Professionalism
Theory/Concepts/Rationale
- Burack JH, Irby DM, Carline JD, Root RK, Larson EB. Teaching compassion and respect. Attending physicians' responses to problematic behaviors. J Gen Intern Med 1999;14:49-55.
Abstract: OBJECTIVE: To describe how and why attending physicians respond to learner behaviors that indicate negative attitudes toward patients. SETTING: Inpatient general internal medicine service of a university- affiliated public hospital. PARTICIPANTS: Four ward teams, each including an attending physician, a senior medicine resident, two interns, and up to three medical students. DESIGN: Teams were studied using participant observation of rounds (160 hours); in-depth semistructured interviews (n = 23); a structured task involving thinking aloud (n = 4, attending physicians); and patient chart review. Codes, themes, and hypotheses were identified from transcripts and field notes, and iteratively tested by blinded within-case and cross- case comparisons. MAIN RESULTS: Attending physicians identified three categories of potentially problematic behaviors: showing disrespect for patients, cutting corners, and outright hostility or rudeness. Attending physicians were rarely observed to respond to these problematic behaviors. When they did, they favored passive nonverbal gestures such as rigid posture, failing to smile, or remaining silent. Verbal responses included three techniques that avoided blaming learners: humor, referring to learners' self-interest, and medicalizing interpersonal issues. Attending physicians did not explicitly discuss attitudes, refer to moral or professional norms, "lay down the law," or call attention to their modeling, and rarely gave behavior-specific feedback. Reasons for not responding included lack of opportunity to observe interactions, sympathy for learner stress, and the unpleasantness, perceived ineffectiveness, and lack of professional reward for giving negative feedback. CONCLUSIONS: Because of uncertainty about appropriateness and effectiveness, attending physicians were reluctant to respond to perceived disrespect, uncaring, or hostility toward patients by members of their medical team. They tended to avoid, rationalize, or medicalize these behaviors, and to respond in ways that avoided moral language, did not address underlying attitudes, and left room for face-saving reinterpretations. Although these oblique techniques are sympathetically motivated, learners in stressful clinical environments may misinterpret, undervalue, or entirely fail to notice such subtle feedback.
Reprinted with permission by Blackwell Science, Inc.
- Epstein RM. Communication between primary care physicians and consultants. Arch Fam Med 1995;4:403-9.
Abstract: Optimal communication between primary care physicians and consultants includes transfer of relevant clinical information, including the patient's perspectives and values, and provides a means of collaboration to provide meaningful and health-promoting interventions. Communication difficulties arise because of lack of time, lack of clarity about the reason for referral, patient self-referral, and unclear follow-up plans. Also, primary care physicians and consultants may have different core values and may have little day-to-day contact with each other. Poor communication leads to disruptions in continuity of care, delayed diagnoses, unnecessary testing, and iatrogenic complications. Changes in the health care system offer the opportunity for improved collaboration between physicians by creating smaller administrative units within large health care systems that facilitate contact between primary care physicians and consultants; incorporation of discussions of uncertainty, patient preferences, and values into referral letters; adoption of a friendlier consultant letter format; and the improvement of the transfer of clinical data.
Reprinted with permission by Archives of Family Medicine, 1995, 4:403-9, Copyrighted 1995, American Medical Association.
- Epstein RM. Mindful practice. JAMA 1999;282:833-9.
Abstract: Mindful practitioners attend in a nonjudgmental way to their own physical and mental processes during ordinary, everyday tasks. This critical self-reflection enables physicians to listen attentively to patients' distress, recognize their own errors, refine their technical skills, make evidence-based decisions, and clarify their values so that they can act with compassion, technical competence, presence, and insight. Mindfulness informs all types of professionally relevant knowledge, including propositional facts, personal experiences, processes, and know-how, each of which may be tacit or explicit. Explicit knowledge is readily taught, accessible to awareness, quantifiable and easily translated into evidence-based guidelines. Tacit knowledge is usually learned during observation and practice, includes prior experiences, theories-in-action, and deeply held values, and is usually applied more inductively. Mindful practitioners use a variety of means to enhance their ability to engage in moment-to-moment self-monitoring, bring to consciousness their tacit personal knowledge and deeply held values, use peripheral vision and subsidiary awareness to become aware of new information and perspectives, and adopt curiosity in both ordinary and novel situations. In contrast, mindlessness may account for some deviations from professionalism and errors in judgment and technique. Although mindfulness cannot be taught explicitly, it can be modeled by mentors and cultivated in learners. As a link between relationship-centered care and evidence-based medicine, mindfulness should be considered a characteristic of good clinical practice.
