Resident Educator Development The RED Program A Residents-as-Teachers Curriculum Developed by Heather A. Thompson, MD

The RED Program Team Leadership How to Teach at the Bedside The Microskills Model: Teaching during Oral Presentations How to Teach EBM The Ten Minute Talk Effective Feedback Professionalism Patient Safety and Medical Errors

Resident Educator Development (RED) Program Professionalism Resident Educator Development (RED) Program

What is Professionalism? Recall a situation or behavior that you observed in which the physician involved seemed very professional; write down why these actions were considered professional. Conversely, recall a situation in which the physician’s actions seemed UNprofessional. Why was this so? Allow 3-5 minutes for this brainstorm exercise. Then, take down a suggestion or two from everyone in the room; jot these down on a white board or flip chart. Alternatively, the participants could discuss in pairs or groups.

Resident examples of unprofessional behavior Poor conference attendance Poor documentation Signing out early with things left undone Coming in late on a consistent basis Ignoring the attending’s instruction Not answering pages in a timely fashion Complaining about “soft” admits, “rocks” Disrespectful of nursing, social work, ward clerks Disrespectful of other medical specialties Poor communication with other MDs, other care providers, patient, family Sometimes, it is easier to define “unprofessional” behavior than it is to define professionalism. This is a list generated by the U of MN Internal Medicine Residents themselves. These are some real life examples that the residents can relate to.

From the ACGME Evaluation Tool: Unprofessional vs. Professional Puts self-interest above that of the patient Tendency towards arrogance; doesn’t recognize limitations or accept feedback Disrespectful of team members, patients Cuts corners, doesn’t strive for excellence Dedication to patient care; goes “Above and Beyond” Admits mistakes, tries to correct them Good at self-assessment; seeks feedback Has high standards, strives for excellence Courteous towards other team members, patients

Patient Complaints about Physician Behaviors: A Qualitative Study (In Descending Order of Frequency) Perceived Unavailability Disrespect Inadequate information Disagreement about expectations of care Distrust Interdisciplinary miscommunication Academic Medicine Vol 79(2) Feb 2004 134-138 What do patients think is unprofessional? From an article in Academic Medicine Vol 79(2) Feb 2004 134-138.

Patient quotes: unprofessional behavior “My other doctor didn’t take the time to explain any of my test results. They just sent me a letter with ‘normal, abnormal’ on it.” “I couldn’t understand my physician, they used too much medical jargon.” “My previous doctor dismissed every single symptom I had as being normal or else related to anxiety.” “My previous doctor acted like they didn’t care if I lived or died, they just wanted to get me out of the office.”

Professionalism Defined What is professionalism? --Competence --Engagement --Reliability --Dignity --Agency --Dual focus on illness and disease --Concern for quality in health care Archives of Internal Medicine, 163(2) 145-149, 27 Jan 2003 Professionalism is a term that is used frequently, but is hard to define. It encompasses many things. This Archives article outlines the key tenets very well.

Professionalism Defined: ABIM • Professionalism encompasses: --Primacy of Patient Welfare --Patient Autonomy --Social Justice --Professional Competence --Honesty with Patients --Patient Confidentiality Annals of Internal Medicine 136(3) Feb 2002 243-246 American Board of Internal Medicine (ABIM): from their statement, “Medical Professionalism in the New Millennium.”

Professionalism Defined: ABIM • Professionalism Encompasses: --Maintaining Appropriate Relations with Patients --Improving Quality of Care --Improving Access to Care --Just Distribution of Finite Resources --Commitment to Scientific Knowledge --Managing Conflicts of Interest --Commitment to Professional Responsibilities Annals of Internal Medicine 136(3) Feb 2002 243-246 American Board of Internal Medicine (ABIM): from their statement, “Medical Professionalism in the New Millennium.”

Professionalism Good communication: with patients, with nurses, with the family, with other teams. “This is how I would want my mother treated if she were in the hospital.” During residency, professionalism also involves respecting educational time and the process of teaching and learning. Alternative definitions of professionalism.

View the Video Clip An intern and a resident on call at night are alerted of a new admission Show this video clip to vary the stimulus a bit, and perhaps say something like “based on our definitions, is this behavior professional, or unprofessional?”

Professionalism: Why do we care? It is an ACGME competency: your level of professionalism is evaluated on each and every rotation Frequently, a cause of real life problems --Residency Program --Issues with the Medical Board --Affects Employment Opportunities --Increased risk of litigation --Affects day to day functioning As program directors, we often get calls from Fellowships, Clinics, or Hospital systems regarding potential job offers. The questions are almost always directed at professionalism—”Was this resident able to work well with others?”—and not at actual medical knowledge base.

“Unprofessional behavior, rather than problems with clinical skills, is the most common reason cited by the Medical Board of California for physicians to receive disciplinary action.” David Thorton, supervisor, enforcement, Medical Board of California.

U of MN—Internal Medicine Experience Again, illustrates how more residents run into problems with professionalism than with overall clinical competency.

