Question 1...Medical Professionalism in Clinical Endocrinology Answers and Rationale Question 1 Correct Answer: A The correct answer is: Under the ACGME¹ and ABMS² six Core Competencies,

Medical Professionalism in Clinical Endocrinology Answers and Rationale

Question 1

Correct Answer: A

The correct answer is: Under the ACGME¹ and ABMS² six Core Competencies, Professionalism is the demonstration of a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations. The incorrect answers define other Core Competencies.

To demonstrate skills that result in effective information exchange and teaming with patients, their families and professional associates defines the Core Competency of Interpersonal and Communication Skills.

To demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and their application in patient care defines the Core Competency of Medical Knowledge.

To be able to investigate and evaluate patient care practices, appraise and assimilate scientific evidence, and improve the practice of medicine defines the Core Competency of Practice-based Learning.

Reference(s): Accreditation Council for Graduate Medical Education. ACGME Home. http://www.acgme.org/acgmeweb/ Accessed August 22, 2014.

American Board of Medical Specialties. Higher standards, better care. http://www.abms.org/ Accessed August 22, 2014.

Educational Objective: Define the ACGME and ABMS Core Competency of Professionalism for quality patient care.

Question 2

Correct Answer: D

Understanding Medical Professionalism¹ delineates four areas of expression of professionalism. In this example, there is little to no conflict between physicians and patients, between members of the medical team, or between elements of the medical practice setting. The conflict between physicians and a medical specialty examination board is clearly in the realm of professional organizations and the external environment. The ultimate mutually favorable resolution of this conflict will depend on the good faith efforts of both the concerned physicians and the leadership of the medical specialty examination board to express behaviors that are compatible with the highest standards of professionalism.

Reference(s): Levinson W, Ginsburg S, Hafferty FW, Lucey CR. Understanding Medical Professionalism. New York, NY: McGraw-Hill Medical; 2014.

Educational Objective: Differentiate the four arenas in which behaviors that are characteristic of professionalism can be observed.


Question 3

Correct Answer: A

The ABMS1 defines Part II of the Maintenance of Certification process as:

Part II: Lifelong Learning and Self-Assessment – participating in educational and self-assessment programs determined by the individual physician’s member Board

The Physician Charter on Medical Professionalism2 defines the Commitment to Professional Competence:

Physicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care. More broadly, the profession as a whole must strive to see that all of its members are competent and must ensure that appropriate mechanisms are available for physicians to accomplish this goal.

Thus, a physician’s participation in Part II Maintenance of Certification activities fulfills the commitment to maintain professional competence in medical knowledge and clinical and team skills.

The Physician Charter on Medical Professionalism2 defines the Commitment to Patient Confidentiality:

Earning the trust and confidence of patients requires that appropriate confidentiality safeguards be applied to disclosure of patient information. This commitment extends to discussions with persons acting on a patient’s behalf when obtaining the patient’s own consent is not feasible. Fulfilling the commitment to confidentiality is more pressing now than ever before, given the widespread use of electronic information systems for compiling patient data and an increasing availability of genetic information. Physicians recognize, however, that their commitment to patient confidentiality must occasionally yield to overriding considerations in the public interest (for example, when patients endanger others).

The Physician Charter on Medical Professionalism2 defines the Commitment to Scientific Knowledge:

Much of medicine’s contract with society is based on the integrity and appropriate use of scientific knowledge and technology. Physicians have a duty to uphold scientific standards, to promote research, and to create new knowledge and ensure its appropriate use. The profession is responsible for the integrity of this knowledge, which is based on scientific evidence and physician experience.

The Physician Charter on Medical Professionalism2 defines the Commitment to the Just Distribution of Finite Resources:

While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the resources available for others.


Reference(s): American Board of Medical Specialties. ABMS Maintenance of Certification® http://www.abms.org/Maintenance_of_Certification/ABMS_MOC.aspx Accessed August 29, 2014.

ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002 Feb 5;136(3):243-6.

