Medicine,Dentistry andVeterinary Medicine

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Teaching and Assessing Patient Centred Professionalism in the Undergraduate Curriculum

Trudie Roberts

Kathy Boursicot

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Workshop format

• Setting the scene – What is Professionalism in the 21st century

• Defining patient centred professionalism• Development of professionalism in undergraduates• How to teach professionalism in context?• Methods for assessing professionalism• Devising an assessment strategy?• General discussion

Medicine,Dentistry andVeterinary Medicine

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What is Professionalism in the 21st Century

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Content

• Conceptualisation and Definitions• Why teach and assess professionalism?• What do we mean by professionalism today?

– Changes in the workplace– Changes in workforce

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What is Professionalism?

• Profession (Latin) meaning:

“speaking forth”

• In the future everyone will be a professional

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Why do we need to teach and assess professionalism?

• Most complaints against doctors are because of conduct not competence.

• Students do not arrive at medical school with a full complement of professional behaviours - needing only teaching of medical knowledge and skills.

• All students are vulnerable to lapses in professional behaviour and can benefit from explicit systematic attention in this domain.

• Evidence that there may be a deterioration in professional attitudes: idealism → cynicism.

• Recent evidence about lack of professionalism in a student’s UG career is linked to problems later in their careers (Papadakis)

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Changing world of work

• Can medical professionalism survive in the modern healthcare environment?– Erosion of autonomy– Employee/technician– Increased accountability– EWTD– Up-skilling of other healthcare workers

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Changing world of work

• Unique point in time – 4 distinct groups of workers

Duxbury 2002

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Types

• Traditionalists • Baby boomers • Generation X • Generation Y

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Pre 1946 Traditionalists

• Totally committed to the ‘company’• Horrified by unemployment• Would go down with the ship• Typified by unquestioning loyalty

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1947- 1967 Baby Boomers

• Workaholics• Accept stress as part of the job• Used to belt tightening and sacrifice• Work predicated on delayed gratification • Value titles and status symbols

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1968 – 1980 Generation X

• Place more importance on career than personal life• Mistrustful and suspicious of employers• Products of downsizing and cost cutting• Usually had experience of many jobs• Not committed to a particular company• Want immediate gratification

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1980 – 1995 Generation Y

• Want a balance of work and personal life

• Take time off for personal life enhancement

• Demand flexible environments and benefits

• Do not expect a job for life

• Expanding job market and shrinking work force

• Expect and get immediate reward

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How do our students and our Faculty interpret professionalism?

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Workshop format

• Setting the scene – Professionalism in the 21st century

• Defining professionalism• How to teach professionalism• How to assess professionalism and ensure fitness to

practice• Summary

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ConceptualisationThemes from the literature

• Interpersonal professionalism - meeting the demand for adequate contact with patients• Altruism, respect, integrity, honesty

• Public professionalism – meeting the demands society• Accountability, excellence, self regulation

• Intrapersonal professionalism – meeting the demands to function as an individual in a profession• Lifelong learning, self awareness, morality

Van de Camp et al 2004

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Definitions

• UK’s GMC• Duties of a Doctor• Good Medical Practice

• CanMEDS• Medical expert, communicator, collaborator, manager, health

advocate, scholar, professional• ABIM/ACP/EFIM – “A Physician Charter”

• Patient welfare• Patient autonomy• Social justice

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Tomorrow’s Doctors 2003

• Attitudes and behaviour that are suitable for a doctor must be developed.

• The core curriculum must set out the essential knowledge, skills and attitudes students must have by the time they graduate.

• Only those students who are fit to practice as doctors should be allowed to complete the curriculum.

• Students who do not meet the necessary standards in terms of demonstrating appropriate knowledge , skills, attitudes and behaviour must be advised to follow alternative careers.

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Patient Centred Professionalism

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Definitions

RCP Medical professionalism – definition

Medical professionalism signifies a set of values, behaviours, and relationships that underpins the trust the public has in doctors.

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RCP

Medical professionalism – description

Medicine is a vocation in which a doctor’s knowledge, clinical skills, and judgement are put in the service of protecting and restoring human well-being. This purpose is realised through a partnership between patient and doctor, one based on mutual respect, individual responsibility, and appropriate accountability.

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Definitions (2)

• Swick• Need for a definition• 9 professional behaviours

• Cruess & Cruess• Physician as Healer / as Professional• Damaged social contract

• Cosgrove• Professionalism – state not trait

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Definitions (3)

• Calman “The Profession of Medicine”• High ethical standards• CPD, change and improvement, R&D• Teamwork• Health as well as illness• Concern with clinical effectiveness & outcomes• Ability to communicate

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Elements of Professionalism

• Literature– Knowledge

– Altruism

– Accountability

– Respect

– Integrity

– Ethical code

– Lifelong learning

– Honesty

– Compassion

– Excellence

– Self regulation

• From research– Knowledge and skills

(appropriate)

– Altruism

– Respect

– Integrity

– Ethical

– Working with others

– Empathy

– Honour

– Reflection

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Group Work - 1

• Define ‘patient-centered professionalism’

– What are the characteristics you consider desirable in a professional in training?

