Six core competencies and seven deadly sins: A virtues-based approach to the new guidelines for graduate medical education

Building on Strengths: An Affirmational and Systems-Level Approach to Revisiting Character in Medicine

ABSTRACT

Although U.S. medical education has continued to place increased emphasis on defining competency standards and ensuring accountability to the public, health care inequities have persisted, several basic health outcomes have worsened, public trust in the health care system has eroded, and moral distress, burnout, and attrition among practicing physicians have escalated. These opposing trends beg the question of how the "good doctor" concept may be strengthened. In this perspective, the authors argue that revisiting the construct of physician character from an affirmational perspective could meaningfully improve medical education's impact on overall health by more holistically conceptualizing what-and who-a good doctor is. The authors introduce positive psychology's framework of character strengths, probe the distinction between character strengths and medical professionalism, and summarize the role of character strengths in promoting physician engagement and well-being in health care work. They contend that a systems-level approach to cultivating character strengths will foster physician moral agency and well-being and, by extension, transformational change in health care. Consistent with best practice in modern character education, the authors propose that institutions mindfully cultivate moral community among all stakeholders (students, faculty, staff, postgraduate trainees, and patients) and that moral community interaction centers on each member's personal aspirations with respect to living a good life, guided by the character strengths framework and informed by patient perspectives.

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.

Character Strengths Profiles in Medical Professionals and Their Impact on Well-Being

Character strengths profiles in the specific setting of medical professionals are widely unchartered territory. This paper focused on an overview of character strengths profiles of medical professionals (medical students and physicians) based on literature research and available empirical data illustrating their impact on well-being and work engagement. A literature research was conducted and the majority of peer-reviewed considered articles dealt with theoretical or conceptually driven 'virtues' associated with medical specialties or questions of ethics in patient care (e.g., professionalism, or what makes a good physician). The virtues of compassion, courage, altruism, and benevolence were described most often. Only a limited number of papers addressed character strengths of medical students or physicians according to the VIA-classification. Those articles showed that the VIA-character strengths fairness, honesty, kindness, and teamwork were considered most often by respondents to be particularly important for the medical profession. Available cross-sectional (time span: six years) and longitudinal (time span: three years) data regarding VIA-character strengths profiles of medical professionals were analyzed (N = 584 medical students, 274 physicians). These profiles were quite homogenous among both groups. The character strengths fairness, honesty, judgment, kindness, and love had the highest means in both samples. Noteworthy differences appeared when comparing medical specialties, in particular concerning general surgeons and psychiatrists, with the former reporting clearly higher levels of e.g., honesty (d = 1.02) or prudence (d = 1.19). Long-term results revealed significant positive effects of character strengths on well-being and work engagement (e.g., perseverance on physicians' work engagement) but also significant negative effects (e.g., appreciation of beauty and excellence on students' well-being). Further, hope was significantly associated both positively with physicians' well-being and negatively with students' work engagement, possibly indicating specific issues concerning medical education or hospital working conditions. According to the modern-day physician's pledge, medical professionals should pay attention to their own well-being and health. Therefore, promoting self-awareness and character building among medical professionals could be a beneficial strategy.

Discussing harm-causing errors with patients: an ethics primer for plastic surgeons

Plastic surgery is a field that demands perfection, yet despite our best efforts errors occur every day. Most errors are minor, but occasionally patients are harmed by our mistakes. Although there is a strong ethical requirement for full disclosure of medical errors, data suggest that surgeons have a difficult time disclosing errors and apologizing. "Conventional wisdom" has been to avoid frank discussion of errors with patients. This concept is fueled by the fear of litigation and the notion that any expression of apology leads to malpractice suits. Recently, there has been an increase in the literature pointing to the inadequacy of this approach. Policies that require disclosure of harm-causing medical errors to the patient and the family, apology, and an offer of compensation cultivate the transparency necessary for quality improvement efforts as well as the positive moral development of trainees. There is little published in the plastic surgery literature regarding error disclosure to provide guidance to practitioners. In this article, we will review the ethical, therapeutic, and practical issues involved in discussing the error with the patient and apologizing by presenting a representative case. This primer will provide an understanding of the definition of medical error, the ethical support of error disclosure, the barriers to disclosure, and how to overcome those barriers.

