Professionalism in GME: Defining and Measuring Professionalism

Professionalism in GME:Defining and Measuring Professionalism David T. Stern, MD, PhD Vice Chair for Professionalism Mount Sinai School of Medicine Albert Einstein College of Medicine 11 May 2010

Defining and Measuring Professionalism • What is (and is not) “professionalism” • How can we measure something as “subjective” as professionalism? • 4 measures of professionalism

What is a Profession? • An occupation for which the necessary preliminary training is intellectual in character . . . • . . . Pursued largely for others and not merely for one’s self • . . . In which the amount of financial return is not the accepted measure of success. Louis Brandeis, Brown University Commencement, 1912

What is a Professional? • A professional has command of a special body of knowledge and skills. • A professional is given specific rights not generally provided to the public. • A professional has specific responsibilities or duties not generally expected of the public. Cruess and Cruess 2000

Professionals have specialized knowledge and skills • Physicians: Therapies, surgical procedures • Lawyers: Details of the content and process of the law (local, state, and federal) • Clergy: Religious ritual and scriptural interpretation

Professionals havespecific rights • Physicians: Asking private questions, prescribing narcotics, performing operations • Lawyers: Lawyer-Client privilege • Clergy: Participation, leadership, and access to certain religious rituals

Common Elements • Excellence • Humanism • Accountability • Altruism Arnold L. Acad Med, May 2002.

Excellence • A commitment to competence • Lifelong learning • Continuous quality improvement • Promotion of scientific knowledge

Humanism • Caring, compassion, empathy • Honor and integrity • Respect for patients and their families

Humanism “Humanism is the passion that animates authentic professionalism. Humanism is a way of being. It comprises a set of deep-seated personal convictions about one’s obligations to others, especially others in need.” Jordan Cohen, Acad Med 2007

Accountability • “procedures and processes by which one party justifies and takes responsibility for its activities” • Responsibility to: patients, families, society • Accountability for: quality care, upholding principles, managing conflicts of interest • Self and professional regulation

Altruism • The interests of patients should guide behavior more than the interests of the individual physician. • Can be part of excellence, humanism, or accountability

Professionalism Excellence Humanism Accountability Altruism Ethical and Legal Understanding Communication Skills Clinical Competence (Knowledge of Medicine) Arnold and Stern, 2006 Arnold and Stern, 2006

The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy. Martin Luther King Jr.Strength to Love, 1963 . . . and wise application . . .

Three Ways to Promote Professionalism • Expectations • Experiences • Evaluation Stern and Papadakis, 2006

How to Measure the “Subjective” • Connoisseurship • Criticism • Choice

Connoisseurship A means through which the complexities of situations can be noticed; it is a way of seeing what is subtle and significant. Elliot Eisner

Criticism The reeducation of perception. It is intended to illuminate through commentary or narrative what is subtle but significant in a situation so that those less sophisticated in a particular domain can come to see what they had not. Elliot Eisner

Purpose of Measurement To provide the tools with which you can convert connoisseurship into criticism in a formal and consistent manner.

Choice:For What Purpose are you Measuring? • To select (summative) • Allows the comparison of students • Provides information for feedback • Could identify residents not fit to practice • To improve (formative) • Does not allow for comparisons • Intended purpose is for feedback • More likely to be honest and critical

Four Examples • Administrative Data • Self-Evaluation • Faculty • Patients

Administrative Evaluations • Cohort study of the entering Class of 1995 at University of Michigan medical school • Question: What predicts professional behavior in the clinical years? • Nothing from the admissions packet • Evaluation completion • Immunization compliance Stern et al., 2005

Actual vs. Self Assessed Performance Stern et al., 2005

Faculty Evaluations • Identified all Federation of State Medical Board sanctions for unprofessional behavior from graduates of 3 medical schools • Selected 2 controls for each case by year of graduation and specialty • Abstracted all student records, looking for any grades, indications or evaluations that comment on professionalism

AECOM Student Evaluation • Professional Attributes • Exhibits compassion, advocates for his/her patients • Reliability, attendance • Willingness to “pitch in” • Ability to bridge potential barriers of social class, gender, ethnicity, disability • Willingness to elicit and respond constructively to feedback • Overall interpersonal effectiveness

Predictive Validity of Faculty Evaluations Papadakis, Teherani, Banach, Knettler, Rattner, Stern, Veloski, Hodgson, NEJM 2005

Important Types of Behavior

Patient Concerns Cumulative Distribution of Physician Cohort Members and Unsolicited Complaints Hickson GB, et al., JAMA. 2002;287:2951-2957.

Why Measure Professionalism? • To identify a few in need • To honor and support many • To create a culture of professionalism for all And • To ensure public trust

Special Thanks • Arnold P. Gold Foundation for Humanism in Medicine • Institute on Medicine as a Profession • Research Collaborators: • University of California, San Francisco • Maxine Papadakis • University of Michigan • Alice Frohna, Barbara Kritt, Paul Gauger, Larry Gruppen, James Woolliscroft • University of Missouri, Kansas City • Louise Arnold, Carrie Shue • University of Toronto: • Shiphra Ginsburg, Brian Hodges, Lorelei Lingard, Nancy McNaughton, Glenn Regehr

Professionalism in GME: Defining and Measuring Professionalism