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Hello, my name is Ann Gronowski. I am a Professor of Pathology & Immunology and Obstetrics fixed & Gynecology at Washington University School of Medicine. Welcome to this Pearl of Laboratory Medicine on “Medical Professionalism.”
The term "professionalism" is one we hear a lot these days. The Miriam-Webster Dictionary defines professionalism as "the skill, good judgment, and polite behavior that is expected from a person who is trained to do a job well."
A quick search of the term “professionalism” on the Internet will return a whole host of resources for assessing and improving professionalism, regardless of your occupation, such as this one that suggest things like:
- Make being on time a priority
- Don’t be a grump
- Dress appropriately
- Watch your mouth
- Offer to help colleagues
- Don’t gossip
- Try to stay positive
- Don’t hide from your mistakes
- Always fight fair
- Don’t lie
- Don’t air your dirty laundry
These are good tips no matter what your profession you’re in, but because medical professionals have such an important job, they are held to even higher standards of professionalism.
Some say that the concept of medical professionalism can be traced back to the Hippocratic Oath. Many people think the Hippocratic Oath is "First, do no harm", but in fact it relates to professionalism.
Perhaps the best published description of medical professionalism is the Charter on Medical Professionalism published in 2002 jointly by ABIM Foundation, American Board of Internal Medicine; ACP-ASIM Foundation, American College of Physicians-American Society of Internal Medicine; and the European Federation of Internal Medicine.
The charter also lists 10 professional responsibilities which require a commitment to:
- Professional competence
- Honesty with patients
- Patient confidentiality
- Maintaining appropriate relations with patients
- Improving quality of care
- Improving access to care
- Just distribution of finite resources
- Scientific knowledge
- Maintain trust by managing conflicts of interest
The document contains additional descriptions of each of these 10 responsibilities. To what extent do practicing physicians agree with and act consistently within the domains of this charter?
Well, in 2007, Campbell et al published a report that addressed these 2 questions. The authors first developed a set of questions to measure physician support for the professional norms.
Then, they developed a set of questions that assessed behaviors. They randomly selected 3504 physicians from 6 subspecialties listed in the 2003 AMA Masterfile. 1662 completed the questionnaire.
This table shows physician attitudes towards the 10 professional norms listed in the previous slide. There are a few things to note. The survey did not have any questions that assessed attitudes towards patient confidentiality. Second, there were some categories that had more than one question; hence, there is more than one number in the right hand column. More than 90% of physicians agreed with 8 of the 12 normative statements regarding professionalism posed in the survey. Agreement fell below 80% only for one question about recertification under "professional competence."
Here, we can compare the left-hand column, which is the self-reported behaviors. The extent to which the behaviors were consistent with the opinions varied with each specific norm. For instance, 96% of physicians stated that they felt physicians should report all instances of significantly impaired or incompetent colleagues (under professional responsibilities), yet 45% indicated that they had not reported at least once. In addition although there was not a question about patient confidentiality in the agreement with the norms, 11% of physicians indicated that they had inappropriately revealed information about a patient.
A limitation of this paper is the quality of the questions. For instance, for the question on scientific knowledge, the responses would seem to indicate that physicians do not conform to norms in scientific knowledge with only 10 and 41% answering that they conform to the norms. However, upon closer examination, the questions in this survey were: “Have you served as a reviewer for a scientific journal?” and “Have you encouraged a patient to enroll in a scientific study?” I suspect the average physician has done neither; therefore, the results need to be viewed within the context of the specific questions that were given. The paper does demonstrate nearly universal acceptance of the key professional norms but suggest that there may be opportunities to improve conformance to those norms.
What about residents in training? What kind of professionalism should they conform to? This word cloud was created by Jacob Steinberg of Albert Einstein College of Medicine based on the unpublished survey by Ron Domen that I’m going to discuss later in this presentation. In short, residents need to conform to the same professional standards as physicians. In addition, although clinical chemists and other health professionals are not specifically mentioned here, to the extent that their work is intimately involved with patient care and that they interact extensively with physicians, they too should aspire to the same levels of professionalism.
The Accreditation Council for Graduate Medical Education (ACGME) states in its common program requirements that "Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. To that end, residents are expected to demonstrate:
- compassion, integrity, and respect for others;
- responsiveness to patient needs that supersedes self-interest;
- respect for patient privacy and autonomy;
- accountability to patients, society and the profession;
- sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation."
In order to assess residents on their professionalism behaviors, we need to link those requirements to specific behaviors. This table lists the ACGME requirements on the left with the some tangible behaviors on the right. Some of these are taken from a paper in 2007 by Lynne Kirk entitled "Professionalism in medicine: definitions and considerations in teaching." The table is not meant to be all-inclusive, but rather, illustrate some examples such as:
- To assess compassion, integrity and respect for others, residents should not make inappropriate demands on others, and they should not be abusive and critical in times of stress.
- To assess that residents are responsive to patient needs that supersedes self-interest, residents should listen well, be patient, and be sensitive to patient physical & emotional needs.
- To assess that residents are respecting patient privacy and autonomy, residents should maintain patient confidentiality.
To assess accountability to patients, society, and the profession, residents should follow through on tasks, arrive on time, accept blame for failure, should not be hostile, derogatory, sarcastic, loud, disruptive, or overly confident, they should accept constructive criticism, and seek new knowledge.