What can we learn from narratives in medical education?

Medical literature has demonstrated the effectiveness of narrative writing in enhancing self-reflection and empathy, which opens the door for deeper understanding of patients' experiences of illness. Similarly, it promotes practitioner well-being. Therefore, it is no surprise that narrative writing finds a new home in medical education. The Accreditation Council of Graduate Medical Education (ACGME), through its Outcome Project, established six core competencies that every residency program must teach. However, no specific pedagogies were suggested. We explored the role that narrative writing can play in reconciling the ACGME core competencies with daily encounters in medical education. Our study suggests a hidden wealth in reflective writing through narratives with a promising potential for application in medical education. Reflective writing may turn out to be an innovative tool for teaching and evaluating ACGME core competencies.

Application of the core competencies after unexpected patient death: consolation of the grieved

OBJECTIVES

To review and assess educational strategies and formats regarding communication with families/survivors in the aftermath of unexpected and untimely patient death. To propose an integrated curriculum designed and intended to foster proficiency, competence, confidence, and composure in relaying catastrophic information in the context of the professional experience of a cohort of seasoned surgeons.

BACKGROUND

Unexpected and untimely patient death is emotionally and psychologically wrenching for families, surgeons, and healthcare providers. We have previously proffered that 2 distinct, but interactive, phases of response are relevant when communicating with a family before and after the event: a proactive phase intended to establish a positive therapeutic relationship with the family; and a reactive phase intended to respond to the family in a compassionate and respectful manner and to ensure self-care for the physicians and health care providers.

STUDY DESIGN

Survey of a cohort of senior surgeons (membership of the Southern Surgical Association) and Surgical Residency Program Directors (membership of the Association of Program Directors in Surgery).

RESULTS

Sixty percent of the senior surgeons surveyed had experienced unexpected patient death. They advised strategies to cope with that clinical situation commensurate with the core competencies of the Accreditation Council for Graduate Medical Education: Medical Knowledge: maximize objective information/data and minimize subjective opinion; Patient Care: critique the events and conduct postmortem analyses; Interpersonal and Communication Skills: honesty, empathy, and patience; Professionalism: provide emotional and psychological support to family and personnel with privacy and in a nonaccusatory manner; Practice-Based Learning and Improvement: preoperative discussion and documentation in the context of informed consent and advanced directives vis-á-vis risk-benefit, effort-yield, and benefit-burden analyses; and Systems-Based Practice: involve chaplains and hospital personnel. Thirty-six percent of the graduate surgical educational programs surveyed allegedly provided educational venues to enable surgical residents to cope with unexpected patient death, although the formats were not specified.

CONCLUSIONS

Graduate, postgraduate, and continuing educational programs aspire to prepare physicians and surgeons for independent professional practice-scientifically, humanistically, and artistically. Incorporating educational strategies to enable graduates to cope with the emotional and psychological turmoil of unexpected patient death is relevant.

Proficiency of surgical faculty and residents with ethical dilemmas: is modeling enough?

OBJECTIVE

Professionalism, an Accreditation Commission for Graduate Medical Education (ACGME) competency, embraces the concept of adherence to ethical principles. Despite this, most surgical residencies do not currently include ethics as part of their core curriculum. Further, expertise in effectively managing ethical dilemmas is frequently obtained via modeling after the attending physician. This study evaluated surgical faculty (SF) and residents (SR) on their understanding of basic ethical principles and their overall confidence in translation of these principles into clinical practice. The objective was to determine if there are any differences in the overall levels of knowledge and confidence in ethics between SR and SF.

DESIGN AND SETTING

Immediately before the first session of a Kamangar Grant supported monthly Ethics Forum, all SF and SR completed a Pre-Curriculum Questionnaire (PCQ) on their knowledge about ethical principles and their confidence in dealing with ethical issues. PQC contained 13 multiple-choice and true/false knowledge questions and 8 questions evaluating confidence rated on a 5-point Likert scale.

PARTICIPANTS

Surgical faculty (SF) (n = 16) and SR (n = 36). Knowledge and confidence scores were compared between SR and SF, using Student t-test analysis to evaluate differences between groups.

RESULTS

No significant differences were found in ethical knowledge scores between faculty and residents. Faculty confidence is higher than resident (p < 0.05). Further, female faculty confidence is higher than that of their male counterparts (p < 0.05).

