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Willis MH, Friedman EM, Donnelly LF. Optimizing Performance by Preventing Disruptive Behavior in Radiology. Radiographics 2019; 38:1639-1650. [PMID: 30303780 DOI: 10.1148/rg.2018180019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Disruptive behaviors impede delivery of high-value health care by negatively impacting patient outcomes and increasing costs. Health care is brimming with potential triggers of disruptive behavior. Given omnipresent environmental and cultural factors such as constrained resources, stressful environments, commercialization, fatigue, unrealistic expectation of perfectionism, and burdensome documentation, a burnout epidemic is raging, and medical providers are understandably at tremendous risk to succumb and manifest these unprofessional behaviors. Each medical specialty has its own unique challenges. Radiology is not exempt; these issues do not respect specialty or professional boundaries. Unfortunately, preventive measures are too frequently overlooked, provider support programs rarely exist, and often organizations either tolerate or ineffectively manage the downstream disruptive behaviors. This review summarizes the background, key definitions, contributing factors, impact, prevention, and management of disruptive behavior. Every member of the health care team can gain from an improved understanding and awareness of the contributing factors and preventive measures. Application of these principles can foster a just culture of understanding, trust, support, respect, and teamwork balanced with accountability. The authors discuss these general topics along with specific issues for radiologists in the current medical environment. Patients, providers, health care organizations, and society all stand to benefit from better prevention of these behaviors. There is a strong moral, ethical, and business case to address this issue head-on. ©RSNA, 2018.
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Affiliation(s)
- Marc H Willis
- From the Department of Radiology (M.H.W.) and Center for Professionalism in Medicine (E.M.F.), Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030; and Department of Radiology, Lucile Packard Children's Hospital at Stanford, Palo Alto, Calif (L.F.D.)
| | - Ellen M Friedman
- From the Department of Radiology (M.H.W.) and Center for Professionalism in Medicine (E.M.F.), Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030; and Department of Radiology, Lucile Packard Children's Hospital at Stanford, Palo Alto, Calif (L.F.D.)
| | - Lane F Donnelly
- From the Department of Radiology (M.H.W.) and Center for Professionalism in Medicine (E.M.F.), Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030; and Department of Radiology, Lucile Packard Children's Hospital at Stanford, Palo Alto, Calif (L.F.D.)
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Hoonpongsimanont W, Sahota PK, Chen Y, Patel M, Tarapan T, Bengiamin D, Sutham K, Imsuwan I, Dadeh AA, Nakornchai T, Narajeenron K. Physician professionalism: definition from a generation perspective. INTERNATIONAL JOURNAL OF MEDICAL EDUCATION 2018; 9:246-252. [PMID: 30269110 PMCID: PMC6387766 DOI: 10.5116/ijme.5ba0.a584] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 09/18/2018] [Indexed: 05/23/2023]
Abstract
OBJECTIVES The primary objective of this study was to determine whether consensuses on the definition of emergency physician professionalism exist within and among four different generations. Our secondary objective was to describe the most important characteristic related to emergency physician professionalism that each generation values. METHODS We performed a cross-sectional survey study, using a card-sorting technique, at the emergency departments of two university-based medical centers in the United States. The study was conducted with 288 participants from February to November 2017. Participants included adult emergency department patients, emergency medicine supervising physicians, emergency medicine residents, emergency department nurses, and fourth- and second-year medical students who independently ranked 39 cards that represent qualities related to emergency physician professionalism. We used descriptive statistics, quantitative cultural consensuses and Spearman's correlation coefficients to analyze the data. RESULTS We found cultural consensuses on emergency physician professionalism in Millennials and Generation X overall, with respect for patients named the most important quality (eigenratio 5.94, negative competency 0%; eigenratio 3.87, negative competency 1.64%, respectively). There were consensuses on emergency physician professionalism in healthcare providers throughout all generations, but no consensuses were found across generations in the patient groups. CONCLUSIONS While younger generations and healthcare providers had consensuses on emergency physician professionalism, we found that patients had no consensuses on this matter. Medical professionalism curricula should be designed with an understanding of each generation's values concerning professionalism. Future studies using qualitative methods across specialties, to assess definitions of medical professionalism in each generation, should be pursued.
