. A priori categories based on the CanMEDS Physician Roles Framework were used to map content.

RESULTS

A total of 107 students consented to the use of their reflections (n = 315). The CanMEDS roles of Communicator, Professional and Scholar predominated. Students were seen applying prior knowledge to new situations and reflecting on them. For some, the confirmation of previous learning was the outcome; for others, the mismatch between practice and the formal curriculum led to the questioning of both. The roles of Manager, Collaborator and Health Advocate were less frequently reflected upon. Differences between the affordances of hospital and community placements were seen. Means to address findings are discussed with reference to Billett's duality of workplace learning.

CONCLUSIONS

Reflective narratives reveal how students construe professional roles in practice. Mapping the content of reflections to a competency framework confirmed the mismatch between the formal and enacted curricula. Billett's duality of workplace learning provides a useful lens through which to identify means to address this, through the structural aspects of access and guidance, and through the promotion of individual engagement and reflection.

Lessons from medical students' perceptions of learning reflective skills: a multi-institutional study

BACKGROUND

A core competency during undergraduate medical training is the development of reflective learning. The current literature is limited to demonstrating how reflective learning has been implemented or the approaches to its development. There is a lack of insight into students' perceptions of reflection and the factors that support development of reflective practice. Bridging this gap may provide insight into how reflective learning within the curriculum can be better developed to increase engagement from learners.

METHODS

Eight focus group interviews with second year students from four UK medical schools were held. Results were thematically analysed.

KEY FINDINGS

Students have a high level of understanding of the purpose of reflection in practice but they perceive that there is a tension between public and private reflections. Assessment of the reflective process was perceived to be useful for developing reflective skills but grading of their reflective writing was not considered to be useful. Staff who champion the development of reflective skills and mentor students were perceived to play key roles in aiding the development of reflective skills. Appropriate experiences were seen to be a key part of developing reflective skills.

CONCLUSION

These findings highlight potential ways to revise and improve engagement with the reflective learning components of undergraduate courses.

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.

The trouble with assessing students' professionalism: theoretical insights from sociocognitive psychology

The academic literature on professionalism assessment in medical education is burgeoning, and its focus has primarily been on the assessment of professional behaviors. Consequently, the attitudinal elements of professionalism have largely been ignored in the literature. As a result, educators chiefly rely on professional behavior alone as the primary measure for professionalism without giving proper consideration to students' underlying attitudes. Using theoretical insights from sociocognitive psychology, this viewpoint article begins by discussing the relationship between attitudes and behaviors. It suggests that attitudes are poor predictors of behavior when external constraints, such as social pressure to behave in a particular way, are strong. It continues with a critical examination of the phenomenon of "faking it"--students faking professional behaviors to garner positive reactions from observers. This practice is contrasted with students who at times behave unprofessionally in response to social pressures or other contextual components, despite having professional attitudes. So, in using behavioral assessment alone, we may pass students with professional behaviors but unethical attitudes and fail students with unprofessional behaviors but ethical attitudes. Guided by a sociocognitive model of behavioral explanation, the article ends with some practical recommendations for coupling observation with conversation to assess students' professional behaviors and their attitudes more fairly.

Responding to the professionalism of learners and faculty in orthopaedic surgery

Recent developments in assessing professionalism and remediating unprofessional behavior can curtail the inaction that often follows observations of negative as well as positive professionalism of learners and faculty. Developments include: longitudinal assessment models promoting professional behavior, not just penalizing lapses; clarity about the assessment's purpose; methods separating formative from summative assessment; conceptual and behavioral definitions of professionalism; techniques increasing the reliability and validity of quantitative and qualitative approaches to assessment such as 360-degree assessments, performance-based assessments, portfolios, and humanism connoisseurs; and systems-design providing infrastructure support for assessment. Models for remediation have been crafted, including: due process, a warning period and, if necessary, confrontation to initiate remediation of the physician who has acted unprofessionally. Principles for appropriate remediation stress matching the intervention to the cause of the professional lapse. Cognitive behavioral therapy, motivational interviewing, and continuous monitoring linked to behavioral contracts are effective remediation techniques. Mounting and maintaining robust systems for professionalism and remediating professional lapses are not easy tasks. They require a sea change in the fundamental goal of academic health care institutions: medical education must not only be a technical undertaking but also a moral process designed to build and sustain character in all its professional citizens.

Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements

BACKGROUND

The Accreditation Council for Graduate Medical Education duty hour requirements may affect residents' understanding and practice of professionalism.

OBJECTIVE

We explored residents' perceptions about the current teaching and practice of professionalism in residency and the impact of duty hour requirements.

DESIGN

Anonymous cross-sectional survey.

PARTICIPANTS

Internal medicine, neurology, and family practice residents at 3 teaching hospitals (n=312).

MEASUREMENTS

Using Likert scales and open-ended questions, the questionnaire explored the following: residents' attitudes about the principles of professionalism, the current and their preferred methods for teaching professionalism, barriers or promoters of professionalism, and how implementation of duty hours has affected professionalism.

RESULTS

One hundred and sixty-nine residents (54%) responded. Residents rated most principles of professionalism as highly important to daily practice (91.4%, 95% confidence interval [CI] 90.0 to 92.7) and training (84.7%, 95% CI 83.0 to 86.4), but fewer rated them as highly easy to incorporate into daily practice (62.1%, 95% CI 59.9 to 64.3), particularly conflicts of interest (35.3%, 95% CI 28.0 to 42.7) and self-awareness (32.0%, 95% CI 24.9 to 39.1). Role-modeling was the teaching method most residents preferred. Barriers to practicing professionalism included time constraints, workload, and difficulties interacting with challenging patients. Promoters included role-modeling by faculty and colleagues and a culture of professionalism. Regarding duty hour limits, residents perceived less time to communicate with patients, continuity of care, and accountability toward their colleagues, but felt that limits improved professionalism by promoting resident well-being and teamwork.

CONCLUSIONS

Residents perceive challenges to incorporating professionalism into their daily practice. The duty hour implementation offers new challenges and opportunities for negotiating the principles of professionalism.

Community paediatrics: soft science or firm foundations?

Community paediatrics strives to integrate the biology of health into the social and psychological worlds within which children grow and develop. Consumer demand for limited community paediatric clinical services is increasing and medico-legal pressures escalate professional and personal concern. Meanwhile, the profession, through training and professional support, has struggled to keep up. Research into community paediatrics and its integration into policy and clinical practice remains limited, raising the perception that it is a 'soft' science. Our viewpoint is that necessary progress in this field requires leadership, apprenticeship and research. We argue that to build firm foundations for the future requires structures to enable clinical specialisation and continuing professional development in this area.