Vanessa Thompson, MDAndrea Marmor, MD Assistant Professor, MedicineAssociate Professor, Pediatrics University of California, San Francisco

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 Introductions  Defining the problem:  What is professionalism?  Why is it important?  Description of the SOAP approach  Work on cases in small groups  Large group review and wrap-up

1. Recognize categories of professionalism challenges in learners 2. Apply the SOAP model to help further understand and assist learners in difficulty 3. Review strategies for communicating about professionalism concerns with a learner 4. Develop an initial approach to addressing professionalism issues in trainees

 One or two KEY WORDS:  E.g., late, rude, deferential, slacking off

 Think of a person you feel exemplifies professionalism  Try to describe why  All  1 minute alone (write or think)  2 minutes in pairs (share)  4 minutes in groups of 4 (compare/contrast)  5 minutes all (each group shares ONE idea)

 Definitions  ABMS (2012): “…a belief system about how best to organize and deliver health care…shared competency standards and ethical values” ▪ Includes means to ensure these are lived up to  Lucey (2010): “…not an innate quality but a skill developed with deliberate practice over time…” ▪ Observed in interpersonal and organizational domains  Frameworks  Wilkinson/Papadakis

 Unprofessional behavior correlated with  Subsequent disciplinary action by Board (Papadakis)  Medical errors  Poor patient satisfaction  Staff turnover  Institutional reputation  Health care costs Dayton J Qual & Patient Saf 2007;33: Gewande Surgery 2003; 133: While Obstet Gynecol 2005;105: Lingard Qual Saf Health Care 2004;13:

1. Recognize categories of professionalism challenges in learners 2. Apply the SOAP model to help further understand and assist learners in difficulty 3. Review strategies for communicating about professionalism concerns with a learner 4. Develop an initial approach to addressing professionalism issues in trainees

1. Recognize categories of professionalism challenges in learners 2. Apply the SOAP model to help further understand and assist learners in difficulty 3. Review strategies for communicating about professionalism concerns with a learner 4. Develop an initial approach to addressing professionalism issues in trainees

 Application of a clinical framework to an educational problem  Learner-centered, instead of patient-centered  Takes us from our impressions (subjective) to a plan for action and reassessment

 The sense/judgment that there is a problem  “Current Complaint”  Should drive initial hypotheses (“differential diagnoses”) but not assessment  Consider:  Personal reactions  Alternate explanations for behavior

 Collection of information to support/refute hypotheses (“differential diagnosis”)  Consider the scope of problem  Domains/areas of professionalism  Settings affected  Isolated vs. pattern  Individual vs. Interpersonal vs. Societal  Consider multiple sources of information

 Classroom  Attendance  Faculty evaluations  Peer evaluations  Paper or SP Exams  Practice-Based  Patient satisfaction  Self-administered rating scales  360 degree evaluations  Clinical Training  Faculty/resident/student evaluations  Critical incidents  Observation of clinical encounters  Completion of the medical record

 Develop a “working diagnosis”  Incorporate collected objective data  Consider the differential  Are there other possibilities?  How will you distinguish between them?  Put your nickel down  Pick ONE issue to focus on

What level of intervention is appropriate?

1. Open the conversation  What will you say? What will they say? 2. Coach  What strategies would you use? 3. Reassess  When? How?

 Vignettes that represent different challenging learners  Your task: 20 minutes  Use the discussion guide to apply the SOAP method to these learners  May modify the specifics to suit your setting  Large group discussion:  Be prepared to present what you learned, and your INITIAL approach to the learner

Each group will present… 1. ONE new idea/revelation  Did anything surprise you? 2. How would you OPEN your discussion with this learner?

 Senior resident on inpatient service  Reputation for academic strength  Recently has acted disinterested/burnt-out  Interns/students intimidated  Background:  First in family to attend college, leader in professional school

 Junior student with a PhD  Late to rounds, poor job on H and P and presentation  However, good knowledge of pathophysiology  Does not respond to feedback on these issues  Thinks he performed well, feels others are uncomfortable with his intelligence

 Senior student on specialty elective  Expresses enthusiasm about learning, and gets her work done  Looking at/typing in smart phone on rounds, in patient rooms and during teaching  Others have noticed, but aren’t sure how to handle it  Unclear if she is using phone for learning or personal

 Residency previously intervened re: duty hours  Devoted to her patients, but consistently behind on patient care and charting  Defensive when approached about unfinished notes

1. Recognize categories of professionalism challenges in learners 2. Apply the SOAP model to help further understand and assist learners in difficulty 3. Review strategies for communicating about professionalism concerns with a learner 4. Develop an initial approach to addressing professionalism issues in trainees

1. Recognize categories of professionalism challenges in learners 2. Apply the SOAP model to help further understand and assist learners in difficulty 3. Review strategies for communicating about professionalism concerns with a learner 4. Develop an initial approach to addressing professionalism issues in trainees

 Pick one case to delve into more deeply  What are the components of an effective plan for this learner?

1. Open the conversation  Address learner directly, kindly  Focus on behavior, not personality  Pause for response: assess learners’ self-awareness 2. Coach  Redefine the goal  Individualized intervention, based on assessment 3. Reassess  Shared accountability  Must be able to document “competence”

 “Cup of Coffee” conversation  Ask, Tell, Ask  Use real incidents as examples  Instruction with practice, feedback and reflection  Set clear, consistent expectations

Attributed to Gandhi