CONCLUSIONS

While SF are more confident in their ethical decision-making, their fundamental knowledge base in ethics is not different from that of SR. Female SF report greater self-confidence over their male counterparts. In total, SF may not possess the foundation to effectively mentor residents in appropriate ethical principles and their translation to clinical practice. This study supports the need for both SR and SF to engage in an integrated education program in ethics to promote on-going dialogue in this complex topic.

Care and competence in medical practice: Francis Peabody confronts Jason Posner

In this paper, I discuss the role of care and competence, as well as their relationship to one another, in contemporary medical practice. I distinguish between two types of care. The first type, care(1), represents a natural concern that motivates physicians to help or to act on the behalf of patients, i.e. to care about them. However, this care cannot guarantee the correct technical or right ethical action of physicians to meet the bodily and existential needs of patients, i.e. to take care of them-care(2). To that end, physicians must be competent in the practice of medicine both as evidence-based science (technical competence) and as patient-centered art (ethical competence). Only then, I argue, can physicians take care of (care(2)) patients' bodily and existential needs in a compassionate and comprehensive manner. Importantly, although care(1) precedes competence, competence--both technical and ethical--is required for genuine care(2), which in turn reinforces an authentic care(1). I utilize the play Wit, especially the character Jason Posner, and Francis Peabody's exposition on caring for patients, to illustrate the role of care and competence in contemporary medical practice.

Applying global frameworks to assessment in medical education: an example of a nationally produced curriculum for cancer education

The past decade has seen an increased effort to standardized medical curricula internationally. Despite these efforts, a lack of standardization remains evident, most likely owing to the lack of specificity with which such frameworks are often (out of necessity) constructed. As such, inconsistencies may arise owing to differences in adopted definitions and approaches to assessment. The authors highlight six key points to aid the individual educator in translating overarching frameworks into specific learning objectives that are measurable, written at a level of generality, complexity and difficulty that is clear, appropriate and explicit in what is required of the student.

A novel simulation model for minimally invasive spine surgery

OBJECTIVE

Minimally invasive spine surgery (MISS) is among the fastest growing technologies in general neurosurgical practice. In addition, great demand exists to teach these skills to neurosurgery residents. With newly enforced work hour restrictions, opportunities to acquire these skills are limited, necessitating development of alternative strategies of education. We describe a novel simulation model for MISS supplemented by resident self-assessment analysis and evaluation.

METHODS

The simulator was constructed using a nontransparent Plexiglas frame supplemented with a modified halo frame on which to affix spine specimens. Interchangeable copper tubing was affixed to a 360-degree pivot system to replicate a working portal. Deer skulls and spines were then collected and prepared accordingly. Laboratory exercises were based on the resident's level of training with emphasis on proper drilling techniques. Eight neurosurgery residents were asked to complete the exercises and complete a self-assessment survey regarding their competence level on a scale of 0 to 5, both before and after completing the skill sets. Additionally, they were asked to complete an exit survey that was used to assess the simulation exercises.

RESULTS

All exercises were completed successfully with the exception of placing 2 separate pedicle screws through the same portal, which posed difficulty on some specimens because of the of lack of lordosis of the specimens, leading to unfavorable trajectories using a free-hand technique. With regard to the resident self-assessment analysis, the mean confidence rating for performing an MISS laminectomy improved by a difference of 1.25 points (n = 8; 95% confidence interval, 0.66-1.84; P = 0.0015), from 2.50 to 3.75 before and after simulation exercises, respectively, and reached statistical significance. For the senior-level residents, the mean confidence rating for performing MISS placement of pedicle screws using a free-hand technique improved by a difference of 1.00 (n = 3; 95% confidence interval, -1.48-3.48; P = 0.225), from 3.33 to 4.33 before and after simulation exercises, respectively. Results of the exit survey were encouraging.

CONCLUSION

The MISS simulator is a feasible, inexpensive, and reproducible adjunct to neurosurgery resident training and provides a new teaching method for spine surgery. Further investigation of this technology is warranted, although multicenter, randomized, controlled trials assessing its validity may not be practical because of ethical constraints with regard to patient safety.

