Catherine R. Lucey

A Behavioral and Systems View of Professionalism

Professionalism may not be sufficient to drive the profound and far-reaching changes needed in the US health care system, but without it, the health care enterprise is lost. Formal statements defining professionalism have been abstract and principle based, without a clear description of what professional behaviors look like in practice. This article proposes a behavioral and systems view of professionalism that provides a practical approach for physicians and the organizations in which they work. A more behaviorally oriented definition makes the pursuit of professionalism in daily practice more accessible and attainable. Professionalism needs to evolve from being conceptualized as an innate character trait or virtue to sophisticated competencies that can and must be taught and refined over a lifetime of practice. Furthermore, professional behaviors are profoundly influenced by the organizational and environmental context of contemporary medical practice, and these external forces need to be harnessed to support--not inhibit--professionalism in practice. This perspective on professionalism provides an opportunity to improve the delivery of health care through education and system-level reform.

Reforming internal medicine residency training : A report from the society of general internal medicine's task force for residency reform

The structure, process, and outcomes of internal medicine residency training have concerned the profession for over 20 years.1–9 Over the last decade the initiative to move to outcomes-based education redefined the competencies physicians should obtain during training.10,11 The core principle of outcomes-based education is the objective demonstration that a graduating trainee, whether from medical school or a residency, possesses the knowledge, skills, and attitudes necessary to progress to the next stage of his or her professional career.12,13 The Accreditation Council for Graduate Medical Education (ACGME) and the Institute of Medicine (IOM) have defined core competencies for physicians shown in Table 1.10,14 While both the ACGME and IOM provide a framework for the desired outcomes, medical educators bear the burden of designing the structures and processes to achieve them.15 Table 1 Comparison of the IOM and ACGME Competencies Educators face several key challenges in redesigning residency programs. First, residency programs must prepare trainees for a variety of general internal medicine and subspecialty careers. Second, the settings and resources for residency training are highly heterogeneous. Third, an aging and increasingly diverse population, combined with rapidly expanding medical information and procedural technology, challenges all internists to acquire and maintain the knowledge, skills, attitudes, and performance necessary to provide high-quality care within their chosen discipline.16,17 Finally, growing public dissatisfaction, substantial health care disparities, increased acuity but shorter lengths of stay for hospitalized patients, new work hour requirements, increasing medical student debt, and changing student demographics and lifestyle concerns further complicate residency reform.18–25 To provide recommendations for residency reform. The Society of General Internal Medicine (SGIM) convened a task force consisting of physicians representing a broad range of views within general medicine, expertise and experience in clinical education, and who represented internal medicine organizations outside of SGIM (Appendix 1). The task force focused on reform in 5 specific areas: ambulatory education, inpatient education, residency curriculum, health disparities, and life-long learning skills. To prepare this report, 4 subcommittees performed literature reviews that guided a prospective, systematic process to develop the final recommendations. The guiding principles, task force timeline, and the specific findings of the 4 subcommittees can be viewed at http://www.sgim.org. We acknowledge this report cannot cover all important aspects of residency training. The task force enthusiastically welcomes comments from other educators and internal medicine specialty organizations. Only through active collaboration and serious dialogue can we improve residency training.

Medical Education Part of the Problem and Part of the Solution

Medical education today is pedagogically superb, but the graduates of our educational programs are still unable to successfully translate decades of biomedical advances into health care that reliably meets the Institute of Medicine quality criteria. Realizing the promise of high-quality health care will require that medical educators accept that they must fulfill their contract with society to reduce the burden of suffering and disease through the education of physicians. Educational redesign must begin with the understanding that the professional identity of the physician who was successful in the acute disease era of the 20th century will not be effective in the complex chronic disease era of the 21st century. Medical schools and residency programs must restructure their views of basic and clinical science and workplace learning to give equal emphasis to the science and skills needed to practice in and lead in complex systems. They must also rethink their relationships with clinical environments so that the education of students and residents accelerates the transformation in health care delivery needed to fulfill our contract with society.

Perspective: the problem with the problem of professionalism.

Enhancing professionalism is an important goal of all physicians, both as individuals and as members of educational and institutional communities of practice. Despite a great deal of dialogue and discourse, the medical profession struggles to ensure that all physicians are able to embrace and live the values of professionalism, notwithstanding the myriad stressors present in todays evolving health care environment. The authors suggest a move beyond the traditional educational paradigms focused on reinforcing rules, providing role models, rewarding right behavior, and removing those who falter, and that we instead view the problem of professionalism as a complex adaptive challenge requiring new learning. Approaching lapses in professionalism as a form of medical error may provide a fresh outlook and may lead to the development of successful strategies to help physicians realize their commitment to the values of professionalism, despite the inevitable challenges that arise throughout their careers.

