You are an organized physician and
your patients appreciate and expect
your promptness. Your start times for
rounds and clinic have been reviewed
on several occasions with Bill a third
year student on his comprehensive
community clerkship. Routinely Bill
shows up late, unprepared in ripped
jeans and a base ball cap.
What strategies would you use in your
discussions with Bill?
Teaching Professionalism:
Critical Conversations
With Our Learners
Northern Constellations 2013
Sudbury, Ontario
January 19, 2013
James Goertzen MD MClSc CCFP
Associate Professor , NOSM
Medical Director Faculty Development, NOSM
Laurel Snyder MD CCFP-EM
Associate Professor, NOSM
Kenora Site Director, NOSM
Conflict Disclosure Information:
No financial or industry
relationships to disclose.
Creative Commons Attribution
Noncommercial/No Derivative Works
Canada License
Learning Objectives:
►Review contextual nature of
professional behavior.
►Review critical role of
preceptors in development of
professionalism among
learners.
►Provide effective strategies
for dealing with learner
unprofessional behavior.
Core Competency
Professionalism is a core
competency for students,
residents and practicing
physicians. Preceptors have
critical roles in assisting their
learners in the development of
professionalism.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012.
Preceptor Challenges
Though it is essential to provide
feedback that addresses the
professional behavior of
learners, preceptors tend to be
silent about professional
expectations and rationalize
lapses in professionalism.
Goertzen J. Developing professionalism in our learners: Critical conversations. The
Foundation for Medical Practice Education, 2011.
Professionalism: Biased
Perception
• As physicians we accept that
we all have limits to our medical
knowledge & expertise.
• In contrast, physicians are less
comfortable in acknowledging
their professional failings,
attitudes and behaviors.
Ladouceur R. Family physicians and professionalism. Can Fam Physician 2009;55:961.
Define
Professionalism:
Definition of Professionalism
• Adherence to ethical practice
principles.
• Effective interactions with
patients and with people
important to those patients.
• Reliability and accountability.
Wilkinson T, Wade W. A blueprint to asses professionalism: Results of a systematic
review. Acad Med 2009;84:551-8.
Definition of Professionalism
• Effective interactions with
people working within the health
care system.
• Commitment to maintenance
and improvement of competence
in self, others, and systems.
Wilkinson T, Wade W. A blueprint to assess professionalism: Results of a systematic
review. Acad Med 2009;84:551-8.
Definition of Professionalism
• Professionalism can be difficult to
define since is not limited to a
static set of traits or
characteristics.
• Concepts of professionalism
evolve with changes in social
norms and patient expectations.
Goertzen J. Developing professionalism in our learners: Critical conversations. The
Foundation for Medical Practice Education, 2011.
Definition of Professionalism
Professionalism is largely
contextual and best understood
as a series of behaviors within a
clinical setting rather than a
series of personal character
traits or attributes.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Preceptor Challenges
The challenge for preceptors is
to provide relevance for their
learners to the seemingly
abstract concepts of
professionalism within the
clinical setting.
Goertzen J. Developing professionalism in our learners: Critical conversations. The
Foundation for Medical Practice Education, 2011.
Preceptor Challenges
Within the clinical setting,
patient problems rarely have
black and white solutions.
Learners often struggle to
balance competing demands.
Leong R. Do FP agree on what professionalism is? No. Can Fam Physician
2009;55:969-71.
Role of Preceptors
Preceptors can assist learners by
linking the principles of
professionalism to their
relationships with patients, with
other physicians and health care
professionals, with communities,
and with self.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Attaining Competence
Development of professionalism
follows a parallel process to
attaining clinical competence.
Following the introduction of the
principles of professionalism,
application with in the clinical
setting leads to competence.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Role Modeling
Within the clinical setting, as
students and residents
internalize the concepts of
professionalism, they are greatly
influenced through the role
modeling of their preceptors and
other health care professionals.
Cruess Rl, Cruess SR. Teaching professionalism: General principles. Med Teacher
2006;28(3):205-8
Role Modeling
Effective preceptors exhibit the
positive aspects of
professionalism articulating the
rational for their behaviors. They
provide clinical opportunities for
learners to exhibit professional
behaviors along with time to
reflect and discuss experiences.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Purposeful Preceptoring
Involving learners in common
clinical scenarios can be
purposeful when the encounter is
used as a catalyst for discussion
of potential patient physician
conflict such as requests for
diagnostic tests or negotiating
length of work absences.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Program Expectations
It is important that programs
clarify professional values and
expectations with all learners.
These expectations can act as a
frame of reference by which
lapses in professional behavior
can be measured.
Larkin GL, Binder L, Houry D, Adams J. Defining and evaluating professionalism: A
core competency for graduate emergency medical education. Acad Emer Med
2002;9(11):1249-56.
You are an organized physician and
your patients appreciate and expect
your promptness. Your start times for
rounds and clinic have been reviewed
on several occasions with Bill a third
year student on his comprehensive
community clerkship. Routinely Bill
shows up late, unprepared in ripped
jeans and a base ball cap.