Question 4

Correct Answer: C

The ABMS1 defines Part IV of the Maintenance of Certification process as:

Part IV: Practice Performance Assessment – the physician’s ability to demonstrate the use of best evidence and practices compared to peers and national benchmarks

The Physician Charter on Medical Professionalism2 defines the Commitment to Improving Quality of Care:

Physicians must be dedicated to continuous improvement in the quality of health care. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error, increase patient safety, minimize overuse of health care resources, and optimize the outcomes of care. Physicians must actively participate in the development of better measures of quality of care and the application of quality measures to assess routinely the performance of all individuals, institutions, and systems responsible for health care delivery. Physicians, both individually and through their professional associations, must take responsibility for assisting in the creation and implementation of mechanisms designed to encourage continuous improvement in the quality of care.

Thus, a physician’s participation in Part IV Maintenance of Certification activities fulfills the commitment to improve quality of care.

The Physician Charter on Medical Professionalism2 defines the Commitment to Honesty with Patients:

Physicians must ensure that patients are completely and honestly informed before the patient has consented to treatment and after treatment has occurred. This expectation does not mean that patients should be involved in every minute decision about medical care; rather, they must be empowered to decide on the course of therapy. Physicians should also acknowledge that in health care, medical errors that injure patients do sometimes occur. Whenever patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously compromises patient and societal trust. Reporting and analyzing medical mistakes provide the basis for appropriate prevention and improvement strategies and for appropriate compensation to injured parties.

The Physician Charter on Medical Professionalism2 defines the Commitment to Appropriate Relations with Patients: Given the inherent vulnerability and dependency of patients, certain relationships between physicians and patients must be avoided. In particular, physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose.


The Physician Charter on Medical Professionalism2 defines the Commitment to Improving Access to Care:

Medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.

Reference(s): American Board of Medical Specialties. ABMS Maintenance of Certification® http://www.abms.org/Maintenance_of_Certification/ABMS_MOC.aspx Accessed August 29, 2014.


Educational Objective: Interpret the Ten Commitments of the Physician Charter on Medical Professionalism.

Question 5

Correct Answer: A

The correct answer is: Public skepticism and distrust of the medical profession in the 1800s, general acceptance of the concept of medicine as an altruistic activity in the mid-1900s, and deterioration of the image of the medical profession in the early 2000s.

In the 1800s, there was widespread and deep distrust of the medical practitioners because of the perception that most practitioners’ actions were motivated by self-interest. Influential writers such as Adam Smith and George Bernard Shaw expressed profound suspicion of medical practitioners and reflected the public beliefs of their times.1

In the early 20th century, the concept of Medical Professionalism received scrutiny from sociologists, and in the resulting attention, organized medicine began to refine its practices and its image. At the time, Abraham Flexner (continuing his studies following his critical exposé of medical education) noted: “Insofar as accepted professions are prosecuted at a mercenary or selfish level, law and medicine are ethically no better than trades.”1

By the mid-20th century, Paul Starr noted that organized medicine had become remarkably successful in its efforts to redefine its image and to take on the mantle of a profession.2 This was the relatively short-lived “Marcus Welby, MD” era of American medicine.

Today, new pressures and challenges are being felt, and there is a rise of skepticism concerning the professional status and privileges afforded to medicine by society. These challenges include the issues of conflict of- interest, duty hours limitations for medical and surgical trainees, and the virtually instantaneous transmission of news and opinion across the various channels of social media.1



Starr P. The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. New York, NY: Basic Books; 1984.

Educational Objective: Summarize the history of medical professionalism over several centuries.

Question 6

Correct Answer: B

The Physician Charter on Medical Professionalism1 defines the Commitment to Professional Responsibilities:

As members of a profession, physicians are expected to work collaboratively to maximize patient care, be respectful of one another, and participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards. The profession should also define and organize the educational and standard-setting process for current and future members. Physicians have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance.

The Physician Charter on Medical Professionalism1 defines the Commitment to Maintaining Trust by Managing Conflict of Interest:

Medical professionals and their organizations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage. Such compromises are especially threatening in the pursuit of personal or organizational interactions with for-profit industries, including medical equipment manufacturers, insurance companies, and pharmaceutical firms. Physicians have an obligation to recognize, disclose to the general public, and deal with conflicts of interest that arise in the course of their professional duties and activities. Relationships between industry and opinion leaders should be disclosed, especially when the latter determine the criteria for conducting and reporting clinical trials, writing editorials or therapeutic guidelines, or serving as editors of scientific journals.