Reprinted with permission by JAMA, 1999, 282:833-9, Copyrighted 1999, American Medical Association.
- Frankford DM. The normative constitution of professional power.
J Health Polit Policy Law 1997;22:185-221.
Abstract: This article concerns the manner in which we think and talk about power in health care policy and regulation, and the political and social practices allied with that discourse. I assert that in health care policy and practice we speak of and live within the era of countervailing power. In this language and practice power is a force exercised by one actor to enforce its will against another actor against whom power is exerted. I contend that this language inculcates an individual and social passivity in which citizens rely upon various types of representatives to constitute health care for them in a manner in which they do not and cannot participate. However, this language of power and the political and social practice with which it is associated is merely a contingent, historical product. I claim that an alternative discourse of power is possible, in which power consists of the social interactions in which all of us mutually participate but no one of us can control. Power in this sense is participatory by nature, and because no one is in control, it makes no sense to relegate tasks to specialized, nonparticipatory domains. This alternative discourse of power, therefore, might call forth participatory practices in health care and a concomitant diminution of specialization and expansion of the public sphere. The result would be to blur the lines separating politics from everyday interaction, politics from economy, professionals from patients, and insurers from insureds. Participation would mean much more than casting a vote or writing a check but would also include the mutual sharing of time and energy in the tasks that need to be done: long-term and short-term care, practices of prevention, caring for the chronically ill, and monitoring bureaucratic and professional activities.
Reprinted with permission by Duke University Press
- Gorlin R, Strain J, Rhodes R. Physicians' reactions to patients: what has happened during the past 10 years. Mt Sinai J Med 1996; 63:420-7.
Abstract: New stresses have been added to the medical life of physicians in training during the past decade. These include the newly diverse and complex sociocultural environment of the patient, new and renascent lethal diseases, widespread substance abuse, and the effects of the breakdown of the fabric of our society. These factors complicate the practice of medicine as never before. Educators must keep pace and prepare young physicians to understand and then cope with these major new forces.
- Green MJ. What (if anything) is wrong with residency overwork? Ann Intern Med 1995; 123:512-17.
Abstract: Long work hours during residency are a time-honored tradition. Efforts have recently been made to shorten work hours. This paper examines the main arguments supporting reform: that sleep deprivation is harmful to patients and residents and that it is exploitative. Because the data on the harms and benefits are mixed and because exploitation is difficult to prove, a stronger argument for reducing work hours is an ethical one: that overwork interferes with the development of professional values and attitudes that are an essential part of the moral curriculum of residency. Providing a climate that promotes moral growth during training is an important curricular objective that may be better achieved by shortening work hours, providing better resident supervision, and using substitute workers for some of the noneducational tasks of residency.
Reprinted with permission by American College of Physicians-American Society of Internal Medicine.
- Swick HM, Szenas P, Danoff D, Whitcomb ME. Teaching professionalism in undergraduate medical education. JAMA 1999; 282:830-2.
Abstract: CONTEXT: There is a growing consensus among medical educators that to promote the professional development of medical students, schools of medicine should provide explicit learning experiences in professionalism. OBJECTIVE: To determine whether and how schools of medicine were teaching professionalism in the 1998-1999 academic year. DESIGN, SETTING, AND PARTICIPANTS: A 2-stage survey was sent to 125 US medical schools in the fall of 1998. A total of 116 (92.3%) responded to the first stage of the survey. The second survey led to a qualitative analysis of curriculum materials submitted by 41 schools. MAIN OUTCOME MEASURES: Presence or absence of learning experiences (didactic or experiential) in undergraduate medical curriculum explicitly intended to promote professionalism in medical students, with curriculum evaluation based on 4 attributes commonly recognized as essential to professionalism: subordination of one's self-interests, adherence to high ethical and moral standards, response to societal needs, and demonstration of evincible core humanistic values. RESULTS: Of the 116 responding medical schools, 104 (89.7%) reported that they offer some formal instruction related to professionalism. Fewer schools have explicit methods for assessing professional behaviors (n = 64 [55.2%]) or conduct targeted faculty development programs (n = 39 [33.6%]). Schools use diverse strategies to promote professionalism, ranging from an isolated white-coat ceremony or other orientation experience (n = 71 [78.9%]) to an integrated sequence of courses over multiple years of the curriculum (n = 25 [27.8%]). Of the 41 schools that provided curriculum materials, 27 (65.9%) addressed subordinating self-interests; 31 (75.6%), adhering to high ethical and moral standards; 17 (41.5%), responding to societal needs; and 22 (53.7%), evincing core humanistic values. CONCLUSIONS: Our results suggest that the teaching of professionalism in undergraduate medical education varies widely. Although most medical schools in the United States now address this important topic in some manner, the strategies used to teach professionalism may not always be adequate.