Transforming From Centers of Learning to Learning Health Systems The Challenge for Academic Health Centers

Health care organizations face intensifying pressure to achieve the triple aims of better patient experience, better health, and affordability. Although all health systems grapple with these imperatives, the tripartite mission of research, education, and patient care presents particular challenges for academic health centers in responding to demands for high-value, patient-centered care and population health. In this Viewpoint, we propose that health reform offers an opportunity for academic health centers to create new synergies across mission areas to become exemplary learning health systems.

Elephants in academic medicine.

Purpose To study the types, causes, and consequences of academic health center (AHC) “elephants,” which the authors define as obvious problems that impair performance but which the community collectively does not discuss or confront. Method Between April and June 2010, the authors polled all the chairs of departments of medicine and of surgery at the then 127 U.S. medical-degree-granting medical schools, using a combination of Web and postal surveys. Results Of the 254 chairs polled, 139 (55%) responded. Of 137 chairs, 95 (69%) reported that elephants in their organizations were common or widespread. The most common elephant reported was misalignment between goals and available resources. Chairs felt that the main reason faculty are silent is their perception that speaking up will be ignored and that the consequences of elephants include impaired organizational learning, flawed information resulting in poor decisions, and negative effects on morale. Chairs felt elephants were more problematic among deans and hospital leaders than in their own departments. Of 139 chairs, 87 (63%) said that elephants were discussed inappropriately, and of 137 chairs, 92 (67%) believed that creating a culture that dealt with elephants would be difficult. Chairs felt the best antidote for elephants was having senior leaders lead by example, yet 77 of 139 (55%) reported that the actions of top leaders fed, rather than dispelled, elephants. Conclusions AHC elephants are prevalent and detrimental to learning, organizational decision making, and morale, yet the academic medicine community, particularly its leadership, insufficiently confronts them.

Methods of teaching and evaluating electrocardiogram interpretation skills among cardiology fellowship programs in the United States

BACKGROUND This study examines the methods used by cardiology training programs within the United States to teach electrocardiogram (ECG) interpretation and prepare fellows for the American Board of Internal Medicine board examination. METHODS A link to an 18-question Web-based survey was electronically mailed to 198 fellowship directors in the United States. RESULTS The response rate was 45%. Most participating programs were university hospitals or affiliates (77%) and of moderate size (at least 11 total fellows [72%]). Programs were coordinated by senior (68%) general (60%) cardiologists. Only 42% of the programs performed formal testing. The American Board of Internal Medicine answer sheet was used by most faculty (92%) when teaching ECG interpretation. CONCLUSIONS Teaching of ECG interpretation varies among US fellowship programs. Coordination of curricula is performed by senior faculty, likely reflecting a trend toward subspecialization and dilution of ECG expertise among younger faculty. Future endeavors should focus on curriculum standardization with regular competency assessment.