The Physician Charter on Medical Professionalism1 defines the Principle of the Primacy of Patient Welfare:

This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician–patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.

The Physician Charter on Medical Professionalism1 defines the Principle of Patient Autonomy:


Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.

The Physician Charter on Medical Professionalism1 defines the Principle of Social Justice:

The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

Reference(s): ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002 Feb 5;136(3):243-6.

Educational Objective: Explain the Ten Commitments of the Physician Charter on Medical Professionalism.

Question 7

Correct Answer: C

Adherence to a specific code of ethics is a behavioral trait which, along with others such as altruism and conscientiousness, characterizes professionalism. The other answers are incorrect because they define characteristics of a profession.1


Educational Objective: Differentiate between the idea of a profession and the concept of professionalism.

Question 8

Correct Answer: A

The Core Value of Integrity and Accountability are addressed by the Commitments to: Honesty with Patients, Patient Confidentiality, and Improving Quality of Care. Additionally Integrity and Accountability are addressed by the Commitments to Maintaining Appropriate Relations with Patients, to Maintaining Trust by Managing Conflicts of Interest, to Fulfilling Professional Responsibilities and by upholding the Fundamental Principles of the Primacy of Patient Welfare and Patient Autonomy.¹ ² The chart shown in Figure 1 presents a map of the relationships between the Core Values of Professionalism and the Principles and Commitments of the Physician Charter on Medical Professionalism.¹ ²


(Figure 1)


Levinson W, Ginsburg S, Hafferty FW, Lucey CR. Understanding Medical Professionalism. New York, NY: McGraw-Hill Medical; 2014.

Educational Objective: Assess the Fundamental Principles and Commitments of the Physician Charter on Medical Professionalism and group them into the four Core Values of Professionalism.

Question 9

Correct Answer: D


The correct answer is: Lapses of professionalism are infrequent and unpredictable and are dealt with swiftly and severely. It is most consistent with a view of medical professionalism as an innate character attribute. Either one has it, or one does not. Any breach of the tenets of professionalism defines the physician as “unprofessional.” The health care system has no role in the conduct of professionalism; it is merely the stage on which actions are carried out. The medical educational system has the dual responsibility of selecting individuals who are intrinsically professional and of training them to maintain their professionalism.1

The other options are most consistent with a view of medical professionalism as a series of competencies of knowledge, attitudes, skills, and judgment. Medical professionalism can be taught, and it can be learned in a developmental arc from beginner to expert. A lapse in professionalism does not necessarily define an “unprofessional” physician. Challenges to professionalism are common. The response to a lapse in professionalism should be educational and should be based on the fundamental causes of the lapse. Punishment should be reserved for those who fail to respond to educational interventions. Health care system organizational and operational characteristics can either promote or undermine professionalism. The medical educational system and all of its participants have the responsibility to continuously support, reinforce and guide physicians in advancing their professionalism throughout their careers.1


Educational Objective: Distinguish between the vision of medical professionalism as a static character trait of physicians and the view of medical professionalism as a series of competencies of knowledge, attitudes, skills, and judgment.

Question 10

Correct Answer: C

The correct answer is: Punishment for lapses in professionalism should be reserved for those who fail to respond to educational interventions. It is most consistent with a view of medical professionalism as a series of competencies of knowledge, attitudes, skills, and judgment. Medical professionalism can be taught, and it can be learned in a developmental arc from beginner to expert. A lapse in professionalism does not necessarily define an “unprofessional” physician.

Challenges to professionalism are common. The response to a lapse in professionalism should be educational and should be based on the fundamental causes of the lapse. Punishment should be reserved for those who fail to respond to educational interventions. Health care system organizational and operational characteristics can either promote or undermine professionalism. The medical educational system and all of its participants have the responsibility to continuously support, reinforce and guide physicians in advancing their professionalism throughout their careers.1


The other answers are most consistent with a view of medical professionalism as an innate character attribute. Either one has it, or one does not. Any breach of the tenets of professionalism defines the physician as “unprofessional.” Such lapses are infrequent and unpredictable and are dealt with swiftly and severely. The health care system has no role in the conduct of professionalism; it is merely the stage on which actions are carried out. The medical educational system has the dual responsibility of selecting individuals who are intrinsically professional and of training them to maintain their professionalism.1


Educational Objective: Distinguish between the vision of medical professionalism as a static character trait of physicians and the view of medical professionalism as a series of competencies of knowledge, attitudes, skills, and judgment.