Reprinted with permission by JAMA, 1999, 282:830-2, Copyrighted 1999, American Medical Association.
- Wear D. On white coats and professional development: the formal and the hidden curricula. Ann Intern Med 1998; 1299:734-7.
Abstract: White coat ceremonies are a recent phenomenon in medical education. Selected as a symbol by the Arnold P. Gold Foundation to impress upon medical students the importance of compassion and humility, the white coat has had a long association with all things medical, scientific, and healing. It is also associated with the attributes of purity and goodness traditionally symbolized by the color white. Thus, its selection as the material focus of the white coat ceremony seems natural. This article situates the white coat ceremony as a curricular event and suggests that, in addition to having the meanings cited above, the white coat has other meanings that fall into the realm of the hidden curriculum--it can symbolize caregiving hierarchies and spheres of practice, the social and economic privilege of physicians, and medicine's well-established practices of determining membership in the profession. Finally, this paper suggests several other ceremonies or rituals that may be better than the white coat ceremony for encouraging compassion and humility in medical students.
Reprinted with permission by American College of Physicians-American Society of Internal Medicine.
Teaching-Learning
- DeWitt TG, Roberts KB. Teaching residents about patient and practice termination in community- based continuity settings. Arch Pediatr Adolesc Med 1995; 149:1367-70.
Abstract: BACKGROUND: The pediatric residency program at the University of Massachusetts Medical Center, Worcester, has based its continuity experience in community practices since 1988. Residents develop a relationship not only with their patients but also with the preceptors, with whom they are paired one-on-one, and with office staff. OBJECTIVE: To describe the structure and results of an educational program that was developed to address the termination issues that arise at the end of residency. The educational program consists of four components: (1) a seminar, (2) a "mini-block" rotation, (3) office staff involvement, and (4) a resident-preceptor dinner. RESULTS: The following issues and themes have been recurrent in the discussions during the past 4 years: (1) the importance, for patient and resident, of identifying who will be the subsequent health care provider for the patient; (2) the inability to identify which patients had strongest attachment to residents; (3) parental surprise about the resident's departure, even though all parents had been told that the resident was going to be in the practice for only a limited period; (4) the desire of residents to have follow-up on patients after termination; (5) critical aspects of the process of informing patients about the resident's departure; (6) the importance of identifying and addressing the attachment of the resident to the preceptor and office staff, as well as to patients; and (7) the affirming experience that the termination sessions with the patients can be for the residents. CONCLUSION: Although the termination process is potentially emotionally difficult, it can be a personally and educationally valuable experience for residents.
Reprinted with permission by Arch of Pediatr Adolesc Med, 1995, 149:1367-70, Copyrighted 1995, American Medical Association.
- Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA 1997; 278(6):502-9.
Abstract: Physicians' personal characteristics, their past experiences, values, attitudes, and biases can have important effects on communication with patients; being aware of these characteristics can enhance communication. Because medical training and continuing education programs rarely undertake an organized approach to promoting personal awareness, we propose a "curriculum" of 4 core topics for reflection and discussion. The topics are physicians' beliefs and attitudes, physicians' feelings and emotional responses in patient care, challenging clinical situations, and physician self-care. We present examples of organized activities that can promote physician personal awareness such as support groups, Balint groups, and discussions of meaningful experiences in medicine. Experience with these activities suggests that through enhancing personal awareness physicians can improve their clinical care and increase satisfaction with work, relationships, and themselves.
Reprinted with permission by JAMA, 1997, 278:502-9, Copyrighted 1997, American Medical Association.
- Swick HM, Simpson DE, Van Susteren TJ. Fostering the Professional Development of Medical Students. Teach Learn Med 1995; 7:55-60.
Abstract: Medical education in the 1990s faces many challenges as it prepares graduates to practice in a rapidly changing environment. Recognizing that biomedical knowledge and skills alone are not sufficient preparation for medical practice, the Medical College of Wisconsin has implemented a 2-year curriculum explicitly designed to facilitate medical students' development of their professional identities, with an emphasis on the ability to make reasoned judgments in the fact of uncertainty. Grounded in student development theory, the Profession of Medicine Program (POMP) is structured to challenge medical students' conceptions of the physicians' roles, responsibilities, values, and competencies through a series of short didactic courses and small-group preceptor meetings. Results of a 3-year study designed to evaluate the impact of POMP on students' assumptions about the nature of knowledge and of uncertainty in medicine indicate that POMP students score significantly higher on the Measure of Intellectual Development than do a nonequivalent control group of medical students.
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