Professionalism in GME:
Defining and Measuring Professionalism
David T. Stern, MD, PhD
Vice Chair for Professionalism
Mount Sinai School of Medicine
Albert Einstein College of Medicine
11 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 have
specific 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
Professionalism
Altruism
Accountability
Humanism
Excellence
Ethical and Legal Understanding
Communication Skills
Clinical Competence (Knowledge of Medicine)
Arnold
and Stern,
Arnold
and Stern,
20062006
. . . 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
100
90
80
70
60
50
40
30
20
10
0
Actual
Performance
Self-Assessed
Performance
1st
Quartile
2nd
Quartile
3rd
Quartile
4th
Quartile
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