DISCUSSION:
1. How is Bill’s behavior
unprofessional?
2. What strategies would you use
when discussing your concerns
with Bill?
DISCUSSION:
3. How would you respond to
Bill’s concern that it is unfair
that his day starts earlier than
the other students and
preceptors in your community?
DISCUSSION:
4. Due to your responsibilities as
Department Head for Family
Medicine, you have been late
for several of your clinics over
the week. How would you
respond to Bill’s comments
that you are not always on
time?
Learning Objectives:
►Review contextual nature of
professional behavior.
►Review critical role of
preceptors in development of
professionalism among
learners.
Lapses in Professionalism
Lapses in professional behavior by
learners are common and to be
expected. It is through the
experience of learning within a
supervised clinical setting that
the principles of professionalism
can be truly integrated.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Learner Defenses
Maladaptive defence mechanisms
for unprofessional behavior:
• Denial It was really a lapse.
• Discounting He did yell at the
nurse but she had it coming.
• Distancing It was a mistake
but we are all human.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Lapses in Professionalism
A lapse in professional behavior
can be transformed into a critical
learning scenario when we have a
collegial conversation with our
learner and encourage reflection
and assimilation of appropriate
professional behaviors.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Collegial Conversation
Assuming each clinical situation
has one right answer may
truncate dialogue, raising the
likelihood that the learner will
become defensive and limit
exploration of alternatives to
their behavior.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Collegial Conversation
Allow the learner to initially explain
the clinical context and rational
for apparent unprofessional
behavior. In many clinical
situations, conflict may result
from two or more divergent
professional or personal values.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Context and Process
When preceptors understand the
clinical context and process used
by the learner which resulted in
the lapse of professionalism,
effective educational
interventions can be developed
which are learner specific.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Context and Process
Lapses in professionalism can be
resolved when learners realize
the negative impact of their
behavior with patients, physician
colleagues, other health care
professionals, or the profession.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Lapses Occur on a Continuum
Preceptors can address the
majority of learner professional
lapses with a confidential
collegial conversation linked to a
learner commitment to a change
in their professional behavior.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Lapses Occur on a Continuum
Following the collegial
conversation, it is essential for
the preceptor to provide the
learner with further clinical
encounters to address the lapse
along with specific feedback and
appropriate reinforcement.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Lapses Occur on a Continuum
Lapses of a more serious nature
require a staged response:
collegial conversation,
clarification of context and
process resulting in the lapse,
learner reflection, and planning of
future educational activities.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Lapses Occur on a Continuum
Documentation of the lapse is
important. Learners should be
notified of the consequences of
not improving their behavior.
Consult with your program
director for support and to ensure
you are following proper process.
Goertzen J. Teaching professionalism. In: Kelly L. Community-based Medical
Education: a teacher’s handbook, 2012
Your second year resident aspires to be
an excellent physician. She is early at
rounds & clinics along with reading
around cases. She is always on her
smart phone and you have received
complaints from patients and nurses.
When you observe a patient interview,
she looks at her phone every time it
buzzes with seemingly personal calls.
What strategies would you use in your
discussions with Janice?
DISCUSSION:
1. How is Janice’s behavior
unprofessional?
2. What strategies would you use
when discussing your concerns
with Janice?
DISCUSSION:
3. While discussing the impact of
her phone use on patient care,
Janice is searching for articles
to prove that today’s youth are
better multi-taskers than their
older preceptors. You leave the
meeting fuming and threatening
to fail her.
What do you do next?
Lapses in Professionalism
It is critical that preceptors
address lapses of professionalism
during medical training since
student unprofessional behavior
is associated with residency
difficulties and disciplinary action
by licensing bodies in practice.
Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is
associated with subsequent disciplinary action by a state medical board. Acad Med 2004;79(3):244-9.
UNPROFESSIONAL BEHAVIOR
Purpose: Determine if medical students who demonstrate
unprofessional behavior are more likely to have
subsequent licensing board disciplinary action.
Method: Case control study of all California medical school
graduates disciplined by the California Medical Board
from 1990-2000 (68 graduates). Control graduates (196)
were matched by medical school graduation year and
specialty. Variables examined included gender,
undergraduate GPA, MCAT scores, National Board
Examination Part 1 scores, negative excerpts
describing unprofessional behavior in rotation
evaluations, Deans letters for residency placement,
and administrative correspondence. Out come
variable was state board disciplinary action.
Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is
associated with subsequent disciplinary action by a state medical board. Acad Med 2004;79(3):244-9.
UNPROFESSIONAL BEHAVIOR
Results: Medical students graduated from 1943-89. 95% of
disciplinary actions were for deficiencies in
professionalism. Prevalence of negative excerpts in
undergraduate evaluations was 38% and 19% in
controls. Logistic regression analysis showed that
disciplined physicians were more likely to have
negative excerpts (Odds ratio 2.15; 95% CI 1.15-4.02;
p = .02).
