1. Teaching and Assessing Medical Professionalism at Mayo Clinic
Paul S. Mueller, MD, MPH
Associate Professor of Medicine

2. Objectives Define professionalism
Describe the rationale for teaching and assessing professionalism
Describe methods for teaching and assessing professionalism
Describe Mayo Clinic experiences with teaching and assessing professionalism

3. What is professionalism?

4. Hallmarks of a profession
Competence in a specialized body of knowledge
Acknowledgment of specific duties and responsibilities
Autonomy to train, admit, monitor, and discipline its members; a privilege granted by society through licensure

5. AAMC Medical School Objectives
Physicians must be:
Altruistic
Knowledgeable
Skillful
Dutiful

6. Accreditation Council for GME General competencies http://www. acgme

7. ABIM/ACP Charter on Medical Professionalism Ann Intern Med 2002;136: and Ann Intern Med 2003;138:
Less than 15 months after its release, the Charter was endorsed by more than 90 specialty societies.

8. Clinical competence (knowledge)
Excellence
Humanism
Accountability
Altruism
Professionalism
Sound ethics
Communication skills
Clinical competence (knowledge)
From: Stern D., ed. Measuring Professionalism (New York: Oxford University Press, 2006). 8

9. Professionalism at Mayo Clinic Historical perspective
Altruism
Reflection
Teamwork
Humanism
Communication
Excellence
“The best interest of the patient is the only interest to be considered… and in order that the sick may benefit from advancing knowledge a Union of Forces is necessary”
William J. Mayo, MD June 1910

10. Mayo’s primary value “The needs of the patient come first.”

11. Mayo’s mission “Mayo will provide the best care to every patient every day through integrated clinical practice, education, and research.”

12. The Mayo Clinic Model of Care

13. What makes Mayo unique? Not smart physicians or breadth of science
Rather:
Patient-centered care
Multidisciplinary teamwork
Allied health personnel
Remarkable facilities
Unique culture and ethos

14. Should professionalism be taught?

15. Patient expections Ideal physician behaviors Mayo Clin Proc
192 patients in 14 specialty settings:
Confident: engenders trust
Empathetic: “Understands my feelings”
Humane: compassionate and kind
Personal: patient is a person, not a disease
Forthright: “Tells me what I need to know”
Respectful: “Takes my input seriously”
Thorough: conscientious and persistent

16. Mayo Clinic patient satisfaction
High correlation
High satisfaction
2006 PRC 3-Site Outpatient Satisfaction, n=36500

17. Reasons for concern Professionalism lapses
Conflicts of interest among physicians common
Declining trust in the medical profession

18. Reasons for concern
Unprofessional behavior in training associated with later disciplinary action by licensing boards (NEJM 2005;353: )
Nearly all physician leaders and nurses have experienced disruptive physician behavior (Phys Exec 2004;Sept-Oct:6-14, Am J Nurs 2005;105:54-64, AORN J 2001;74: )

19. Consequences of disruptive physician behavior http://cme. medscape
Reduced employee satisfaction, morale and productivity and increased employee turnover
Reduced communication, teamwork, and efficiency and increased costs
Decreased learner satisfaction, burnout, depression and unprofessional behavior

20. Reasons for optimism

21. Professionalism is not simply innate.
Professionalism can be taught “Advancing Education in Medical Professionalism.” ACGME Outcome Project, 2004.
Formal and informal curricula influence professional attitudes and beliefs, moral reasoning, and behaviors
Role models influence attitudes and behavior; “hidden curriculum”
Professionalism is not simply innate.

22. Professionalism is associated with important outcomes “Advancing Education in Medical Professionalism.” ACGME Outcome Project, 2004.
Increased patient satisfaction and trust
Increased patient treatment adherence
Patients more likely to “stay with” and recommend physician
Fewer patient complaints
Less patient litigation
Overall physician excellence

23. Should professionalism be taught. Yes
Should professionalism be taught? Yes. “Advancing Education in Medical Professionalism.” ACGME Outcome Project, 2004
We are a profession
AAMC, ACGME, ABIM, and JCAHO recommendations and requirements
Expectations of patients and society
Formal and informal curricula influence professional attitudes and beliefs, moral reasoning, and behaviors
Associated with important outcomes

24. How do you teach professionalism?

25. Clinical competence (knowledge)
Excellence
Humanism
Accountability
Altruism
Professionalism
Consider the elements of professionalism.
Sound ethics
Communication skills
Clinical competence (knowledge)
From: Stern D., ed. Measuring Professionalism (New York: Oxford University Press, 2006). 25

26. Teaching professionalism Methods “Advancing Education in Medical Professionalism.” ACGME Outcome Project, 2004
Lectures
Discussion groups
Role plays, simulation
Experiential (eg, clinical setting)
Team learning
Role modeling
Independent learning

27. Teaching professionalism Strategies JAMA 2001;286:1067-1074
Establish a climate of humanism
Be practical and relevant
Recognize and use seminal events
Role model
Encourage self-reflection
Address the “hidden” curriculum

28. Should professionalism be assessed? Yes.
Professionalism can be assessed (Stern DT. Measuring Professionalism; Oxford, 2006)
Formative and summative feedback
“They don’t respect what you expect; they respect what you inspect.” (Cohen JJ. Forward. In Measuring Professionalism; Oxford, 2006)
Evaluate education programs
Failure to assess sends conflicting messages to learners, physicians, and patients.