Question 11

Correct Answer: C

The correct answer is the scenario involving the endocrinology fellow in the medical intensive care unit, who is sleep-deprived and is trying to manage a patient who is rapidly deteriorating. The simplest, fastest, and most effective therapy for the acutely ill patient is not available for a reason that appears to be caused by unavailability of clinical services. The circumstances are ripe for an inappropriate display of anger and aggression by the fellow toward the nurse around her.

Professionalism challenges are defined as situations that may make it difficult for a physician to remain true to professionalism values. Professionalism lapses are errors in judgment, skill or attitude that lend an otherwise competent physician to behave in a manner contrary to established professional norms.1 All of the circumstances described are stressful and are potential professionalism challenges, but in the medical intensive care scenario, the endocrinology fellow is physiologically challenged by sleep deprivation and is dealing with a difficult and frustrating clinical situation of acute time urgency.


Educational Objective: Recognize challenging circumstances that may increase the risk of a lapse of professionalism.

Question 12

Correct Answer: B

The correct answer is the humiliation or demeaning treatment of others. This is an example of deliberate humiliation and demeaning treatment of the medical student.


Disrespectful, unprofessional, behavior is a major problem, and its consequences may go beyond the immediate interpersonal damage that it causes. Leape et al.1 posit that the culture of medicine is dysfunctional because it is tolerant of disrespectful behavior and that the dysfunctional culture is the “root cause” of the poor record of improvement in patient safety that has characterized the last decade. They have characterized six common types of unprofessional and disrespectful behavior in physicians in Figure 1.

The authors list five endogenous causes of disrespectful behavior: insecurity and anxiety, depression, narcissism, aggressiveness, prior victimization. They also discuss exogenous factors which include institutional and societal culture, the hierarchical nature of the healthcare environment, and the highly stressful environment of healthcare.

The same authors recommend specific steps in reversing the status quo of tolerance for disrespectful behavior within the healthcare system. These include: charging leadership to motivate and inspire the cultural change, establishing preconditions for a culture of respect, leading the establishment of policies regarding disrespectful behavior, facilitating the engagement of frontline workers, and creating a learning environment.2

(Figure 1)

Reference(s): Leape LL, Shore MF, Dienstag JL, et al. A culture of respect, Part 1: the nature and causes of disrespectful behavior by physicians. Acad Med 2012; 87:845-52.

Leape LL, Shore MF, Dienstag JL, et al. A culture of respect, Part 2: creating a culture of respect. Acad Med 2012; 87:853-8.

Educational Objective: Identify unprofessional and disrespectful behaviors within the healthcare system.

Question 13

Correct Answer: D


The correct answer is social regulation. In the example, you are actively coaching your colleague in an effort to stop the unprofessional behavior.

Wendy Levinson et al. suggest four categories of skills which can be specifically developed by individuals: self-awareness, self-regulation; social awareness; social regulation.1 These competencies are summarized in the table, and questions are provided which may be useful in professionalism challenge situations.

(Figure 1)


Educational Objective: Explain professionalism-enhancing skills which may be used in dealing with situations that challenge professionalism.

Question 14

Correct Answer: A

The correct answer is a discussion of the potential benefits and risks of the alternatives. This is an example of a physician presenting to the patient information which discloses the potential benefits and


risks of both medications.3 With this information, the patient is able to make a more informed decision that he or she could without understanding these potential risks and benefits.

A statement of the clinical issue could be: “Your high blood sugar, increases the risk that you will have blindness. We want to reduce that risk with a safe and effective medication.”

An assessment of the patient’s understanding could begin with a question such as: “Does what we’ve discussed make sense to you?”

An exploration of the patient’s preference could begin with a question such as, “Does that sound reasonable to you?”



Braddock CH 3rd, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back to basics. JAMA. 1999;282:2313-20.

