FREDERIC W. HAFFERTY PH.D. PROFESSOR UNIVERSITY OF MINNESOTA SCHOOL OF MEDICINE–DULUTH Professionalism, Best Evidence & Medical Education: A Cautionary Tale December 11, 2009 Warwick Medical School The University of Warwick

Caring versus credentials

A TIMELINE BACKGROUND & CONTEXT

U.S. Medicine’s Modern-Day Professionalism Movement

Key Sub-Movements [WAVES] The call for better definitions The call for better measurement tools The institutionalization of definitions and tools The [possible] shift from an individual motives- based conception of professionalism to a structural view of professionalism

U.S. Medicine’s Modern-Day Professionalism Movement

Professionalism & The Hidden Curriculum

“…the chief barrier to medical professionalism education is unprofessional conduct by medical educators, which is protected by an established hierarchy of academic authority. Students feel no such protection, and the current structure of professionalism education and evaluation does more to harm students' virtue, confidence, and ethics than is generally acknowledged.” Professionalism and the Hidden Curriculum: A Critique Brainard and Brislen: “Learning professionalism: A view from the trenches." Academic Medicine, 82: ; 2007.

U.S. Medicine’s Modern-Day Professionalism Movement

The Conflicted Nature of COI “Unprofessional commercialism” versus ‘appropriate’ commercial activity

Media Coverage: ABC News

Wall Street Journal

An Editorial from the Boston Globe

A Series of Articles from the Milwaukee Sentinel

Milwaukee Sentinel

A Graphic From The Same News Story

Milwaukee Sentinel

AMSA’s PharmFree Scorecard

AMSA’s Scorecard

Original Study

TENSIONS COI as a personal insult [people get insulted when you even raise the issue] COI as evidence-based [we do have research] The dependence on outside funding to run the educational enterprise

AAMC Report

MANAGE

An Opening Salvo

The Myths Small Gifts Full Disclosures

Chimonas, S., Brennan, T. A. & Rothman, D. J. Physicians and drug representatives: Exploring the dynamics of the relationship. Journal of General Internal Medicine 22, (2007)

The Rub

The Nub

Minneapolis Star Tribune

THE CLASH Elimination Versus Management

Traditional Organizational Map Krebs, Valdis. “Managing the 21st Century Organization.” IHRIM Journal 11, no. 4 (2007): 2-8.

How Work Actually Gets Done Krebs, Valdis. “Managing the 21st Century Organization.” IHRIM Journal 11, no. 4 (2007): 2-8.

Map One

Map Two

Map 3

Map Four

A First Year Student Network

MAPPING CONCEPTS

Another Reference: Longitudinal and Integrated Medical Training Hirsh, David A., Barbara Ogur, George Thibault, E., and Malcolm Cox “'Continuity' as an organizing principle for clinical education reform." NEJM 356:

Recent JAMA COI Article

ACGME Competencies Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

MEDICAL SCHOOLS MUST ENSURE THAT THE LEARNING ENVIRONMENT FOR MEDICAL STUDENTS PROMOTES THE DEVELOPMENT OF EXPLICIT AND APPROPRIATE PROFESSIONAL ATTRIBUTES (ATTITUDES, BEHAVIORS, AND IDENTITY) IN THEIR MEDICAL STUDENTS. THE LEARNING ENVIRONMENT INCLUDES FORMAL LEARNING ACTIVITIES AS WELL AS ATTITUDES, VALUES, AND INFORMAL "LESSONS" CONVEYED BY INDIVIDUALS WITH WHOM THE STUDENT COMES INTO CONTACT. MS-31-A The Learning Environment

U.S. Medicine’s Modern-Day Professionalism Movement