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Affiliation(s)
| | - Preet K Sahota
- Department of Emergency Medicine, University of California, Irvine, Orange, CA, USA
| | - Yanjun Chen
- Institute for Clinical and Translational Sciences, University of California, Irvine, Irvine, CA, USA
| | - Mayuri Patel
- Department of Emergency Medicine, University of California, Irvine, Orange, CA, USA
| | - Tanawat Tarapan
- Department of Emergency Medicine, University and King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
| | - Deena Bengiamin
- Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, CA, USA
| | - Krongkarn Sutham
- Department of Emergency Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Intanon Imsuwan
- Department of Emergency Medicine, Thammasat University, Pathumthani, Thailand
| | - Ar-Aishah Dadeh
- Department of Emergency Medicine, Prince of Songkla University, Songkla, Thailand
| | - Tanyaporn Nakornchai
- Department of Emergency Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Khuansiri Narajeenron
- Department of Emergency Medicine, University and King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
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Kraft-Todd GT, Reinero DA, Kelley JM, Heberlein AS, Baer L, Riess H. Empathic nonverbal behavior increases ratings of both warmth and competence in a medical context. PLoS One 2017; 12:e0177758. [PMID: 28505180 PMCID: PMC5432110 DOI: 10.1371/journal.pone.0177758] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 05/03/2017] [Indexed: 01/10/2023] Open
Abstract
In medicine, it is critical that clinicians demonstrate both empathy (perceived as warmth) and competence. Perceptions of these qualities are often intuitive and are based on nonverbal behavior. Emphasizing both warmth and competence may prove problematic, however, because there is evidence that they are inversely related in other settings. We hypothesize that perceptions of physician competence will instead be positively correlated with perceptions of physician warmth and empathy, potentially due to changing conceptions of the physician’s role. We test this hypothesis in an analog medical context using a large online sample, manipulating physician nonverbal behaviors suggested to communicate empathy (e.g. eye contact) and competence (the physician’s white coat). Participants rated physicians displaying empathic nonverbal behavior as more empathic, warm, and more competent than physicians displaying unempathic nonverbal behavior, adjusting for mood. We found no warmth/competence tradeoff and, additionally, no significant effects of the white coat. Further, compared with male participants, female participants perceived physicians displaying unempathic nonverbal behavior as less empathic. Given the significant consequences of clinician empathy, it is important for clinicians to learn how nonverbal behavior contributes to perceptions of warmth, and use it as another tool to improve their patients’ emotional and physical health.
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Affiliation(s)
- Gordon T. Kraft-Todd
- Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Psychology, Yale University, New Haven, Connecticut, United States of America
- * E-mail:
| | - Diego A. Reinero
- Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Psychology, New York University, New York, New York, United States of America
| | - John M. Kelley
- Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
- Program in Placebo Studies, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Psychology, Endicott College, Beverly, Massachusetts, United States of America
| | - Andrea S. Heberlein
- Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Psychology, Boston College, Chestnut Hill, Massachusetts, United States of America
| | - Lee Baer
- Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
| | - Helen Riess
- Empathy and Relational Science Program, Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
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Fellow use of medical jargon correlates inversely with patient and observer perceptions of professionalism: results of a rheumatology OSCE (ROSCE) using challenging patient scenarios. Clin Rheumatol 2015; 35:2093-2099. [PMID: 26585177 DOI: 10.1007/s10067-015-3113-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 09/16/2015] [Accepted: 11/04/2015] [Indexed: 10/21/2022]
Abstract
The NYC Rheumatology Objective Structured Clinical Examination (NYC-ROSCE) is held annually to assess fellow competencies. We recently redesigned our OSCE to better assess subspecialty trainee communication skills and professionalism by developing scenarios in which the patients encountered were psychosocially or medically complex. The objective of this study is to identify which types of verbal and non-verbal skills are most important in the perception of professionalism in the patient-physician interaction. The 2012-2013 NYC-ROSCEs included a total of 53 fellows: 55 MD evaluators from 7 NYC rheumatology training programs (Hospital for Special Surgery-Weill Cornell (HSS), SUNY/Downstate, NYU, Einstein, Columbia, Mount Sinai, and North Shore/Long Island Jewish (NSLIJ)), and 55 professional actors/standardized patients participated in 5 stations. Quantitative fellow performance assessments were made on the following: maintaining composure; partnering with the patient; honesty; professionalism; empathy; and accountability. Free-text comments were solicited regarding specific strengths and weaknesses. A total of 53/53 eligible (100 %) fellows were evaluated. MD evaluators rated fellows lower for professionalism than did the standardized patients (6.8 ± 0.6 vs. 7.4 ± 0.8, p = 0.05), suggesting that physicians and patients view professionalism somewhat differently. Fellow self-evaluations for professionalism (6.6 ± 1.2) were concordant with those of the MD evaluators. Ratings of empathy by fellows themselves (6.6 ± 1.0), MD evaluators (6.6 ± 0.7), and standardized patients (6.6 ± 1.1) agreed closely. Jargon use, frequently cited by evaluators, showed a moderate association with lower professionalism ratings by both MD evaluators and patients. Psychosocially challenging patient encounters in the NYC-ROSCE permitted critical assessment of the patient-centered traits contributing to impressions of professionalism and indicate that limiting medical jargon is an important component of the competency of professionalism.
