S. DAWSON THEOGARAJ
30TH ANNUAL LECTURE
Mary H. McGrath, MD MPH
Professor of Surgery
University of California San Francisco
May 7, 2015
S. Dawson Theogaraj, MD FACS
Charlie
McDowell
Wyndell
Merritt
Dawson
Theogaraj
1976 First successful
hand replant in Virginia
S. DAWSON THEOGARAJ
30TH ANNUAL LECTURE
HOW CAN WE TEACH ACCOUNTABILITY AND
PROFESSIONALISM?
Mary H. McGrath, MD MPH
Professor of Surgery
University of California San Francisco
May 7, 2015
Disclosure
Dr. McGrath and collaborators have
funding from The Josiah Macy Foundation
IMAP professionalism grant to study
faculty development in a professionalism
learning community.
This presentation at a glance • Definition of the term
• Why are we being told we must
teach accountability?
• Review past teaching successes
and failures
• Potential blueprint for the future
Four dimensions of Accountability
1. Responsibility – “a duty that binds to the
course of action”
2. Answerability – “being called to account”
3. Trustworthiness – “a trait of being
worthy of trust and confidence”
4. Liability – “being legally bound to a debt
or obligation”
Source of definitions: Webster’s Dictionary
Question for Attendings
Were you taught professionalism and
accountability during your surgical
training?
a) Yes
b) No
Question for Attendings
How did you learn accountability in your
training?
a) Lectures / Grand Rounds
b) Seminars / discussions / rounds
c) M & M Conference
d) Observing other surgeon(s) / role mode
e) I had it before I started training
f) None of the above
Question
Do you think professionalism and
accountability need to be part of the
formal curriculum for surgery residents
today?
a) Yes
b) No
Question
Are surgical trainees today less
committed to professional values?
a) No, they are the same as in the past
b) Yes, they are faced with more challenges
to professional values
Question
Which of the following are primary
challenges to the professional development
of surgical trainees?
a) The social and ethical fabric nationally
b) Resident work hour restrictions
c) The health care delivery system including
employment options
d) Student indebtedness
e) Absence of training in accountability and
professionalism
To summarize . . .
International Social Survey Programme survey (ISSP)
March 2011 through April 2013 (International
Social Survey Programme Research Group.
Supported by RWJ Foundation, and NIMH
n engl j med 371;17 nejm.org october 23, 2014
Public Trust in Physicians — U.S. Medicine in International Perspective
Robert J. Blendon, Sc.D., John M. Benson, M.A., Joachim O. Hero, M.P.H.
• project supported by Robert Wood Johnson Foundation & National Institute of
Mental Health
• polling data on public trust in U.S.physicians and medical leaders 1966-2014
• public trust in the leaders of the U.S.medical profession has declined sharply
over the past half century.
• In 1966, 73% of Americans said they had great confidence in the leaders of
the medical profession.
• In 2012, 34% expressed this view
• only 23% express “a great deal” or “quite a lot” of confidence in the system
(Gallup 2014).
“We believe that the medical profession and its leaders are
a contributing factor.”
“The US is unique among the countries in that it ranks near the bottom in the public’s
trust in the country’s physicians but near the top in patients’ satisfaction with their own
medical treatment.”
Organized medicine’s
response
Public lack of trust
in medical
institutions and
delivery systems
• Evidence based medicine
• Patient safety
• Quality of care
• Team based care
• Physician workforce
• Disclosure of errors
• Physicians need to
rediscover professionalism
• Teach and assess
physician professionalism
Accountability for what?
Evolution of the curriculum in professionalism
Past
Methods
• Group discussion
• Written reflections
• Case based narratives
Topics
• Communication, cultural
diversity, substance abuse,
privacy, disclosing error,
disparities, health delivery
systems, team training
• Altruism, integrity,
compassion, respect,
accountability,
responsibility.
Present
Methods
• Clinical setting with real
patients, real illness
• Exposure to role-model MDs
• Guidance of faculty mentors
• “teachable moment”
Topics
• same
What’s Missing?
JAMA. 2010;304(24):2732-2737
A Behavioral and Systems View of Professionalism
Lesser, CS, Lucey, CR, Egener B, et al.
JAMA. 2010;304(24):2732-2737
A Behavioral and Systems View of Professionalism
Lesser, CS, Lucey, CR, Egener B, et al.
JAMA. 2010;304(24):2732-2737
Individual Physician Behaviors
A Behavioral and Systems View of Professionalism
Lesser, CS, Lucey, CR, Egener B, et al.
JAMA. 2010;304(24):2732-2737
A Behavioral and Systems View of Professionalism
Lesser, CS, Lucey, CR, Egener B, et al.
JAMA. 2010;304(24):2732-2737
Organizational Behaviors (practice settings, professional organizations, physician
advocacy
We do not act rightly because
we have virtue or excellence
but rather we have those
because we have acted rightly.
We are what we repeatedly do.
—Aristotle
. . . an art won by training and habituation
Accountability - not a laudable
attribute, but a behavioral
competency
Virtue
Behavior
Teachable skill
Trustworthiness
Conscientious performance of tasks
Time management skills
Responsibility
Responding to pages constructively
Communication skills
Emotional intelligence
Creating a Professionalism Learning Community
(PLC) to Promote Skills Development of Faculty
through Case-Based Workshops
Tess Lang, MD; Maria A.Wamsley, MD; Arianne Teherani, PhD; Mary H. McGrath, MD MPH; Louise
Aronson, MD MFA; Rachael Lucatorto, MD; Sandrijn van Schaik, MD PhD; Christine Burke; Maxine
Papadakis, MD; Patricia O’Sullivan, MS EdD; Catherine Lucey, MD
Funded by The Josiah Macy/IMAP professionalism grant
Discussion after the moment
Peer coaching
De-escalation
Mental models and triggers
Conflict resolution
Crisis communication
Candid conversations about
unprofessional behavior
Preventing Risks Of Professionalism Slips (PROPS)
Anticipating unprofessional behavior before it happens
Place yourself in their situation
Recommend alternative strategies
Orient them towards sustainable behavior
Provide encouragement
Structure resources into their work *
Regulating Professionalism in the Moment
Disrupting unprofessional behavior when it happens
Recognize and call out the emotion
Relate to the individual in question
Recalibrate towards correct behavior
Redirect the conversation
Summary:
Framework for teaching professionalism
• Clarify domains of a physician’s commitment
• Individual physician’s personal competency
• Social contract with institutions and society (disparity, access, costs,
systems improvement)
• Articulate ideals and values as observable behaviors
• Identify sets of teachable skills that enable the behavior
• Develop faculty trained to teach the skills
• Provide for practice of the skills with guidance, ie feedback
and reflection
• Appreciate the “hidden curriculum” of attending role
modelling and importance of same standards of behavior
Thank you!