Educational Objective: Discuss the benefits of shared decision making and why it is a key component of Patient-Centered Care.

Question 15

Correct Answer: C

• The mean time spent with patients during office visits for no-claims physicians was 18.3 minutes vs 15.0 minutes for physicians with a medical professional liability claims history.

• There was no discernible difference in communications styles between surgeons with a medical professional liability claims history and those without.

• “No-claims” physicians were more likely to encourage patients to talk and to solicit patients’ opinions than were physicians with medical professional liability histories.

• "No-claims” physicians were more likely to educate patients about what to expect in their care than were physicians with medical professional liability histories.

Reference(s): ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College Physicians- American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002 Feb 5;136(3):243-6.



Levison W, Roter DL, Mullooly JP, Dull VT. Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277:553-9.

Educational Objective: Explain the potential benefits of effective physician communication with patients.

Question 16

Correct Answer: B

The correct answer is the "Bristol Affair". Failure of a hospital medical staff to recognize and correct poor pediatric cardiac results associated with the work of two surgeons at the Bristol Royal Infirmary in the late 1990s resulted in a public outcry and the creation of a Council for the Regulation of Health Professionals overseeing the work of the medical profession. Half of the Council is composed of members of the lay community.1, 2

Resident work hour’s laws and regulations were instituted partially as a result of the Libby Zion case, but this case had no effect on the societal privilege of physician self-regulation.

Crossing the Quality Chasm3 is a volume that provided the Institute of Medicine’s recommended roadmap to improve the quality of medical care in the United States. It is the follow-on of To Err is Human.4 Neither publication resulted in loss of physicians’ privilege of self-regulation.

“Choosing Wisely” is a program that encourages patients and physicians to have an exchange of information and ideas when a procedure or test is recommended that make have dubious treatment or diagnostic benefit.5 Designed to encourage honesty with patient’s one of the ten commitments of Medical Professionalism,6 “Choosing Wisely” has no impact physicians’ privilege of self-regulation.

Reference(s): Walshe K, Offen N. A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. Qual Health Care. 2001. December;10(4):250-6.


Committee on Quality of Health in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.

Kohn L, Corrigan J, Donaldson M, eds. To Err is Human: Building a Safer Health System. Committee on Quality Health Care in America. Institute of Medicine. Washington, DC: National Academy Press; 2000.

American Board of Internal Medicine Foundation. Choosing Wisely. http://www.choosingwisely.org/



Educational Objective: Interpret the Core Value of Integrity and Accountability and explain its role in medical professionalism.

Question 17

Correct Answer: D

Clinical teams express their integrity and accountability by: being attentive to and supportive of their members and by seeking help for them when it is needed; by diligently providing honest feedback and constructive criticism of their members; and by establishing and adhering to handoff and sign-out techniques that protect patients and advance their care during times of provider transition.1

Insuring patient confidentiality, judicious use of the Internet for communications purposes, maintaining appropriate relationships with patients, maintaining trust by managing conflicts of interest are integrity and accountability responsibilities of individual physicians and providers.

Imposing encryption standards on information technology devices, supporting the disclosure of medical injuries, creating a safe environment where errors can be studied and lessons applied for improvement of care are integrity and accountability responsibilities of clinical healthcare settings.

Establishing and maintaining databases that document patient satisfaction and training and board certification status of physicians are integrity and accountability responsibilities of large healthcare organizations such as medical specialty societies, licensure boards, or members of the American Board of Medical Specialties.


Educational Objective: Interpret the Core Value of Integrity and Accountability and explain its role in medical professionalism.

Question 18

Correct Answer: A

Working as part of a team to achieve best outcomes for patients reflects a commitment to excellence and acknowledges that this commitment should be held by all those involved in delivering care to patients, not just the physician.

While assuring use of resources does reflect an aspect of medical professionalism, it is an example of a different core value: fair and ethical stewardship of health care resources.

While striving to achieve the highest standards of professional probity does reflect an aspect of medical professionalism, it is an example of a different core value: integrity and accountability.


Commitment to “providing at least as good patient care as my colleagues” is a commitment to being ‘average’ and does not reflect a commitment to excellence.