How does one TEACH professionalism? Most teaching of professionalism comes from role modeling and mentoring “Caught, not taught” “Practice what you teach” Leading by example Daily patient care interactions Therefore, most “teaching” of professionalism is done by RESIDENTS

“Hidden Curriculum” The ideas, the goals, the objectives conveyed by our ACTIONS is what is actually being taught. The hidden curriculum is more important than any other curriculum (written materials, lectures). Example: telling your team to attend all educational conferences, then skipping Grand Rounds to finish up paperwork. “Hidden Curriculum” is a phrase that comes from Hafferty and Frank’s work in 1994 and was further expanded upon by David Stern MD.

Survey: Senior Residents Most Useful Methods for Learning Professionalism #1 = Contact with positive role models (93.5% of respondents) #2 = Interactions with patients and families (50% of respondents) #3 = Contact with negative role models (43.5% of respondents) Academic Med Vol 67(7) July 2001 Responses indicate that role models and daily interactions with patients matter the most.

Professionalism and the Senior Resident You are, as the senior resident, the role model for professionalism on the team. You spend the most time with the intern and the students. You will leave an indelible impression the interns and students you work with. You will witness acts of professionalism (or unprofessionalism) in your students and interns, more often than the attending. This is why we include a module on professionalism in a Residents As Teachers curriculum.

“Lapses in Professionalism” David Stern MD: all physicians, even the BEST ones, suffer from lapses in professionalism This occurs during increased work stress, sleep deprivation, personal problems, family issues, time constraints, illness, etc We need to RECOGNIZE that this happens and FIND WAYS to minimize the “lapses” “Hidden Curriculum” is a phrase that comes from Hafferty and Frank’s work in 1994 and was further expanded upon by David Stern MD.

Work through case examples Break into pairs Discuss the following cases

Case #1 A pharmaceutical representative comes to you to talk about drug X. During the conversation, the representative gives you a pen with the drug’s name on the side. Is it ethical to accept this pen or other inexpensive gifts? What about attending a dinner? What about compensation of $1000 for giving a talk?

Teaching Points: Case #1 Guidelines on Accepting Gifts (AMA) Any gifts accepted by physicians individually should primarily entail a benefit to the patient and should not be of substantial value (e.g. textbooks, expensive meals, drug samples). Individual gifts of minimal value are permissible as long as the gifts are related to the physician’s work (e.g. pens and notepads).

Guidelines on Accepting Gifts (AMA) Subsides for CME or professional meetings can improve patient care and are permissible. Subsidies should be accepted by the conference sponsor and used to reduce the conference’s registration fee; it should not pay for personal expenses of physicians attending conferences or meetings. Conference faculty or consultants may accept reasonable honoraria and reimbursement for travel, lodging, and food.

Other Considerations… There is no evidence that physician’s knowingly or intentionally compromise their patient’s care as the result of gifts. Gift giving, however, influences practice patterns based on considerations that go beyond scientific knowledge and patient needs.

Other Considerations… By accepting a gift, an individual “assumes certain social duties, such as grateful conduct, grateful use, and reciprocation.” Even when gifts have no effect on a physician’s practices, there may be a public impression of impropriety. The costs of gifts from industry to physicians are ultimately passed on to the public.

Case #2 Husband of a patient contacts patient relations about a resident physician interaction. --Resident failed to contact his wife’s primary neurologist about starting a new medication, even though they asked the team to do so.

Case #2 --After discharge, patient thought she was having an adverse reaction to the new medication. --Upon calling back to the ward for further guidance, pt was told to follow up in clinic. After calling into the outpatient clinic, patient was told “we did not prescribe you that medication.” What is the role of the resident in this situation? What could be done to avoid a similar situation in the future?

Teaching Points--Case #2 --Good communication is key!! --Calling pt’s primary MD/outpatient doctor is often a crucial step --Provide detailed discharge instructions --Dictate discharge summary in a timely fashion --Provide patient education handouts (Up to Date; MedLine Plus)

Case #3 You are the supervising resident on a busy clinical service. You are approached by the charge nurse about difficulties with your intern: not responding to pages, neglecting to fill out discharge paperwork, failing to come back and tell a patient and family about test results as promised. What would you do in this situation? What tools or resources are available to help you?

Teaching Points--Case #3 --First, ”Diagnose” the situation ? Fatigue/work overload ? Personal Issues --Face to Face Feedback is Needed --Help is Available! • Communication Skills: CASE (Communication Assessment and Skill Exercise), EDR (Educational Development and Research) workshops • Mental Health/Burnout: RAP (Resident Assistance Program), Physician Well Being Program at U of MN • Discuss with chiefs, program directors

In Summary ACGME defines professionalism: “Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and a sensitivity to a diverse patient population.”

In Summary “A customer complaint is a gift.” Old Business Adage Look for opportunities to give and receive feedback on professionalism. As the senior resident, you are a role model for professionalism on your team.