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Snider KT, Johnson JC. Professionalism Score and Academic Performance in Osteopathic Medical Students. J Osteopath Med 2014; 114:850-9. [DOI: 10.7556/jaoa.2014.171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Context: During the first 2 years of osteopathic medical school, osteopathic manipulative medicine (OMM) courses use an objective professionalism score to measure student timeliness and appropriate dress for learning activities. Objective: To assess for correlations between this score and the numeric course grades of all first- and second-year basic science and clinical courses at a single osteopathic medical school. Methods: The professionalism scores obtained for each of the 7 quarters of the OMM course (2007-2012) were compared with the students' numeric final course grades and combined grade point average (GPA) of all courses in the corresponding quarter. Spearman correlation coefficients were used to determine the strength of the relationship between the professionalism score and the final course grades and the combined GPA. Results: The mean (SD) professionalism score was 98.6% (3.3%), and scores ranged from 23.1% to 100%. Excluding the OMM course, the professionalism score was positively correlated with 29% of first-year course grades and 65% of second-year course grades. The professionalism score was predictive of academic performance in 16 of 23 clinical courses with the highest correlation for Principles of Medicine and Dermatology (ρ=0.28 and ρ=0.25, respectively). The OMM professionalism score was positively associated with GPA for quarters 1, 6, and 7 (P=.006, P<.001, and P<.001, respectively). Professionalism scores were significantly lower in the second year (P<.001). Conclusion: Objective measures of professionalism correlated with academic performance in many first- and second-year osteopathic medical school courses, particularly clinical courses in the second-year curriculum. J Am Osteopath Assoc. 2014;114(11):850-859 doi: 10.7556/jaoa.2014.171
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Affiliation(s)
- Karen T. Snider
- From the Department of Osteopathic Manipulative Medicine at the A.T. Still University–Kirksville College of Osteopathic Medicine in Missouri (Dr Snider) and the A.T. Still Research Institute at A.T. Still University in Kirksville, Missouri (Dr Snider and Ms Johnson)
| | - Jane C. Johnson
- From the Department of Osteopathic Manipulative Medicine at the A.T. Still University–Kirksville College of Osteopathic Medicine in Missouri (Dr Snider) and the A.T. Still Research Institute at A.T. Still University in Kirksville, Missouri (Dr Snider and Ms Johnson)
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Multi-procedure management in an eyeglasses-related open globe injury. Wideochir Inne Tech Maloinwazyjne 2014; 9:101-6. [PMID: 24729818 PMCID: PMC3983540 DOI: 10.5114/wiitm.2013.40104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 05/29/2013] [Accepted: 06/15/2013] [Indexed: 11/23/2022] Open
Abstract
We present a case of successful multi-procedure management of a patient with an open globe injury. A 47-year-old man sustained an injury to his left eye caused by glass fragments of his own spectacles shattered while he was protecting an unknown woman from physical assault at a bus stop. Over a span of 65 months the patient underwent multiple procedures including primary wound repair, penetrating keratoplasty combined with extracapsular cataract extraction, neodymium: YAG laser capsulotomy, and laser-assisted subepithelial keratectomy (LASEK), and had a successfully treated episode of corneal graft rejection. This sequence of treatment substantially improved his left eye vision from hand movements at the time of admission to 0.9–0.5 × 90 at the last follow-up nearly 10 years after the trauma. Proper initial surgical management of an open globe injury can create the possibility for virtually complete vision restoration.