Educational Objective: Identify a Commitment to Excellence as one of the core values of medical professionalism.

Question 19

Correct Answer: C

The correct answer is individual clinicians and health care systems. Pursuit of excellence is the responsibility of all who are involved in delivering patient care, including organizations (such as hospitals) in which such care is provided.

The option of regulatory bodies is incorrect because it suggests that the pursuit of excellence can be successfully achieved through regulatory processes, whereas at best such processes can only contribute.

The option of professional societies is incorrect because it suggests that publication of clinical guidelines in itself leads to pursuit of excellence, whereas these can only inform and support an individual or organization in this pursuit.

The option of medical schools is incorrect. This implies that the pursuit of excellence can be taught and tested at one stage in a person’s professional life and can be assumed to remain effective thereafter. It suggests the opposite of lifelong learning.



Educational Objective: Identify a Commitment to Excellence as one of the core values of medical professionalism.

Question 20


Correct Answer: B

The most appropriate response is to set criteria for the glycated hemoglobins and revisit the issue after 6 months. Frequent, repetitive processes often waste resources. The competent professional will lead the care team in process improvement that addresses wasteful practices.

“Routine” testing is inefficient, and waste of human or financial resources is counter to the professional’s duty to fair and ethical stewardship of health care resources. The responsibility lies with the entire care team. The team should consider solutions to inefficient practices, remove barriers to those solutions, and monitor the results.

Discarding unneeded glycated hemoglobins and removing the charge from bills is a “one-off” solution that doesn’t address the root cause. Obtaining glycated hemoglobins that ultimately will be tossed out is waste of time and resources. Solutions should be team-based and evidence-supported.

Informed consent is an important aspect of the care process, but it is the duty of the care team to be good stewards of resources, not merely to obtain consent for an unneeded test.

Creating a pool of funds for compensation is also incorrect. Stewardship of health care resources means eliminating waste, not compensating for it.



Educational Objective: Explain the Fair and Ethical Stewardship of Healthcare resources as it applies to the core values of medical professionalism.

Question 21

Correct Answer: A

Implementing dual energy x-ray absorptiometry (DXA) to cut costs for the patient is the correct response. While this may not provide a marked increase in revenue, it serves to save money.

A physician should not put the needs of his or her practice ahead of the needs of the patient1,2. Reducing costs of care is a core principle of optimal care. The patients' clinical symptoms and risks should be used to determine the need for testing, and not financial considerations. The scenarios in the remaining two options are illegal (anti-kickback and Stark laws, respectively)3.




http://starklaw.org/ accessed on January 24, 2015.

Educational Objective: Explain the Fair and Ethical Stewardship of Healthcare resources as it applies to the core values of medical professionalism.

Question 22

Correct Answer: D

Communications with patients’ families are of secondary importance. Dr. Jones may have received lectures and training on the importance of communicating clearly with patients and families as part of the formal curriculum of her fellowship program, and it is highly likely that this has been stressed during attending rounds – perhaps even by Dr. Smith himself – as part of the fellowship’s informal curriculum. These essential lessons are seriously undermined by the hidden curriculum manifested by Dr. Smith’s behavior with his cellular telephone during Dr. Jones’ discussion with the patient’s family.

The other options are incorrect. The attending’s behavior will have a greater impression on the minds of the fellow and other trainees in the room than will the attending’s prior words or the words of a previous lecturer. The formal and informal curricula stress the professionalism principle of the primacy of the patient’s welfare and the professionalism commitment to honesty with patients. The hidden curriculum, presented by Dr. Smith’s actual behavior, blemishes both the professionalism principle and the commitment.


Educational Objective: Recognize the negative effects that the hidden curriculum may have on professionalism.

Question 23

Correct Answer: C

The correct answer is providing consistent display and promotion of the definition of professionalism. A clear definition of professionalism is one of the principles of formal curriculum development. Other principles include: institutional support of the curriculum, allocation of responsibility for the delivery of the curriculum, the establishment and maintenance of a nurturing environment for professionalism, the development of a specific cognitive base for teaching professionalism, and attention to faculty development.2

The other options are incorrect. These are all techniques for promoting an informal curriculum of professionalism.




