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Competency-Based Curriculum Resource for Preclerkship Education (using ACGME Structure):

Professionalism

Lead Authors: John C. Rogers, MD, MPH and Christine Matson, MD

Rationale

When entering core clerkships, students must be prepared to describe the ethical principles of autonomy, beneficence, non-maleficence, and justice that are involved with considerations in daily practice (e.g., patient confidentiality, informed consent, genetic counseling, living wills and advance directives, admission of medical errors, power and sexual boundaries, and physician impairment). Students should be able to explain the need to balance interests of individual patients, their families, and the community or society at large. Students should be able to provide and obtain informed consent, with special attention to patients' perspective on their care.

Competency

Students must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to contextual issues in a diverse patient population.

Goals

Demonstrate commitment to professional virtues and responsibilities.

• Explain what it means to act in a professional way and why a physician must bring characteristics like honesty, integrity, and respect for the patient in all ways into their interactions with patients and other health care professionals.
• Identify challenges to physician responsibilities (e.g., abuse of power, greed, or conflicts of interest), and describe how the welfare of the patient or society should supersede physician's self-interest.
• Demonstrate the ability to take responsibility for one's own actions, including errors.
• Describe examples of systems to improve patient safety.
• Describe the physician's responsibility to choose effective diagnostic and therapeutic modalities based on the best evidence and the patient's priorities.
• Recognize and admit limits of knowledge and skills.
• Demonstrate commitment to lifelong learning.
• Demonstrate self-awareness regarding interactions with others.
• Demonstrate how to cope with difference in people in a constructive way.
• Describe the physiological and psychological consequences of stress.
• Describe personal responses to stress and appropriate stress reduction interventions.
• Describe issues associated with substance abuse and addictive disorders among health professionals.
• Describe students' own risk and resiliency factors for substance abuse and co-dependence.
• Identify useful prevention strategies, treatment resources, and unique recovery issues for substance abuse by health professionals.
• Explain the ethical responsibility for reporting impaired physicians.
• Demonstrate the ability to discuss substance abuse with other health professionals.

Show adherence to ethical principles.

Principles: Autonomy, beneficence, non-maleficence, and justice

• Explain the concepts of autonomy, beneficence, non-maleficence, justice, and virtue.
• Explain the concept of respect for personal autonomy as a foundational principle for ethical conduct in the patient-physician relationship.
• Explain the legal concepts of the common good, informed consent, and battery in the context of the patient-physician relationship.
• Describe the ethical and legal foundations of the right of patients to refuse medical care even when self-harm is the likely result.
• Describe the guidelines for assessing and responding to refusal of treatment by patients.

Provision or withholding of clinical care

• Explain the legal requirements and reasoning behind advance directives.
• Describe the process of assessing a patient's advance directives, including identifying patient's perspective.
• Discuss professional and ethical concept of "duty to treat" in context of physician health risks.
• Describe one's own fears, biases, and attitudes about treating patients or performing procedures presenting real or perceived risks to physicians (e.g., dealing w/ physical violence, AIDS, tuberculosis, hepatitis, or X-ray/chemical/viral exposure).

Confidentiality of patient information

• Describe key concepts that define the essence of privacy as an ethical requirement of the patient-physician relationship.
• Describe the importance of protecting patient privacy through confidentiality.
• Identify personal health information and avoid its inappropriate use.

Informed consent

• Identify the elements of informed consent and recognize clinical situations when obtaining it is required.

Business practices

• Identify the ethical hazard and respond appropriately in situation such as being asked to practice beyond legal limits or personal comfort (e.g., when asked to provide medical care to friends or relatives; use of "doctor" title).