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Nichols BG, Nichols LM, Poetker DM, Stadler ME. Operationalizing professionalism: A meaningful and practical integration for resident education. Laryngoscope 2013; 124:110-5. [DOI: 10.1002/lary.24184] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/26/2013] [Accepted: 04/15/2013] [Indexed: 11/05/2022]
Affiliation(s)
- Brent G. Nichols
- Department of Otolaryngology and Communication SciencesMedical College of WisconsinMilwaukee Wisconsin U.S.A
| | - Laura M. Nichols
- Department of Internal MedicineMedical College of WisconsinMilwaukee Wisconsin U.S.A
| | - David M. Poetker
- Department of Otolaryngology and Communication SciencesMedical College of WisconsinMilwaukee Wisconsin U.S.A
| | - Michael E. Stadler
- Department of Otolaryngology and Communication SciencesMedical College of WisconsinMilwaukee Wisconsin U.S.A
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Al-Eraky MM, Chandratilake M, Wajid G, Donkers J, van Merrienboer J. Medical professionalism: development and validation of the Arabian LAMPS. MEDICAL TEACHER 2013; 35 Suppl 1:S56-62. [PMID: 23581897 DOI: 10.3109/0142159x.2013.765553] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
AIM The attributes of the professional physicians varies among cultures. This study aims to develop and validate a questionnaire that measures attitudes of medical students on professionalism in the Arabian context. METHOD Thirty-two experts contributed to item generation in particular domains. The instrument was administered to Arabian medical students and interns and responses were collected using five-point Likert scales. Data were analyzed to estimate the reliability of the instrument. The inventory in its final version was labeled as the Learners' Attitude of Medical Professionalism Scale (LAMPS). RESULTS A total of 413 medical students and interns responded from two universities in Egypt and Saudi Arabia. Means of item response ranged from 2.38 to 4.72. The highest mainly deals with "Respect to others," while the lowest belong to "Honor/Integrity." The final version of the LAMPS has 28 items in five domains, with a reliability of 0.79. DISCUSSION The LAMPS has salient features compared to other similar instrument. It was designed based on a reliable framework in explicit behavioral items, not abstract attributes of professionalism. The LAMPS can help teachers to identify learning gaps regarding professionalism amongst their students and track attitude changes over time or as the result of interventions. CONCLUSION To the best of our knowledge, the LAMPS is the first context-specific inventory on medical professionalism attitudes in the Arabian context.
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Regis T, Steiner MJ, Ford CA, Byerley JS. Professionalism expectations seen through the eyes of resident physicians and patient families. Pediatrics 2011; 127:317-24. [PMID: 21242219 DOI: 10.1542/peds.2010-2472] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Resident physicians and patient families have not traditionally been involved in setting expectations for professional behavior by physicians. OBJECTIVE To elicit and compare prioritized lists of attributes and behaviors of physician professionalism formulated by residents and patient families. METHODS/DESIGN We used qualitative and quantitative methods to identify and compare prioritized perceptions of important attributes and behaviors of physician professionalism among residents and families of patients. We conducted 3 resident focus groups, 1 for residents in each resident-training year (postgraduate years 1, 2, and 3), and elicited attributes and behaviors the residents associated with physician professionalism by using free-listing and nominal-group techniques. Family perspectives of the attributes/behaviors of physician professionalism were elicited by using semistructured interviews of consecutive families with a child who was admitted to the hospital. All results were transcribed, and common themes were identified. RESULTS Fifty-eight residents (78% of the total in the program) and 40 families participated. Similar themes arose from all 3 resident focus groups, which prioritized tactfulness, support of team members, respectfulness, good communication, and humanism. Residents also provided specific behavioral strategies to put these attributes into practice, such as avoiding jokes about patients and using patient names when addressing and discussing them. Patient families most frequently cited good communication, caring, knowledge, skill, honesty, and attitude. Communication and humanism were aspects consistently endorsed by both residents and patient families. CONCLUSIONS There was important overlap in the attributes of professionalism generated and prioritized by resident physicians and patient families, although only residents identified ways that health care providers should interact with each other. This novel approach to identifying professionalism attributes provides opportunities for curriculum improvement.