Educational Objective: Identify the principles of formal curriculum development for medical professionalism.

Question 24

Correct Answer: B

The correct answer is providing formative feedback. The resident’s performance is checked and critiqued at the time it is observed.

The remaining answers are incorrect. They are all examples of ineffective supervisory behaviors.1

Reference(s): Kilminster S, Cotrell D, Grant J, Jolly B. AMEE Guide No. 27. Effective educational and clinical supervision. Med Tech 2007 Feb ;29(1).

Educational Objective: Evaluate effective educational supervision.

Question 25

Correct Answer: D

The correct answer is Multisource Feedback, which incorporates feedback from peers, self, patients, and other health professionals who surround the individual. For this reason, the method is sometimes called a “360 degree evaluation.” It capitalizes on the unique nature of others’ observations; has been shown to be feasible and valid; and has credibility and authenticity due to its reliance on multiple sources. It is harder to dismiss a criticism if it comes from many different sources. The challenges of this method are that it requires a good infrastructure, health care professionals who participate require training, and many ratings are needed to be reliable, especially from patients. One needs to consider whether evaluations from different groups of participants (e.g., nurses, patients) should be kept separate, because feedback from different groups can diverge. For formative feedback, the multisource feedback method is best when used by well-structured teams with training, and with clarity on how the instrument will be used and who will see it. Institutional buy-in on the value of the assessments and their outcomes are critical to the success of this technique.

The other options are incorrect.


Encounter cards are typically used to evaluate trainees. They were developed to be used at the end of day or shift. Advantages are that they can include professional behaviors, are simple to fill out, and are usually part of a system of evaluation. However, professionalism issues are often not documented with these cards. Issues that arise can get overlooked in the mass of data that are collected or dismissed as outliers.

Professional Mini-Evaluation Exercise (PMEX) was developed to parallel the mini-Clinical Evaluation Exercise (CEX) and involves direct observation and feedback of medical students and trainees. It is focused solely on professionalism and utilizes 24 observable items of medical professionalism that assess 4 different skill areas, and is scored on a 4-point Likert scale. It does, however, have low reliability for peer-to-peer evaluation with concern about the “failure to fail” phenomenon among colleagues.

The Conscientiousness Index awards or deducts points for compliance with important administrative tasks, generally in trainees. Points are awarded based upon tasks accomplished, and this index correlates with future professionalism.

Educational Objective: Identify educational tools commonly used to evaluate practicing physicians or faculty members.

Question 26

Correct Answer: A

The correct response is to ask the fellow to reflect on the event and take steps to protect medical work space. The Fellowship Program Director recognizes that the fellow at issue has no record of problematic behavior, was sleep- deprived with his intense clinical schedule and three children at home; and was frightened by a perceived physical assault. Rather than recording a lapse in professionalism, the Program Director counsels the fellow to attempt to get more sleep, to take other measures to be less “on edge,” and to apologize to the patient and his family. He also realizes that the fellow’s professionalism was affected by an environment in which an apparently emotionally immature patient was able to sneak up on the fellow. Safety measures are initiated with hospital security and nursing staff to avoid similar intrusions into the fellow workroom. This event illustrates the importance of evaluating professionalism from the viewpoints of not only individual behavior but also interpersonal interaction (in this case, a perceived assault) and a socially determined phenomenon. Feedback from this event was formative for the fellow, allowing him to learn from the episode and improve his responses under challenging situations.

Isolated incidents and lapses in behavior can happen to good people and must be interpreted in context. Rather than labelling an individual as “being” unprofessional (implying a bad person), a better strategy is to direct attention to the behavior itself and provide feedback so the behavior does not recur.

This lapse in professionalism occurred in face of the challenging context of a perceived physical assault. Enforcement of an administrative leave of absence for this fellow would be punitive and ignore the context of the situation.


While the patient was immature and used bad judgment, he did not have a psychiatric disorder that would cause danger to others or to himself. A better solution is for the ward team and nursing staff to work with the patient and his family to set boundaries.

Educational Objective: Evaluate lapses in professionalism and determine appropriate responses to different situations.

