Professionalism in GME:Defining and Measuring

ProfessionalismDavid T. Stern, MD, PhD

Vice Chair for ProfessionalismMount Sinai School of Medicine

Albert Einstein College of Medicine11 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

Clinical Competence (Knowledge of Medicine)

Communication Skills

Ethical and Legal Understanding

Exce

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Hu

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Acco

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Altru

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Professionalism

Arnold and Stern, 2006Arnold and Stern, 2006

. . . and wise application . . .

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

Three Ways to Promote Professionalism

• Expectations

• Experiences

• Evaluation

Stern and Papadakis, 2006

Defining and Measuring Professionalism

• What is (and is not) “professionalism”

• How can we measure something as “subjective” as professionalism?

• 4 measures of professionalism

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

Defining and Measuring Professionalism

• What is (and is not) “professionalism”

• How can we measure something as “subjective” as professionalism?

• 4 measures of professionalism

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

0102030405060708090

100

1stQuartile

2ndQuartile

3rdQuartile

4thQuartile

ActualPerformanceSelf-AssessedPerformance

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