Conflicts of interest

• Identify the ethical hazard and respond appropriately in situations such as
• when educational benefit to student increases risk to patient
• performing procedures upon the newly dead
• acceptance of gifts
• collaboration with industry
• when courted by industry to prescribe their products

Display sensitivity to contextual issues (culture, age, gender, sexual orientation, and disabilities) in a diverse patient population

• Demonstrate the ability to investigate impact of patient's culture, age, gender, sexual orientation, and any disability on clinical care and medical decisions.
• Describe the major issues surrounding the interaction of spirituality and medicine.

*or equivalent intensive clinical year

Educational Methods

The area of Professionalism requires an interactive environment for the knowledge, skills, and attitudes to be learned and practiced. For this reason, a variety of different strategies may be required to best facilitate student learning. Knowledge areas may be transmitted in structured environments such as lectures, videos, or readings. But understanding the meaning of this content requires interactive sessions as well, with opportunity for application to clinical situations and reflection on personal values. This would include small-group experiences that require participants to articulate perspectives, not only as a health care provider, but also to discuss the effects on patients. Additionally, Professionalism may be demonstrated in a mentorship relationship with a practicing physician. This experience must be extensive enough to allow students to see a breadth of behaviors, to create a relationship with enough depth that allows for discussion of these persona l issues, and to anticipate personal contexts in which the student's professionalism would be most challenged.

Resources adapted from

• ABIM Foundation ACP-ASIM Foundation European Federation of Internal Medicine Medical Professionalism Project - MPP2002

Professionalism: Current Approaches

• American Board of Internal Medicine. Project Professionalism. American Board of Internal Medicine. Philadelphia. 1995.
  In the last few decades, advances in medical knowledge and technology have placed greater pressures on physicians to absorb and communicate information to patients and other health professionals. In the wake of these changes, unprofessional behavior and attitudes have eroded medicine's respected position. This document emphasizes the signs and symptoms that erode professionalism, describes aids to professionalism, and presents vignettes that illustrate the unique nature of these quandaries.
• American College of Physicians. Ethics manual, 4 th ed. Ann Intern Med. 1998; 128:576-594.
  Some aspects of medicine are fundamental and timeless, but medical practice does not stand still. Clinicians must be prepared to deal with changes and reaffirm what is fundamental. This manual examines emerging issues in medical ethics and revisits older issues that are still very pertinent. The publication is intended to facilitate the process of making ethical decisions in clinical practice and medical research and to describe and explain underlying principles of decision making.
• Arnold EL, Blank LL, Race KEH, Cipparrone N. Can professionalism be measured? The development of a scale for use in the medical environment. Acad Med. 1998; 73:1119-21.
  This article assesses a scale that measures professional attitudes and behaviors associated with the medical education and the residency training environment. Drawing on a survey of more than five hundred medical students and residents, the authors find encouragement toward the development of a reliable measurement scale.
• Barry D, Cyran E, Anderson RJ. Common issues in medical professionalism: room to grow. Am J Med. 2000; 108:136-42.
  This study assesses responses to common challenges to medical professionalism and to ascertain physician satisfaction with training in professionalism. The authors used a series of vignettes that highlight important challenges to medical professionalism. They found that physicians were more likely than house officers to provide the most acceptable response, and house officers in turn were more likely than medical students. The most difficult scenario involved physician impairment, where only 12% of respondents gave the best answer. Other important findings involve the scope of formal training in professionalism provided to physicians, and the extent of satisfaction with such training.
• Berwick D, Davidoff F, Hiatt H, Smith R. Refining and implementing the Tavistock principles for everybody in health care. British Med J. 2001; 323:616-20.

The Tavistock Group has worked to develop ethical principles that might be useful to everybody involved in health care. They were intended for those who are responsible for the healthcare system, those who work in it, and those who use it. This article describes the origins of the principles, discusses the thinking behind them, considers how they might be used, provides case studies, and reflects on where the venture might go now.

