Kathryn M. Ross

The utility of vignettes to stimulate reflection on professionalism: theory and practice

Professionalism remains a substantive theme in medical literature. There is an emerging emphasis on sociological and complex adaptive systems perspectives that refocuses attention from just the individual role to working within one’s system to enact professionalism in practice. Reflecting on responses to professional dilemmas may be one method to help practicing physicians identify both internal and external factors contributing to (un) professional behavior. We present a rationale and theoretical framework that supports and guides a reflective approach to the self assessment of professionalism. Guided by principles grounded in this theoretical framework, we developed and piloted a set of vignettes on professionally challenging situations, designed to stimulate reflection in practicing physicians. Findings show that participants found the vignettes to be authentic and typical, and reported the group experience as facilitative around discussions of professional ambiguity. Providing an opportunity for physicians to reflect on professional behavior in an open and safe forum may be a practical way to guide physicians to assess themselves on professional behavior and engage with the complexities of their work. The finding that the focus groups led to reflection at a group level suggests that effective reflection on professional behavior may require a socially interactive process. Emphasizing both the behaviors and the internal and external context in which they occur can thus be viewed as critically important for understanding professionalism in practicing physicians.

It depends: results of a qualitative study investigating how practicing internists approach professional dilemmas.

Purpose Context has a critical influence on individuals’ behaviors and is essential to understanding lapses in professionalism, yet little is known about contextual factors relevant to practicing physicians. This study used standardized professionalism dilemmas, or challenges, to explore practicing internists’ reasoning in their handling of typical challenges. Method In spring 2011, the authors created several professional challenges relevant to physicians in practice and conducted five focus groups with practicing internists (n = 40). Each group discussed five or six of the challenges, and the facilitators specifically asked what the participants would do and why. The authors used constructivist grounded theory to analyze the transcripts. Results The scenarios were effective in eliciting discussion and debate. Analysis revealed many guiding principles (e.g., patient welfare, keeping patients happy) that influenced physicians in their approach to professionalism challenges, but these principles were highly context-dependent. The authors found individuals’ responses to be malleable and subject to much modification depending on input from peers. Responses often shifted in an iterative and complex manner, depending on factors such as the “type” of patients (including the physician’s personal feelings toward them), the nature of the illness or diagnosis, and the physician’s relationships with others. Conclusions Despite recognizing and articulating basic guiding principles of professionalism, physicians’ approaches to professional challenges were subject to multiple, interdependent, idiosyncratic forces unique to each situation. A deeper understanding of these factors and how they interact is critical for the development of strategies to teach and evaluate professionalism in practice.

Physicians' Knowledge About FDA Approval Standards and Perceptions of the "Breakthrough Therapy" Designation.

Physicians’ Knowledge About FDA Approval Standards and Perceptions of the “Breakthrough Therapy” Designation Before US patients can use new prescription drugs, the US Food and Drug Administration (FDA) reviews the clinical trial results to confirm that benefits outweigh harms for the indication. Approval may involve superiority to placebo, not to an active comparator or standard of care (although approval can be based on uncontrolled or historically controlled studies). Numerous pathways expedite drug development and approval for serious or life-threatening conditions. For example, since 2012, the FDA can designate a drug as a “breakthrough therapy” if preliminary clinical evidence— such as an improvement in a pharmacodynamic biomarker— suggests an advantage over existing options.1 Through April 2015, the FDA designated 76 “breakthrough” drugs,2 and the term is routinely used in press releases3 and prescribing resources.4 Although the term breakthrough leads consumers to overly optimistic beliefs about drug effectiveness,5 it is not known how physicians understand this term—or more generally, what FDA approval means.

Prevalence and Predictors of Generic Drug Skepticism Among Physicians: Results of a National Survey

Prevalence and Predictors of Generic Drug Skepticism Among Physicians: Results of a National Survey Generic drugs are low-cost, therapeutically equivalent versions of brand-name drugs. Use of generic drugs increases patient adherence and improves health outcomes.1 However, a 2009 survey of physicians showed that 23% disagreed that generic dr ugs were as effec t ive as brand-name drugs and 50% reported quality concerns, leading more than one-quarter not to recommend generic drugs as first-line therapy.2 Because generic drugs now make up more than 85% of prescriptions,3 we reassessed physicians’ perceptions and determined how professional or demographic characteristics predict physicians’ support of generic drug prescribing.