Sensitivity and responsiveness to a diverse population should be illustrated by a lack of bias & discrimination.
Each training program should, of course, develop their own criteria to assess these requirements.
These requirements translate into 6 milestones that ACGME training programs are required to report twice annually for all pathology residents. As shown here, these relate to: maintaining licensure/certification, demonstrating honesty/integrity, demonstrating responsibility and follow- through for assigned tasks, giving and receiving feedback appropriately, demonstrating responsiveness to unique patient needs, and demonstrating personal commitment to maintain emotional/physical/mental health. Each resident is rated as level 1-5, or they’re rated as not having achieved Level 1.
It is important to take note when medical professionals do not demonstrate professional behavior not just for the patient’s benefit, but also because this kind of behavior is a warning sign for both the resident and the director, that something else could be wrong underneath the surface that needs to be taken care of such as: divorce, death in family, sick child, abuse, physical or mental illness, etc.
Recently, Dr. Ron Domen, professor of Pathology Medicine and Humanities at Penn State Hershey Medical Center & College of Medicine, undertook a survey of Penn State department pathology faculty and key supervisors, Pathology program directors nationwide, and Penn State program directors and coordinators, to assess professionalism in residency training. I'd like to thank him for sharing his data.
While the groups he surveyed are not limited to pathology programs, they were predominately pathologists. He simply asked two questions:
- What are desirable professional/ethical attributes?
- Give examples of unprofessional/unethical behavior.
He received 25 responses.
In this table, Domen summarizes the desirable professional/ethical attributes that were expressed by the 3 groups he surveyed. These attributes, which include: Honesty, Trustworthy, Integrity, Respect (towards self and to others, colleagues, patients), Accountability/taking responsibility, Dependability/reliability, Effective interpersonal communication skills, Knowing limitations & when to ask for help, Maintaining confidentiality certainly reflect the professional responsibilities listed by the Professionalism charter and the ACGME requirements.
When survey participants were asked about the most common unprofessional resident behaviors, the most common responses were:
- Inappropriate comments about fellow employees (21%)
- Poor attendance/tardiness (21%)
- Being disrespectful to support staff (21%),
- Dishonesty (21%)
Not attending conferences (17%)
These behaviors violate at least 2 out of the 3 ACGME requirements for professionalism.
Domen also lists examples of unprofessional/unethical behavior. Here, I have selected a handful of examples because I think you will recognize some of these from your own center. These include things like:
- Blaming others (or the system) when you are responsible (wholly or in part) for not finishing a task or assignment or for making a mistake.
Denigrating others (usually out of lack of confidence or jealousy).
Being rude to secretaries, techs.
Losing your temper in front of colleagues or those working under you.
Gossiping about colleagues.
Dressing inappropriately for work.
Blatantly ignoring the rules or acting superior to regulations.
Not admitting ignorance and not seeking help when appropriate.
Leaving others to clean up your mess – physical or otherwise.
Not doing the job you are paid to do (e.g., disappearing or “checking out” after boards).
Slide 17 (continued from previous slide):
Wasting time during work hours surfing the internet or playing on one’s phone – You have a responsibility to become an outstanding pathologist. Patients are relying on you.
Setting a bad example for more junior residents. Taking shortcuts that could compromise patient care.
Not attending mandatory lectures without good reason.
Not taking responsibilities seriously. Tasks like looking up clinical history/pulling previous slides are not scut-work. These are important elements of providing a comprehensive pathology interpretation.
Not focusing on your current rotation, getting drawn into other activities to the detriment of your current responsibilities.
There are many more examples, I’m sure you can think of some or maybe have observed some at your own center.
What should be done when residents exhibit unprofessional behavior? I do not have time to dive into this topic in this Pearl, but I direct the viewer to another paper by Ron Domen which explores remediation for unprofessional behavior.
Finally, a discussion of professionalism in this day and age would not be complete without mention of the proper use of social media. In 2011, the American Medical Association issued an opinion on "Professionalism in the Use of Social Media." This opinion states that while social media can have positive influences such as fostering collegiality, disseminating public health messages, and having a professional presence online, physicians need to weigh a number of considerations when using social media. Things to consider include:
Maintaining patient privacy and confidentiality at all times,
Using privacy settings when posting personal material,
Maintaining appropriate boundaries of the patient-physician relationship, and
Separating personal and professional content online.
When medical professionals see unprofessional content online, they have a responsibility to bring it to the attention of the individual. Physicians and all health professionals must recognize that their actions online and content posted may negatively affect their reputations among patients and colleagues and may have consequences for their medical careers.
To summarize, professionalism is important in every profession, but especially important in medicine as it is linked to ethics and the Hippocratic Oath. The ABIM, ACOP, and EFIM published a charter with principles and responsibilities of medical professionalism. A survey indicates physicians support these principles, and the majority abides by them. Residents and trainees are responsible for the same principles as physicians. All health professionals need to be cautious in their use of social media.
Slide 21: References
Slide 22: Disclosures Slide 23: Related Pearls
Slide 24: Thank You from www.TraineeCouncil.org
Thank you for joining me on this Pearl of Laboratory Medicine on “Medical Professionalism.”