• Brownell AKW, Cote L. Senior residents' views on the meaning of professionalism and how they learn about it. Acad Med. 2001; 76:734-7.
  This study demonstrates that residents' knowledge about professionalism reflects their early stage of development as physicians and their daily activities, where such aspects of professionalism as the social contract, codes of ethics, participation in professional societies, and altruism are not highlighted.
• Chervenak FA, McCullough LB. Professionalism and justice: ethical management guidelines for leaders of academic medical centers. Acad Med. 2002; 77:45-7.
  The ethical concepts of professionalism and justice can be used to create a vital, practical, alternative vision for the leadership of AHCs, in which their missions once again become central to their organizational culture. Creating a morally sustainable organizational culture of professionalism and justice should rely not on forced cooperation, but on voluntary cooperation of all stakeholders in the pursuit of a common goal - professional excellence in patient care, teaching, and research - with survival understood to be a means to this goal.
• Cohen JJ. Measuring professionalism: listening to our students. Acad Med. 1999; 74:1010.
  This concise statement by the President of the Association of American Medical Colleges calls on medical educators to pay as much attention to the evaluation of professionalism in medical students as they do to the evaluation of clinical expertise. The author proposes the introduction of peer review as a useful method for promoting the measurement of professionalism in academic medical environments.
• Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002; 287:226-35.
  Current assessment formats for physicians and trainees reliably test core knowledge and basic skills. However, they may underemphasize some important domains of professional medical practice, including interpersonal skills, lifelong learning, professionalism, and integration of core knowledge into clinical practice. This article proposes a definition of professional competence, reviews current means for assessing it, and suggests new approaches to assessment.
• Ginsburg S et al. Context, conflict, and resolution: a new conceptual framework for evaluating professionalism. Acad Med. 2000; 75:S6-11.
  While the need to evaluate professionalism effectively has been recognized for some time, the authors argue that traditional methods of addressing the problem have not been successful. These standard methods rely on abstract and idealized definitions that place the focus on people, rather than their behaviors, and imply that professionalism is simply a stable set of traits. The authors posit that, contrary to this prevailing conception, evaluation of professionalism is incomplete. They identify several important components that are missing from the current framework, including consideration of the context of unprofessional behavior, the conflicts which lead to lapses, and the reasons behind students' decisions.
• Irvine D. The performance of doctors: the new professionalism. Lancet. 1999; 353:1174-7.
  Concerted efforts are being made to find a modern expression of professionalism that should bring the public and the medical profession closer together. While the public appreciates what medical technology can achieve, the profession is seen as limited in its willingness and ability to communicate effectively, to act promptly to protect patients from poor practice, to be open about risks, and to admit to errors. The author examines the public's expectations and compares current trends in regulatory behavior to demonstrate the need for a new concept of professionalism in medicine.
• Ludmerer KM. Instilling professionalism in medical education. JAMA. 1999; 282:881-2.
  In recent years market forces have posed an unprecedented threat to medical professionalism - particularly the physician's obligation to serve the needs of patients. One significant method for redressing this is the incorporation of instruction about professionalism into the medical school curriculum. The author of this concise editorial addresses the debate over the efficacy of formal courses as a means to instill professionalism.
• Ludmerer KM. Time to heal: American medical education from the turn of the century to the era of managed care. 1999. New York: Oxford University Press.
  This widely acclaimed book provides a landmark account of American medical education throughout the twentieth century, and concludes with a call to reform a system handicapped by managed care and the loss of genuine professionalism.
• Papadakis MA, Loeser H, Healy K. Early detection and evaluation of professionalism deficiencies in medical students: one school's approach. Acad Med. 2001; 76:1100-6.
  The authors discuss an innovative system established at the University of California, San Francisco, School of Medicine which monitors and strives to provide remediation for students demonstrating unprofessional behavior
• Pellegrino ED, Relman AS. Professional medical associations: ethical and practical guidelines. JAMA. 1999. 282:984-6.
  Physicians must choose more definitively than ever whether their professional associations will assert the primacy of ethical commitment or shed any pretense of being moral enterprises and, instead, allow economic considerations to dominate their policies. The authors assert that medical associations must be committed, first of all, to the welfare of the sick, even at some risk to the profession's collective pride and profit. They also suggest that a multitude of physicians would endorse membership in professional associations that demonstrate significant moral leadership.
• Prislin MD, Lie D, Shapiro J, Boker J, Radecki S. Using standardized patients to assess medical students' professionalism. Acad Med. 2001:76:S90-2.
  Much energy has been directed toward defining competencies that reflect professionalism and in creating corresponding curricula that will foster learning in this domain. However, having instruments that can accurately measure the attainment of professionalism remains an elusive goal. This study examines the utility of patient-based assessments of professional characteristics.
• Swick HM, Szenas P, Danoff D, Whitcomb ME. Teaching professionalism in undergraduate medical education. JAMA. 1999; 282:830-2.
  There is a growing consensus among medical educators that to promote the professional development of medical students, schools of medicine should provide explicit learning experiences in professionalism. The authors aim to determine whether and how schools of medicine were teaching professionalism during the 1998-99 academic year. They find that the teaching of professionalism varies widely, and although most programs address this topic in some manner, the strategies used may not always be adequate.
• Wear D, Castellani B. The development of professionalism: curriculum matters Acad Med. 2000; 75:602-11.
  The authors propose that professionalism, rather than being left to the chance that students will model themselves on ideal physicians or somehow be permeable to other elements of professionalism, is fostered by students' engagement with significant, integrated experiences with certain kinds of content. To educate broadly educated physicians who develop professionalism throughout their education and their careers requires a full-spectrum curriculum and the processes to support it. The authors sketch the ways in which admission, curriculum, assessment and licensure could function to maximize that end.
• World Medical Association. World Medical Association declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2000; 284:3034-5.
  The World Medical Association has developed the Declaration of Helsinki as a statement of ethical principles to provide guidance to physicians and other participants in medical research involving human subjects. First adopted in 1964, these principles were amended for the fifth time in October 2000.
• Wynia MK et al. Medical professionalism in society. N Engl J Med. 1999; 341:1612-16.
  The authors undertake to clarify the concept of medical professionalism with a focus on the role of physicians in society. They present a model of professionalism that incorporates three elements: devotion to service, profession of values, and negotiation within society.

