1. Professionalism Behaviors in Faculty: The Resident View Kim Ephgrave MD, Brent Stansfield PhD, Jerry Woodhead MD, Gwen Beck MD, John Sharp MD, Tom George MD, Sandy Markham MD, Greg Skopec MD, John Lawrence MD, Mark C. Wilson MD University of Iowa Carver College of Medicine

2. The Working Group Four Core Clinical Disciplines: Medicine, Surgery, Pediatrics, Obstetrics/Gynecology Educators/leaders in both medical student and residency programs Support from the Office for Consultation and Research in Medical Education (OCRME) Formed to respond to a call for proposals from the National Board of Medical Educators

3. Key Events in Professionalism Project December 2003: National Board of Medical Examiners put out call for proposals. Jan-March 2004: Team formed, proposal developed and submitted to test NBME form. May-Aug 2004: Team regroups, creates own tool aimed at residents and faculty. Fall 2004: Pilot testing of tool; data analysis; project redesigned/resubmitted. July 2005: Implementation in 5 departments

4. Why the concern about Professionalism? American Board of Internal Medicine launched Professionalism Project in 1990, in response to perceived erosion from market forces. Literature in ’90’s began discussion of the ‘hidden curriculum’ of academic medical centers, often undermining ethical instruction. Association of American Medical Colleges/National Board of Medical Examiners partner in hosting conference Professionalism in Medical Education: May 2002, focusing on students.

5. Residents Iowa: Change Professionalism Focus to Residents Feedback from students frequently included comments about disrespectful behaviors, questionable role modeling from some residents and faculty on clinical rotations. Graduate medical education in the past considered a hospital responsibility, an apprenticeship more than an educational program. Faculty have responsibility for students, but students spend more time with residents than faculty. Recognition of the key role of residents in our educational continuum seemed overdue.

6. Why Assess Professionalism at Iowa, specifically? Possible purposes proposed at AAMC/NBME conference were: Raising Institutional Awareness Improving Patient Care Improving Patient Perceptions Improving Perceptions of Students and Faculty (and residents?!) Identifying Role Models Rewarding Good Behavior Providing vocabulary for discussion of professionalism Continuous quality improvement of all individuals Identifying Offenders Punishing Unacceptable Behavior

7. What do we mean by “Professionalism”? American Board of Internal Medicine: 6 Categories for positive behaviors: Altruism Accountability Excellence Duty Honor and Integrity Respect for Others

8. Defining Professionalism, #2 ABIM ‘issues’ affecting professionalism Abuse of power Arrogance Greed Misrepresentation Impairment Lack of conscientiousness Conflict of Interest

9. AAMC/NBME May 2002: Eight Categories within Professionalism Altruism Honor and Integrity Caring, Compassion, Communication Respect Responsibility Accountability Excellence and Scholarship Leadership

10. Which categories to use? Leadership, Excellence and Scholarship felt to be difficult for residents to observe regarding faculty behavior. Two of the 8 categories were already combined in AAMC/NBME behavior list. Remaining 5 categories were used: Altruism Honor/Integrity Caring/Compassion/Communication Respect Responsibility/Accountability

11. Development of Pilot Items Team members submitted 20 items each. Primary Source: 180+ specific behaviors grouped into the 8 categories of professionalism from 2002 AAMC/NBME conference. Additional Sources: Specialty specific evaluation tools. Negatively worded items included. All items edited to describe behavior frequency.

12. TESTING the Items: Logistics Team members brought the 20 item pilot form to their own departments. Residents and team members were asked to rate an ‘Outstanding’ physician they knew reasonably well on the items On the back side, they rated another physician labeled ‘Not Outstanding” that they considered at the opposite end of the scale.

13. Results Residents from Surgery (n=16) and Pediatrics (n=19) answered the 20 items for an “outstanding” faculty member. All but one Pediatric resident also rated one ‘not outstanding’ faculty member. The total was thus 69 ratings.

14. Factor Analysis Reliability (Cronbach’s alpha) 0.97 Five categories from which questions originated did not emerge One factor with eigenvalue 11.47; explained 57% of the measured variance. Two additional factors together added ~ 13%

15. ‘Outstanding’ vs. ‘not outstanding’ We used 7 point Likert scale, where ‘7’ was ‘always’ for desirable behaviors, and ‘never’ for undesirable behaviors; 4 was neutral. “Outstanding” item means ranged from 5.41 to 6.57, all substantially above 4. ‘Not outstanding’ means ranged from 2.47 to 4.64, with several also above 4. Group means for all items differed significantly.

16. Strengths for the Outstanding Is prepared for clinical responsibilities Answers questions directly and respectfully Is [not] unfair in decisions affecting co- workers Listens well & responds appropriately Demonstrates respect toward all others, both in direct interactions and indirect references.

17. Lows for the Outstanding [doesn’t] Promotes own interests over those of team or work group [doesn’t] Puts own needs ahead of patients’ Is [not] insensitive to patients’ values and beliefs Is aware of own limitations; seeks and accepts constructive feedback Tactfully offers assistance and support for team members.

18. Lows for the ‘Not Outstanding’ Tactfully offers assistance and support for team members Aware of own limitations; seeks and accepts constructive feedback Listens well and responds appropriately Gives colleagues due credit Inspires trust in patients, colleagues, co- workers and subordinates

19. Highs for the ‘Not Outstanding’ Is prepared for clinical responsibilities [doesn’t] put own needs ahead of patients [doesn’t] inappropriately cross personal boundaries with patients or co-workers

20. > 10% could not assess Aware of own limitations; seeks and accepts constructive feedback. Deals with confidential information discretely and appropriately. Demonstrates personal integrity and a willingness to stand on principle.

21. What are the biggest mean differences ? Listens well and responds appropriately (3.5) Tactfully offers assistance and support for team members (3.4) Demonstrates respect toward all, both in direct interactions and indirect reference (3.3) Gives colleagues due credit (3.3) Inspires trust in patients, colleagues, co- workers and subordinates (3.20)

22. Resident view of faculty Professionalism: Conclusions All 20 items differed between ‘outstanding’ and ‘not outstanding’ group’s behavior frequency ratings. Only one strong factor emerged.

23. Key Behaviors that distinguish outstanding professionals Listening well Offering assistance to team Demonstrating respect for all Giving others due credit