A modified Delphi approach to nurturing professionalism in postgraduate medical education in Singapore

INTRODUCTION

Nurturing professional identities instils behavioural standards of physicians, and this in turn facilitates consistent professional attitudes, practice and patient care. Identities are socioculturally constructed efforts; therefore, we must account for the social, cultural and local healthcare factors that shape physicians' roles, responsibilities and expectations. This study aimed to forward a programme to nurture professionalism among physicians in Singapore.

METHODS

A three-phase, evidenced-based approach was used. First, a systematic scoping review (SSR) was conducted to identify professionalism elements. Second, a questionnaire was created based on the findings of the SSR. Third, a modified Delphi approach, which involved local experts to identify socioculturally appropriate elements to nurture professionalism, was used.

RESULTS

A total of 124 articles were identified from the SSR; these articles revealed definitions, knowledge, skills and approaches to nurturing professionalism. Through the modified Delphi approach, we identified professional traits, virtues, communication, ethical, self-care, teaching and assessment methods, and support mechanisms.

CONCLUSION

The results of this study formed the basis for a holistic and longitudinal programme focused on instilling professional traits and competencies over time through personalised and holistic support of physicians. The findings will be of interest to medical communities in the region and beyond.

Teaching Ethics and Professionalism: A National Survey of Ophthalmology Residency Program Directors

Background While ethics and professionalism are important components of graduate medical education, there is limited data about how ethics and professionalism curricula are taught or assessed in ophthalmology residency programs.

Objective This study aimed to determine how U.S. ophthalmology residency programs teach and assess ethics and professionalism and explore trainee preparedness in these areas.

Methods Directors from accredited U.S. ophthalmology residency programs completed an online survey about components of programs' ethics and professionalism teaching curricula, strategies for assessing competence, and trainee preparedness in these areas.

Results Directors from 55 of 116 programs (46%) responded. The most common ethics and professionalism topics taught were informed consent (38/49, 78%) and risk management and litigation (38/49, 78%), respectively; most programs assessed trainee competence via 360-degree global evaluation (36/48, 75%). While most (46/48, 95%) respondents reported that their trainees were well or very well prepared at the time of graduation, 15 of 48 (31%) had prohibited a trainee from graduating or required remediation prior to graduation due to unethical or unprofessional conduct. Nearly every program (37/48, 98%) thought that it was very important to dedicate curricular time to teaching ethics and professionalism. Overall, 16 of 48 respondents (33%) felt that the time spent teaching these topics was too little.

Conclusion Ophthalmology residency program directors recognized the importance of an ethics and professionalism curriculum. However, there was marked variation in teaching and assessment methods. Additional work is necessary to identify optimal strategies for teaching and assessing competence in these areas. In addition, a substantial number of trainees were prohibited from graduating or required remediation due to ethics and professionalism issues, suggesting an impact of unethical and unprofessional behavior on resident attrition.

Preventing Egregious Ethical Violations in Medical Practice: Evidence-Informed Recommendations from a Multidisciplinary Working Group

This article reports the consensus recommendations of a working group that was convened at the end of a 4-year research project funded by the National Institutes of Health that examined 280 cases of egregious ethical violations in medical practice. The group reviewed data from the parent project, as well as other research on sexual abuse of patients, criminal prescribing of controlled substances, and unnecessary invasive procedures that were prosecuted as fraud. The working group embraced the goals of making such violations significantly less frequent and, when they do occur, identifying them sooner and taking necessary steps to ensure they are not repeated. Following review of data and previously published recommendations, the working group developed 10 recommendations that provide a starting point to meet these goals. Recommendations address leadership, oversight, tracking, disciplinary actions, education of patients, partnerships with law enforcement, further research and related matters. The working group recognized the need for further refinement of the recommendations to ensure feasibility and appropriate balance between protection of patients and fairness to physicians. While full implementation of appropriate measures will require time and study, we believe it is urgent to take visible actions to acknowledge and address the problem at hand.

Exploring the premise of lost altruism: content analysis of two codes of ethics

As an ideal, altruism has long enjoyed privileged status in medicine and medical education. As a practice, altruism is perceived to be in decline in the current generation. A number of educational efforts are underway to reclaim this "lost value" of medicine. In this paper we explore constructions of altruism over a defined period of time through a content analysis of the Canadian and Australian Medical Associations (CMA and AMA respectively) Codes of Ethics. We analyzed all editions of both Codes (1868-2004), using a content analysis approach, including thematic analysis. We coded as altruistic or non-altruistic, respectively, statements in which the interest of the patient is placed ahead of the physician's and statements in which the interest of the physician is given primacy. We examined the pattern of appearance and disappearance of these statements over time. We identified 13 altruistic and 2 non-altruistic statements across all editions. There is a gradual and uneven loss of altruistic content over time. The CMA Codes of 1938, 1970 and 2004 and the AMA code of 1992 represent significant change points. The most recent versions of both Codes contain only 1 altruistic statement and both non-altruistic statements. We conclude that altruism appears to be a fluid and changing concept over time. Loss of altruism is not merely a current generational issue but extends through the past century and is likely due to political and social forces. These results call into question current educational attempts to reclaim altruism, and point to the social evolution of the ideal.

Impact of a Video-Based Interactive Workshop on Unprofessional Behaviors Among Internal Medicine Residents

BACKGROUND

Unprofessional behaviors undermine the hospital learning environment and the quality of patient care.

OBJECTIVE

To assess the impact of an interactive workshop on the perceptions of and self-reported participation in unprofessional behaviors.

METHODS

We conducted a pre-post survey study at 3 internal medicine residency programs. For the workshop we identified unprofessional behaviors related to on-call etiquette: "blocking" an admission, disparaging a colleague, and misrepresenting a test as urgent. Formal debriefing tools were utilized to guide the discussion. We fielded an internally developed 20-item survey on perception and participation in unprofessional behaviors prior to the workshop. An online "booster" quiz was delivered at 4 months postworkshop, and the 20-item survey was repeated at 9 months postworkshop. Results were compared to a previously published control from the same institutions, which showed that perceptions of unprofessional behavior did not change and participation in the behaviors worsened over the internship.

RESULTS

Of 237 eligible residents, 181 (76%) completed both pre- and postsurvey. Residents perceived blocking an admission and the misrepresentation of a test as urgent to be more unprofessional at a 9-month follow-up (2.0 versus 1.74 and 2.63 versus 2.28, respectively; P < .05), with no change in perception for disparaging a colleague. Participation in unprofessional behaviors did not decrease after the workshop, with the exception of misrepresenting a test as urgent (61% versus 50%, P = .019).

CONCLUSIONS

The results of this multi-site study indicate that an interactive workshop can change perception and may lower participation in some unprofessional behaviors.