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Affiliation(s)
- Taylor Regis
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, aUniversity of North Carolina School of Medicine, Chapel Hill, North Carolina 27514, USA
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Dalia S, Schiffman FJ. Who's My Doctor? First-Year Residents and Patient Care: Hospitalized Patients' Perception of Their "Main Physician". J Grad Med Educ 2010; 2:201-5. [PMID: 21975620 PMCID: PMC2930311 DOI: 10.4300/jgme-d-09-00082.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 01/19/2010] [Accepted: 03/01/2010] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Studies have shown that a large portion of patient satisfaction is related to physician care, especially when the patient can identify the role of the physician on the team. Because patients encounter multiple physicians in teaching hospitals, it is often difficult to determine who the patient feels is his or her main caregiver. Surveys evaluating resident physicians would help to improve patient satisfaction but are not currently implemented at most medical institutions. INTERVENTION We created a survey to judge patient satisfaction and to determine who patients believe is their "main physician" on the teaching service. METHODS Patients on a medical teaching service at The Miriam Hospital during 20 days in March 2008 were asked to complete the survey. A physician involved in the research project administered the surveys. Surveys included 3 questions that judged patient's perception and identification of their primary physician and 7 questions regarding patient satisfaction. Completed surveys were analyzed using averages. RESULTS Of the 126 patients identified for participation, 102 (81%) completed the survey. Most patients identified the intern (first-year resident) as their main physician. Overall, more than 90% of patients expressed satisfaction with their main physician. CONCLUSION Most patients on the teaching service perceived the intern as their main physician and were satisfied with their physician's care. One likely reason is that interns spend the greatest amount of time with patients on the teaching service.
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Affiliation(s)
- Samir Dalia
- Corresponding author: Samir Dalia, MD, 164 Summit Avenue, Providence, RI 02906, 401.444.4000,
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Wiggins MN, Coker K, Hicks EK. Patient perceptions of professionalism: implications for residency education. MEDICAL EDUCATION 2009; 43:28-33. [PMID: 19148978 DOI: 10.1111/j.1365-2923.2008.03176.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES The purpose of this study was three-fold: to identify which behavioural, communicative and personal presentation characteristics most closely represent patients' views of professionalism; to determine whether patients perceive resident doctors as displaying these characteristics, and to explore whether or not resident doctor professional behaviour creates an impression of clinical competence to the degree where patients perceive a decreased need for Attending Physician involvement. METHODS We carried out a descriptive, cross-sectional study at an academic centre. An anonymous, voluntary four-question survey with multiple items was administered to all adult patients or the parents of paediatric patients attending an ophthalmology clinic who were seen by a resident doctor followed by an Attending Physician. RESULTS A total of 133 of 148 (90%) surveys were returned. All the itemised characteristics of professionalism were reported to be important or very important to the majority of participants.The most important were: 'Pays attention to my concerns' (90%); 'Is compassionate' (83%), and 'Speaks in terms that I can understand' (83%). Although 85% of respondents reported that resident doctors demonstrated all the characteristics of professionalism listed on the survey, 83% of participants stated that it was important or very important that residents have Attending Physician involvement. CONCLUSIONS Patient-centred components of professionalism, such as communication skills and compassion, are more important to patients than social behaviours, such as appearance and acknowledgement of family members. Resident doctors are perceived to display a high level of professionalism during patient care. Patients clearly desire direct resident doctor
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Affiliation(s)
- Michael N Wiggins
- Department of Ophthalmology, Jones Eye Institute, Universityof Arkansas for Medical Sciences, Little Rock, Arkansas,USA.
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Chabikuli N, Murray M, Fehrsen SG, Hugo JF. Choosing, changing or adhering to a registered doctor in a managed care plan: what will it take? A qualitative survey in rural Mpumalanga, South Africa. S Afr Fam Pract (2004) 2008. [DOI: 10.1080/20786204.2008.10873742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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