Web Sites

• http://www.abim.org/pubs/profess.pdf

Assessment Strategies

The critical importance of physician's professionalism should be reflected in the emphasis on teaching, nurturing, and assessing the professionalism of our students. The assessments should be "high stakes," based on explicit expectations of students, and highly visible. Because self-assessment is an essential element of lifelong learning and self-regulation, students should participate in creating professionalism assessments, including self- and peer- assessments.

Evaluation of Professionalism requires utilization of multiple techniques to address knowledge, skills, and attitudes of future physicians. Videotaping of patient encounters and standardized patient evaluation are methods that enable assessment of behavioral skills (Prislin). Structures within the curriculum must be developed that encourage systematic feedback to students about professional behavior (Papadakis). Careful analyses of students' unprofessional behavior including context, conflict leading to behavior, and reasons may lead to systemic changes that reduce the problem or at least make the behavior more understandable or preventable (Ginsberg). All sources of input are viable, including basic and clinical science faculty, administrative and nursing staff, patients, peers, and self-reflection.

Faculty Development

Faculty development should be focused in the following areas: role of a mentor, discussion of sensitive topics in a non-judgmental fashion, strategies for identifying professional behavior, and methods for providing formative feedback to learners regarding professional behavior.

A key to effecting curricular change regarding professionalism is integrating the concepts across the curriculum rather than adding additional curricular time. Medical educators should make special efforts to identify the counter-professional aspects of the "hidden curriculum" and take steps to achieve congruence between the explicit curriculum and tacit influences, in a positive direction.

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This page last updated November 6, 2004