A perspective from clinical providers and patients: researchers' duty to actively look for genetic incidental findings.

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Commentary: realizing the formative potential of multisource feedback in regulatory-based assessment programs.

Multisource feedback (MSF) is often promoted as a useful approach for formative assessment and is increasingly becoming part of regulatory-based assessment programs, such as revalidation and maintenance of certification. However, to achieve the full potential of MSF, substantially more attention should be directed at the specific purpose of the MSF instruments and processes and the ability of the results to drive and catalyze efforts to improve health care. MSF developers should revisit the use of comments and open-ended questions to detect contextually rich issues that can guide improvement in the local practice context. Greater attention is also needed around the processes of how the results are interpreted, processed, and applied by physicians. Both government and independent professional self-regulatory bodies walk a difficult tight rope in developing instruments that are psychometrically credible to both physicians and the public, yet truly drive improvements in quality and safety. Ultimately, a formative assessment approach is only as good as the quality of care it detects and improves for the benefit of patients and the public.

When professional obligations collide: context matters.

In “Addressing Dual Agency: Getting Specific About the Expectations of Professionalism,” Tilburt (2014) highlights how the ABIM Physician Charter may fail to guide physicians to arrive at informed decisions in the event of conflicting professional obligations. Upon reflecting on Tilburt’s suggestions for addressing dual agency through prioritization, specification, and role morality, we caution that our work supports the notion that professionalism is nearly always gray due to context. When we explored practicing internists’ reasoning in their perceived handling of typical challenges to professionalism, we discovered that physicians act upon a set of rules or guiding principles when encountering challenges to professionalism, but that these rules or principles are context dependent. We therefore argue that context has such a critical influence on individuals’ responses to professionalism challenges—potentially leading physicians to any one of several “right” decisions— that addressing dual agency by offering specific ways to handle conflicting obligations is not always feasible. First, we posit that professional codes are not designed to be all-encompassing, nor are they intended to suggest “the ideal way” for physicians collectively to handle the conundrum of dual agency. Frustration toward professional codes may exist because critics do not view them as guidelines to be applied on a case-by-case basis. There are varying stances on the subject: Veatch (2012) is against the acceptability of any professional code, while Levine (1993) and to some extent Tilburt (2014) argue the need for a “workable” code of professional ethics. Levine (1993) calls for a normative code that requires acceptance of two prerequisites: (1) emphasis on reality and (2) intelligence in order to comprehend the reality. These two prerequisites for a workable professional code may be helpful as we think critically about Tilburt’s conundrum of dual agency. To begin, we believe that codes such as the ABIM Physician Charter are intended as guidelines for living in reality as professionals in the field of medicine. In reality, it would be difficult for any individual to fulfill the expectations of codes of professionalism, becausewe are human and susceptible to relativity and human error. There may also be gaps between the values or attributes physicians believe to be important for professional behavior, and how these values or attributes play out in professional behavior. Moreover, physicians and patients experience and share different personal narratives. Thus, to suggest that a professional code can offer guidance that is both universal and specific enough to address every challenge is a lofty, if not impossible, goal. The issue of context is also important here. Context has a critical influence on individuals’ behavior and is essential to understanding lapses in professionalism (Ginsburg et al., 2000). Campbell and colleagues (2007) have illustrated that gaps do exist between what physicians endorse as important to professionalism, and how they actually act in practice. In one study by DeRoches and colleagues (2010), the reasons physicians cited for not acting in accordance with their own self-endorsed values (e.g., reporting an impaired colleague) included a belief that someone else would take care of the issue, a belief that nothing would change, and fear of retribution. There may be other ways to think about why physicians may not act in accordance with their professional values and beliefs. Do they modify responsibilities outlined by the ABIM Physician Charter and other professional codes, and if so, how frequently or typically? What kinds of situations might prompt this behavior? How do physicians balance conflicting obligations across a spectrum of professional challenges? In one of our studies, we explored how and why practicing physicians respond to a set of professional challenges (Ginsburg et al. 2012). Our goal was to develop a better understanding of how physicians view these challenges, how they come to decisions about how to act, and what factors influence these decisions.