Question 27

Correct Answer: A

Observing unprofessional behavior can generate moral distress among medical students. When surveyed, 25-50% of residents describe witnessing numerous incidents of disrespect of patients, nurses, and students by other residents, and nearly all students describe witnessing unprofessional behavior by faculty residents and peers. In 2012, one-third of students responding to an American Association of Medical Colleges’ survey reported experiencing public humiliation at least once during medical school.

Physicians and nurses who display disruptive behavior, including intimidation and disrespect, have a negative effect on cooperation among the team.

Almost everyone working in health care has witnessed a physician exhibiting unprofessional or disruptive behavior. Verbal abuse by physicians or other nurses toward nurses can lead to transient decrease in concentration or ability to engage in critical thinking. It is also a significant cause of nursing turnover.

At any institution, approximately 3-5% of physicians exhibit unprofessional behavior that requires intervention by an appropriate authoritative figure. Multiple studies have identified a correlation between poor physician communication, patient dissatisfaction and the risk of malpractice litigation.

Reference(s): Rosenstein AH, Naylor B. Incidence and impact of physician and nurse disruptive behaviors in the emergency department. J Emerg Med. 2012 Jul;43(1):139-148.

Wiggleton C, Petrusa E, Loomis K, et al. Medical students’ experiences of moral distress: development of a web- based survey. Acad Med. 2010 Jan;85(1):111-117.

Hickson GB, Pichert JW, Webb LE, et al. Patient complaints and malpractice risk. JAMA 2002 Jun 12;287(22):2951-2957.

Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf 2008 Aug;34(8):464-471.

Educational Objective: Identify the impact of unprofessional and disrespectful behavior on medical students and other healthcare workers.

Question 28

Correct Answer: B


The correct answer is immediately addressing the matter with the colleague. Dr. Anderson’s remark was indeed unprofessional, but was an isolated lapse by a well-respected physician, likely stemming from fatigue. Dr. Anderson likely realizes this herself but, if attention is not drawn to this type of behavior, it will usually be repeated. In addition, the medical students and nurses will be given the implied message that such behavior is acceptable (the “hidden curriculum”).

The other answers listed are incorrect.

Correction after the moment is usually reserved for situations in which the offender is exhibiting a pattern of behavior over time. In addition, this approach results in a missed opportunity to communicate a valuable lesson on professionalism to the medical students and nurses who witnessed the event. Finally, it is often the case that delayed conversations never occur.

Reporting the incident to a supervisor is an approach referred to as “correction and consequences.” It should be applied for repeated unprofessional behavior even after an awareness intervention and is not required in Dr. Anderson’s case, since this was her first episode of unprofessional behavior.

Dr. Anderson’s action simply is not at a level of seriousness to warrant official sanctions, including consulting the institution’s legal counsel.

Reference(s): Papadakis MA, Paauw DS, Hafferty FW, Shapiro J, Byyny RL; Alpha Omega Alpha Honor Medical Society Think Tank. Perspective: the education community must develop best practices informed by evidence-based research to remediate lapses of professionalism. Acad Med. 2012 Dec;87(12):1694-1698.

Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med. 2007 Nov;82(11):1040-1048.

Educational Objective: Evaluate lapses in professionalism and determine appropriate responses to different situations.

Question 29

Correct Answer: D

A healthcare system that voluntarily discloses meaningful performance information is practicing the organizational value of honesty and the professionalism competencies of integrity and accountability.

An organization that reduces disparities is upholding the organizational value of justice and is practicing the professionalism competency of fairness.

An organization that aspires to improve the organization and profession is upholding the organizational value of beneficence and is practicing the professionalism competency of service to the patient, community and profession.

An organization that promotes cultural sensitivity is upholding the organizational value of dignity and is practicing the professionalism competency of respect for self, patients, and employees.


Reference(s): Egener B, McDonald W, Rosof B, Gullen D. Perspective: organizational professionalism: relevant competencies and behaviors. Acad Med 2012 May; 87(5):668-74.


Educational Objective: Recognize the relationships between organizational values, professionalism competencies, and organizational behaviors and how health care systems influence physician behavior.

Documents

Question 1...Medical Professionalism in Clinical Endocrinology Answers and Rationale Question 1 Correct Answer: A The correct answer is: Under the ACGME¹ and ABMS² six Core Competencies,