Conclusion: Problematic behaviour in medical school is
associated with subsequent disciplinary action by a
state medical board. Professionalism is an essential
competency that must be demonstrated for a student
to graduate from medical school.
Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is
associated with subsequent disciplinary action by a state medical board. Acad Med 2004;79(3):244-9.
UNPROFESSIONAL BEHAVIOR
Purpose: Identify the domains of unprofessional behavior
that in medical school that are linked to disciplinary
outcomes in practice.
Method: Case control study of all California medical school
graduates disciplined by the California Medical Board
from 1990-2000 (68 graduates). Control graduates
(196) were matched by medical school graduation year
and specialty. Negative excerpts describing
unprofessional behavior in rotation evaluations, Deans
letters for residency placement, and administrative
correspondence were extracted. Qualitative analysis
was carried out to clarify domains of behaviors that
had been indentified as unprofessional by faculty.
Teherani A, Hodgson CS, Banach M, Papadakis MA. Domains of unprofessional behavior during medical
school associated with future disciplinary action by a state medical board. Acad Med 2005;80(10):S17-20.
UNPROFESSIONAL BEHAVIOR
Results: Three domains of unprofessional behavior
emerged that were significantly related to later
disciplinary action: poor reliability and responsibility,
lack of self-improvement and adaptability, poor
initiative and motivation.
Conclusion: Medical students experiencing difficulty in any
of the three identified domains of unprofessional
behavior were more likely to be disciplined in future
practice. Study findings suggest that faculty include
assessment of these behaviors in their evaluation of
medical students.
Teherani A, Hodgson CS, Banach M, Papadakis MA. Domains of unprofessional behavior during medical
school associated with future disciplinary action by a state medical board. Acad Med 2005;80(10):S17-20.
Hidden Curriculum
Hidden Curriculum
During medical training, learners
must often grapple with the
dissonance between espoused
virtues and professional
responsibilities and the actual
behaviors exhibited by physicians
in every day clinical practice.
Gaufberg EH, Batalden M, Sands R, Bell SK. The hidden curriculum; What can we learn from thirdyear medical student narrative reflections? Acad Med 2010;85(11):1709-16.
Define
Hidden Curriculum:
Hidden Curriculum
Learning that occurs through
informal interactions among
students, faculty, and others
and/or
Learning that occurs through
organizational and cultural
factors intrinsic to training
institutions.
Gaufberg EH, Batalden M, Sands R, Bell SK. The hidden curriculum; What can we learn from thirdyear medical student narrative reflections? Acad Med 2010;85(11):1709-16.
Hidden Curriculum
Learners struggle to understand
explicit professional values they
are taught and the implicit
values of the hidden curriculum.
Conflict invites compromise in
the area of professionalism along
with disillusionment with the
practice of medicine.
Brainard AH, Brislen HC. Viewpoint: Learning professionalism: A view from the trenches. Acad Med
2007;82(11):1010-14.
Preceptor Responsibilities
Preceptors must lead by example
along with holding themselves
accountable for unprofessional
behavior within their clinical
settings. Programs should have
a zero-tolerance policy for
unprofessional behavior of
anyone in a teaching role.
Brainard AH, Brislen HC. Viewpoint: Learning professionalism: A view from the trenches. Acad Med
2007;82(11):1010-14.
Online Professionalism
• Social media (Face book/Twitter)
creates new hazards for medical
professionalism.
• On the internet, physicians may
leave behind a “footprint” that
may have unintended negative
consequences.
Greysen S, Kind T, Chretien K. Online professionalism and the mirror of social media. J
Gen Intern Med 2010;25:1227-9.
Preceptor Responsibilities
As medical trainees become more
technologically savvy, it is the
responsibility of medical
educators to familiarize
themselves not only with the
advantages of the technology
but also with the negative
effects of its misuse.
Farnan J, Paro J, Higa J, Reddy S, Humphrey H, Arora V. Commentary: The relationship status of
digital media and professionalism: It’s complicated. Acad Med 2009;84(11):1479-81..
Physician Self-Care
Professionalism includes physician
self-care. Discussions about
coping strategies, help seeking
behavior, personal physicians,
boundaries, and physician
patients provide opportunities for
learners to develop appropriate
self-care strategies.
Spencer J. Physician, heal thyself but not on your own, please. Med Educ 2005;39(6):548-9.
Learning Objectives:
►Review contextual nature of
professional behavior.
►Review critical role of
preceptors in development of
professionalism among
learners.
►Provide effective strategies
for dealing with learner
unprofessional behavior.
Preceptor Responsibilities
Medical schools and residency
programs begin the process of the
professional development of
medical trainees. It is the
community of practicing
physicians and preceptors who
must accept responsibility for
maintaining professionalism.
Lucey C, Souba W. The problem with the problem of professionalism. Acad Med 2010;85:1018-24.
PROFESSIONALISM
Core competency
Preceptors have central role in modeling
Learner lapses are expected
Lapses are invitation for collegial conversation
Understanding learner’s clinical context is essential
Questions
Comments
Reflections
jgoertzen@tbaytel.net
laurel@breiterphoto.com