Remediation practices for surgery residents

BACKGROUND

This study sought to determine to what extent surgery programs are remediating residents who fail to achieve competency and to offer remediation strategies.

METHODS

A web-based survey was e-mailed to 253 program directors of all US surgery residency programs. Questions were asked about remediation and probation practices for residents failing to meet the competencies.

RESULTS

Programs seem to struggle the least with knowing how to remediate medical knowledge and patient care deficits and struggle more with professionalism and interpersonal communication skills. Most programs have no remediation methods in place for systems-based practice and practice-based learning and improvement deficits.

CONCLUSIONS

Surgery residency programs are cognizant of the reality that some residents perform unsatisfactorily. Most have remediation plans for residents and understand that a process needs to be in place. Remediation methods tend to vary depending on the deficit and are devised tailored to the resident's needs.

Ethics education in surgical residency programs: a review of the literature

Although ethics education in undergraduate medical school curricula has become essentially universal, and because ethics and professionalism have become integral parts of competency-based curricula for residents in nearly all specialties of medicine and surgery, it is not clear to what extent postgraduate surgical training routinely includes ethics education or skills training. Most general surgery residencies do not routinely integrate in-depth ethics skills training and assessment into their didactic curricula. In this article, we review the literature concerning ethics education in postgraduate surgical training programs. The few studies in the literature suggest that ethics education, when integrated in surgical residency curricula, can lead to measurable improvements in resident-centered outcomes, which include knowledge and confidence in handling ethical dilemmas. These curricula may lead to improvements in patient care. These findings suggest that ethics education for surgical residents is valuable but that questions regarding the optimal "dose" of ethics education and training as well as the optimal teaching methods would benefit from extended systematic evaluation and inquiry.

Core Competencies in Palliative Care for Surgeons: Interpersonal and Communication Skills

Surgeons are an important part of the multidisciplinary approach to the care of terminally ill and dying patients. Some surgical residencies have recognized the need to incorporate palliative care—related topics into graduate surgical education. One core competency of utmost importance to palliative care is the effective use of interpersonal and communication skills. Four areas of surgical practice are identified where these communication skills are important: during preoperative counseling, when presenting a devastating diagnosis or poor prognosis, when discussing error, and when discussing death. Case examples and recommendations for the appropriate words and actions to use in these scenarios are offered. It is important for both surgeons in practice and those in training to achieve proficiency with these communication skills.

A quality assurance elective for radiology residents

RATIONALE AND OBJECTIVES

As a component of the practice-based core competency of the Accreditation Council for Graduate Medical Education, all radiology residents must receive training to be able to evaluate and improve their patient care practices. To achieve this goal, our quality management section has implemented a comprehensive elective rotation in quality assurance.

MATERIALS AND METHODS

We have designed a month-long structured resident elective in radiology quality assurance at the Beth Israel Deaconess Medical Center, Harvard Medical School. This elective provides a combination of didactic teaching, self-learning, and practical experience in the methodology, workings, and clinical applications of quality assurance as these relate to improving technical and clinical performance in a large academic radiology department.

RESULTS

During this rotation, residents are exposed to the spectrum of commonly used tools and techniques used for performance improvement related to the practice of radiology. By actively participating in department and hospital quality assurance (QA) committee meetings, and through initiation of a mentored project coupled with didactic instruction, residents are exposed first hand to the practice and role of continuous quality monitoring and to the implementation and monitoring of action items.

CONCLUSION

Participation in our QA elective provides our residents with a comprehensive exposure to the spectrum of quality-related problems, and equips them with the necessary tools to resolve many of the clinical or technical problems they are likely to encounter in their future careers. It is thus an appropriate tool to instruct residents in the competency of "practice-based learning and improvement."

A stitch in time saves nine: intervention strategies for the remediation of competency

The mission of medical educators in all fields is to perfect the science and the art of training competent physicians and the next generation of leaders. To do this, outcomes research regarding effective training and supervision techniques and curricula, the optimal educational environment, assessment, and remediation of competency is needed. It is incumbent upon training directors to continue to provide the primary leadership for the field of training. The areas that are ripe for research and development include effective curricula, effective evaluation and remediation of competency, and leadership skill development. As medicine becomes more complex, so does the task of training physicians. Joint monitoring and outcomes research of the training enterprise are the scholarly and academic missions of the present and the future.