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Workshop format

• Setting the scene – Professionalism in the 21st centuary

• Defining professionalism

• How to teach professionalism?• How to assess professionalism and ensure fitness to

practice?• Summary

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Development of Professionalism

• Is professionalism passively ‘caught’ during the undergraduate years

Or• Should it be formally taught?

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NEW MEDICAL STUDENT

MATURE PROF- ESSIONAL

PERIOD OF PROTO-PROFESSIONALISM

O NAÏVE N

NAIVE

PHRONESIS

Y1 Y2 Y3 Y4 Y5 Q Reg PGT

PBL

SDLEXPERIENCE

MATURITY

+ve ROLEMODELS

Hilton and Slotnick 2005

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NEW MEDICAL STUDENT

MATURE PROF- ESSIONAL

PERIOD OF PROTO-PROFESSIONALISM

O NAÏVE N

CYNICAL

IDEALISTIC

Y1 Y2 Y3 Y4 Y5 Q Reg PGT

BAD EXPERIENCES

ADDICTIVE BEHAVIOURS

-ve ROLE MODELS

POLITICS

FATIGUE

Hilton and Slotnick

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Hierarchy of professional attitudes

• Are some attitudes more important than others?

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How Can Professionalism Be Taught?

• Role Models • Didactics on History of Medicine, Self-Regulation and

Public Policy• Small Group Discussions• Grand Rounds• Named Lectures• Teaching ward rounds • Clinical Vignettes• Reflective Exercises• Self-Assessment/Narratives

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Group work - 2

• Design a framework for teaching professionalism in your own institution/context

– Specific modules?– Part of other modules of teaching?– Teaching methods?

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Workshop format

• Setting the scene – Professionalism in the 21st century

• Defining professionalism• How to teach professionalism?

• How to assess professionalism and ensure fitness to practice?

• Summary

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Knows

Knows how

Shows how

Behaviour~ skills/attitudes

Cognition~ knowledge

Model of competence

Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine (Supplement) 1990; 65: S63-S67.

Does

Pro

fess

ion

al

auth

enti

city

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Climbing the pyramid......

Knows

Shows how

Knows how

Does

Knows Factual tests: MCQ, essay type, oral…..

Knows how (Clinical) Context based tests:EMQ, essay type, oral…..

Shows how Performance assessment in vitro:OSCE, SP-based test…..

DoesPerformance assessment in vivo:Work based assessment, Video, Audits

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New skills emphasized

• learning how to learn• self-appraisal• leadership• team skills• metacognition• professionalism• reflectiveness/reflexiveness…….

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Extending the pyramid

Knows

Shows how

Knows how

Does

Knows

Knows how

Shows how

Does

“Meta” skills

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How to assess “meta-skills”?

• Self assessment• Peer assessment• Co-assessment (combined self, peer, teacher assessment)

• Patient ratings• Log book/diary• Structured evaluations (mini cex etc)• Portfolio assessment……..

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How to assess “meta-skills”?

Basic principles:

Information gathering relying on descriptive and qualitative judgemental information

Systematic documentation Use of multiple tools Processes for making judgements on the information

collected

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Designing an system to assess student professional behaviour and fitness to practise

• ?different schemes/overlap between professional behaviour and FtP – FtP can include issues other than professional behaviour

• Assessment tools should assess the characteristics defined as ‘professional behaviour’

• They must exist within a system of – Systematic data collection– Processes for dealing with unacceptable behaviour

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Group work – 3

Design a system of assessing professionalism in your undergraduates

1. Choose the tools you are going to use

2. Outline a scheme for your institution

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Remediation

• Is it possible?• Attitudes vs behaviours

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Attitudes and behaviours

• Relationship between attitude and behaviour is complex• Behaviour is influenced by attitude• Measures of general attitudes do not necessarily predict specific

behavioursBut

• They do have a good correlation to behaviour over a period of time in a range of situations and contexts (aggregation principle)

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Attitude to performing behaviour

Subjective norm to performing behaviour

Belief about ability to perform behaviour

Behaviour intent

Behaviour

Theory of Planned Behaviour

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Theory of planned behaviour

• Ajzen 1991

A=Σb1.e1

Where:–A=attitude, –b=belief about likelihood of consequence 1–e=evaluation of consequence 1.

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Changing behaviour

• Probably means changing underlying fundamental beliefs

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Workshop format

• Setting the scene – Professionalism in the 21st centuary

• Defining professionalism• How to teach professionalism• How to assess professionalism and ensure fitness to

practice• Summary

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Future issues

• To find a holistic measure(s) of professionalism• Understanding ways of changing professional

attitude/behaviour

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