Putting the Secure Examination to the Test

RECENT CONTROVERSY ABOUT THE AMERICAN Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) process has centered on the role of the secure examination. Some physicians object to taking any examination, whereas others assert that the internal medicine and subspecialty examinations are not sufficiently focused to reflect physician practices. Others have questioned why the examination is not “open-book” to mirror a real-world practice environment. Even though all 24 certifying boards of the American Board of Medical Specialties require secure examinations for MOC, and many have required recertification for decades, the questions raised regarding ABIM examinations have relevance to all medical specialties. This Commentary intends to clarify the science and philosophy behind examination development and the current psychometric principles that guide the process. Certifying boards strive to provide the public with useful information about a physician’s competence while meeting expectations both of physicians and the public for a relevant, valid, and reliable assessment process. The ABIM’s MOC is a multidimensional program that meets these goals through tools designed to evaluate several competencies. Physicians choose assessments of knowledge, practice improvement, and communication skills based on personal evaluation of their learning needs and their practice profile. The secure examination component of MOC assesses the broad-based knowledge that the public expects of a physician who identifies himself or herself as a general internist or subspecialist. Its purpose is to define a discipline as well as test an individual’s clinical knowledge and judgment. The ABIM follows the Standards for Educational and Psychological Testing established through a collaboration of the American Psychological Association, the American Educational Research Association, and the National Council of Measurement and Evaluation. These standards represent a wellestablished professional consensus concerning appropriate and fair test use and are based on psychometrics, the science of testing that governs examination administration, production, content, scoring, generalization, and extrapolation to real-world practice. Developing an examination that meets these standards is a labor-intensive undertaking. Clinical content and case scenarios in the ABIM’s MOC examinations are developed by carefully selected committee members to ensure adequate content coverage and to include the perspectives of physicians both in practice and in academia. Topics in which physician intervention has significant effects on patient health outcomes are identified. Each topic proposed for the test is rated by practicing physicians, program directors, and trainees for importance and frequency in practice. Low-rated topics are typically excluded from the MOC examination. Question stems provide mini case simulations or patient vignettes that present a realistic description of the patient, symptoms, and laboratory values, requiring the integration of information, prioritization of alternatives, and use of clinical judgment in reaching an appropriate conclusion and deciding on a course of action. Vignette questions are more relevant to real-world patient care than nonvignettes. Through committee review and pretesting, questions are evaluated to ensure that they are evidence-based, technically sound, and fair. The performance of each question is reviewed for content, difficulty level, and how well it discriminates between physicians who clearly demonstrate competency in the domains expected of internists and those who do not. If a question is too difficult or does not discriminate well among physicians, it may be revised or discarded. The ABIM MOC examinations as currently constructed maintain high reproducibility of test scores (a Cronbach 0.90 [1.0 is the maximum]). To date, case-based multiple-choice questions portrayed as patient vignettes are the most efficient, cost-effective, and feasible method for assessing a broad domain area and extrapolating to real-world patient care. The ABIM is currently studying ways to incorporate computer clinical simulation into the examination to better assess clinical skills and increase realism. To set a credible pass-fail standard, the ABIM relies on a committee of knowledgeable internists from private practice and academic medicine to set an absolute stan-

Value-Added Clinical Systems Learning Roles for Medical Students That Transform Education and Health: A Guide for Building Partnerships Between Medical Schools and Health Systems.

To ensure physician readiness for practice and leadership in changing health systems, an emerging three-pillar framework for undergraduate medical education integrates the biomedical and clinical sciences with health systems science, which includes population health, health care policy, and interprofessional teamwork. However, the partnerships between medical schools and health systems that are commonplace today use health systems as a substrate for learning. Educators need to transform the relationship between medical schools and health systems. One opportunity is the design of authentic workplace roles for medical students to add relevance to medical education and patient care. Based on the experiences at two U.S. medical schools, the authors describe principles and strategies for meaningful medical school–health system partnerships to engage students in value-added clinical systems learning roles. In 2013, the schools began large-scale efforts to develop novel required longitudinal, authentic health systems science curricula in classrooms and workplaces for all first-year students. In designing the new medical school–health system partnerships, the authors combined two models in an intersecting manner—Kotter’s change management and Kern’s curriculum development steps. Mapped to this framework, they recommend strategies for building mutually beneficial medical school–health system partnerships, including developing a shared vision and strategy and identifying learning goals and objectives; empowering broad-based action and overcoming barriers in implementation; and generating short-term wins in implementation. Applying this framework can lead to value-added clinical systems learning roles for students, meaningful medical school–health system partnerships, and a generation of future physicians prepared to lead health systems change.

Survey of current practices in fellowship orientation.

Background: The transition from medical resident to subspecialty fellow is a critical time period in fellowship training that has not been well described. The current practices of fellow orientation in pulmonary and critical care training programs are not known. Objectives: The aim of this study was to describe orientation practices for training programs in the United States. Methods: A 10-question survey was sent via e-mail to program directors of pulmonary/critical care fellowship programs identified on the American Thoracic Society (ATS) webpage of current programs. Results: Eighty-seven programs responded (61.7%), of which 86% had a formal orientation program. The mean time spent in fellow orientation was 5–10 h in didactic sessions and 0–5 h in wet labs. The most frequent didactic sessions were bronchoscopy in 69 programs (80.2%), pulmonary function testing in 63 programs (73.3%) and orientation to hospital services in 63 programs (73.3%). The most frequent use of wet labs was in bronchoscopy training in 60 programs (81.1%) and ventilators in 45 programs (60.8%). Simulators were used in 37 programs (43%). The majority reported that these areas were covered with on the job training, without a formal designated orientation. Conclusion: This survey demonstrated that early fellow training differs across programs in both time spent and clinical and procedural topics covered. An early, standardized approach to clinical and procedural training can assure appropriate exposure that cannot be guaranteed by on the job training. To provide justification for such an approach, clinical outcomes need to be correlated with training methods.