Addiction as a Disease: The Call for Perspectives From Addicted Individuals’ Family Members and Treatment Providers

In “Addiction: Current Criticism of the Brain Disease Paradigm,” Hammer and colleagues (2013) tackle an important issue by attempting to determine whether or not addiction should be thought of as a disease. Specifically, they look to the opinions of both addicted individuals and addiction researchers to understand this conundrum. The opinions shared weighed the benefits and risks for conceptualizing addiction as a disease, but the authors ultimately conclude that the concept of addiction should remain broad rather than “simply a brain disease.” However, we believe that the authors’ conclusion is missing the viewpoints of others significantly affected by addiction: family members and treatment providers, who offer insight equally as important as that of addicted individuals and addiction researchers. The additional viewpoints and attitudes toward addiction from family members and treatment providers would provide further evidence for whether or not considering addiction a disease would be beneficial for the treatment and research of addiction. Addiction is known to cause ruptures within families, interfere with an individual’s work performance, cost the United States billions of dollars, increase crime and homelessness, and lead to diseases or accidents involving serious injuries or death (Hammer et al. 2013; National Institute on Drug Abuse [NIDA] 2010). While advancements continue to be made toward providing evidence-based treatments for addiction, including psychological and pharmaceutical, the relapse rate of addictive behavior remains high (NIDA 2010). Researchers found relapse and remission rates are similar to those of chronic diseases such as type II diabetes, hypertension, and asthma (McLellan et al. 2000). Research indicates addiction treatment providers, which could include such professionals as certified addiction therapists, psychiatrists, psychologists, social workers, and nurses, vary in their approaches to treatment. White, Boyle, and Loveland (2003) discuss how addicted individuals tend to receive more acute forms of care, despite longheld views of addiction as a chronic disease. They call for

Internal Medicine Physicians’ Financial Relationships with Industry: An Updated National Estimate

Financial relationships between physicians and prescription drug or medical device manufacturers remain controversial. Recent large national studies have shown such relationships are associated with prescription of brand-name drugs, especially those sold by the sponsoring manufacturer, over equally effective lower-cost generics. 2 Since 2013, industry payments and gifts are being publicly reported. Also, some large academic medical centers, physician employers, such as Kaiser Permanente, and states have banned or restricted detailing visits, physician payments, or gifts, and some manufacturers have changed their own practices for certain gifts. We conducted a national survey of internal medicine physicians to assess how their financial relationships with industry have changed in this context.

Do Faculty Benefit From Participating in a Standardized Patient Assessment as Part of Rater Training? A Qualitative Study.

Purpose To explore faculty’s experience participating in a standardized patient (SP) assessment where they were observed and assessed and then received feedback about their own clinical skills as part of a rater training faculty development program on direct observation. Method In 2012, 45 general internist teaching faculty from 30 residency programs participated in an eight-station SP assessment with cases covering common clinical scenarios. Twenty-one participants (47%) received verbal feedback from SPs and a performance-based score report. All participants reflected on the experience through an independent written exercise, one-on-one interviews, and a focus group discussion. Grounded theory was used to analyze all three reflections. Results Eleven participants (24%) previously completed an SP assessment post training. Most found the SP assessment valuable and experienced emotions that increased their empathy for learners’ experiences being observed, being assessed, and receiving nonspecific feedback. Participants receiving verbal feedback from SPs described different themes around personal improvement plans compared with the nonfeedback group. Conclusions Faculty experience many of the same emotions as trainees during SP encounters and view SP assessment as a valuable mechanism to improve their own clinical skills and assessments of trainees. SP assessments may be one approach to provide faculty feedback about core clinical skills needed in their own patient care as well as what they are expected to teach trainees. Although actual changes in participants’ clinical or assessor skills were not measured (more research is merited), findings hint at a “dual benefit” from incorporating SP assessment into a faculty development workshop about assessment.