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How to Cite FMCR
Competency-Based Curriculum Resource for Preclerkship Education (using ACGME Structure):
Lead Authors: John C. Rogers,
MD, MPH and Christine Matson, MD
|Christine Matson, MD, Chair
||Eastern Virginia Medical School
|Scott A. Fields, MD
||Oregon Health and Science University
|Jeffrey Stearns, MD, Executive Committee Liaison
||University of Wisconsin Milwaukee Clinical Campus
|Eric Bass, MD
|Johns Hopkins University
|Thomas Defer, MD
|Allan Goroll, MD
|Larrie Greenberg, MD
||George Washington University
|Mary Ann Kuzma, MD
|Steve Miller, MD
|William Raszka, MD
||University of Vermont
|Rick E. Ricer, MD
||University of Cincinnati
|John C. Rogers, MD, MPH
||Baylor Medical College
|William Wilson, MD
|University of Virginia
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.
Students must demonstrate a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity
to contextual issues in a diverse patient population.
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
- 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
- Describe the physiological and psychological consequences of
- Describe personal responses to stress and appropriate stress
- 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
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
- 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
- Identify personal health information and avoid its inappropriate
- Identify the elements of informed consent and recognize clinical
situations when obtaining it is required.
- 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
- 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
*or equivalent intensive clinical year
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;
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
- 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
- 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.
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.
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
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
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.