29. How do you assess professionalism?

30. Assessing professionalism Stern D, ed
Assessing professionalism Stern D, ed. Measuring Professionalism; Oxford, 2006
“Most practicing physicians observe each others’ behaviors only in the hallways and conference rooms--rarely with patients. The solution to this problem is to expand the number of observers and the settings in which they observe.

31. Effective assessment of professionalism Stern D, ed
Effective assessment of professionalism Stern D, ed. Measuring Professionalism; Oxford, 2006 JAMA 2008;300:
Multiple observers and instruments
Variety of settings
Realistic context
Situations that involve conflict
Not overly stringent
Transparency; learners know purpose of assessment
Symmetry; all levels of the hierarchy are assessed

32. What do you do with the information?
Formative feedback
Summative feedback
Reward exemplars
Evaluate professionalism education programs and generate research hypotheses
Using a “professionalism portfolio”

33. Teaching and assessing professionalism at Mayo
All levels:
Allied health staff
Administrators
Medical students
Resident physicians and fellows
Faculty

34. Mayo Medical School Required (school year) professionalism elements
Bioethics core curriculum(1,3)
Anatomy (1): cadaver as first patient, peer review
Professionalism reflections (2)
“Safe Harbor” professionalism program (3)
Assessment (1-4)
Peer and vertical
Result: portfolio on professionalism incorporated into the Dean’s letter

35. Mayo Medical School Elective
Journal club
MD Connect (new student publication)
1-month “selective”

36. Mayo School of Graduate Medical Education Residency and fellowship training
Required for all:
ACGME core competency for all programs
Orientation module on professionalism
Web-based curriculum in development
DOM additional requirements:
Core curriculum
M+M ethics and professionalism sessions
Professionalism OSCEs
Assessment

37. Assessing internal medicine resident professionalism at Mayo
Tests of knowledge
OSCEs
Mentor review of “lapses”
Patient complaint review
Electronic 360-degree assessments by peers, senior residents, faculty, others
Result: professionalism portfolio

38. Electronic assessment

39. Electronic assessment
These 2 questions have the highest inter-rater reliability.

40. Electronic assessment of professionalism at Mayo JAMA 2008;300:1326-1333
The mean score for top 20% (“highly professional”) IM residents was 4.40, and for the remainder was 4.02 (P<.001)
High professionalism scores were associated with greater knowledge, skills, and conscientious behaviors

41. Mayo faculty Required Periodic web-based and interactive modules
CALD program
Professionalism module
Communication module
Note ABIM maintenance of certification
Assessment: attendance, learner evaluations,360-degree reviews

42. CALD professionalism module
Reflective listening
Attributes of professionalism
Review data supporting professionalism
Recognizing and responding to professional and unprofessional behavior
Collaborate with a psychologist
Feedback: outstanding

43. CALD professionalism module

44. CALD communication module
Communication a core competency
Reflective listening re-emphasized
3-function model:
Relationship building
Information gathering
Patient education (eg, new diagnosis)
Didactic, video vignettes, and role play
Feedback: outstanding

45. CALD communication module

46. Mayo faculty Elective Professionalism conferences
Annual ethics conference
Medical grand rounds

47. Mayo allied health staff Minnesota Medicine. 2007;90:47-49.
Nearly 3000 DOM allied health staff
Didactic lectures, video vignettes, and role plays
>95% reported benefit
Increased patient satisfaction in all divisions

48. Teamwork is REAL Relationship building Effective communications
The nexus of professionalism and quality is teamwork
Enterprise-wide program
Common language
Outcomes measured
Relationship building
Effective communications
Assertion
Leading with mutual respect

49. Teamwork Relationship Building Effective Communications Assertion
Work in partnership with all colleagues for the genuine concern and well being of our patients and others
Reflective Listening
PEARLS
Effective Communications
Listen for understanding to the diverse opinions of others
Assertion
Empowered to voice my opinion and trust that it will be heard
Leading with Mutual Respect
Treat one another with respect and courtesy
Acknowledge and value the contributions of others
SBAR
Positive Assertion
Tools

50. Conclusions Medical professionalism is a core competency
Professionalism is associated with important clinical outcomes
Professionalism should be taught and assessed
Professionalism can be taught, learned and assessed

51. Thank you mueller.pauls@mayo.edu
“The best interest of the patient is the only interest to be considered… and in order that the sick may benefit from advancing knowledge a Union of Forces is necessary”