PROFESSIONALISM & SUPERVISION Carrie Tibbles, MD Associate Director, GME Beth Israel Deaconess Medical Center GME Orientation 2009

Why study or teach professionalism ? Is it inherent? Can it be learned? Wasn’t your mother really responsible for this stuff?

Boston Doctor abandons patient during spine surgery to cash check The Boston Globe August 18th, 2002 “THE DOCTOR IS OUT” Boston Doctor abandons patient during spine surgery to cash check

Professionalism Altruism Accountability Excellence Duty Service Responsive

Professionalism Punctual Cooperative Displays initiative Provides effective leadership Maintains timely records

Professionalism and clinical excellence 148 Internal medicine residents Multiple evaluators over a year High Professionalism scores predicts- Better in-training exam scores Higher Mini-CEX scores Completion of Evaluations Less likely to be on probation Reed, D. JAMA 2008;300 (11).1326

Are Professional Values important? Surgery residency results 24 Residents tracked over 50 months Subjective and Objective measures Rowley et al Clin Ortho & Related Research 2000;378:110

Professionalism & Performance Measures Professional /Subjective Ethical standards & reliability, Punctuality, Patient relations, Interpersonal skills with staff Performance / Objective Test scores, surgical skills, organization, teaching Rowley et al Clin Ortho & Related Research 2000;378:110

Rowley et al Clin Ortho & Related Research 2000;378:110 Each resident received a scores in Professionalism (subjective) and Performance (objective) areas All residents scoring below the mean in Professionalism scored lower (< 0.001) on all performance (objective) measures when compared to those with scores above the mean on the Professionalism measures Rowley et al Clin Ortho & Related Research 2000;378:110

Unprofessional behaviors .. subsequent disciplinary actions Does unprofessional behavior in residency predict future disciplinary action? Over 66,000 internal medicine graduates Measures included Resident Evaluations and ABIM Certification Exams Papadakis et al 2008; Annals Internal Medicine148:869-876.

Supervision …. “residents must be supervised by teaching staff in such a way that the residents assume progressively increasing levels of responsibility according to their level of education, ability and experience.”

It’s about the Patient Patient care should always come first The patient deserves the appropriate level of care Be willing to ask for help

Supervision Know who is supervising you Know who you are supervising Check in on a regular basis Know how to call for help Stat Page system

Some events require attending notification The attending physician needs to be notified in certain circumstances Variable across departments Make sure you know – or ask

Problems arise Not always clear who is responsible to notify the attending Be explicit – ask the question – WHO ? Follow through …

Not enough supervision or Too much supervision Be specific – What could have been different? How is the supervision affecting your autonomy? Talk to chief residents Talk to attendings you know Talk to the PD or Chief

Successful Supervision = win-win situation Easy accessibility Not punitive Allows progressive assumption of increased responsibility / autonomy Superior patient care

Francis W. Peabody The Care of the Patient JAMA 1927 On Professionalism “To begin with, the fact must be accepted that one cannot expect to be a skilful practitioner of medicine in the 4 or 5 years allotted…. Medicine is not a trade to be learned but a profession to be entered. It is an ever widening field that requires the continued study and prolonged experience in close contact with the sick.” Francis W. Peabody The Care of the Patient JAMA 1927