Evaluating professionalism in emergency medicine: clinical ethical competence

Clarifying perspectives: Ethics case reflection sessions in childhood cancer care

BACKGROUND

Childhood cancer care involves many ethical concerns. Deciding on treatment levels and providing care that infringes on the child's growing autonomy are known ethical concerns that involve the whole professional team around the child's care.

OBJECTIVES

The purpose of this study was to explore healthcare professionals' experiences of participating in ethics case reflection sessions in childhood cancer care.

RESEARCH DESIGN

Data collection by observations, individual interviews, and individual encounters. Data analysis were conducted following grounded theory methodology.

PARTICIPANTS AND RESEARCH CONTEXT

Healthcare professionals working at a publicly funded children's hospital in Sweden participated in ethics case reflection sessions in which ethical issues concerning clinical cases were reflected on.

ETHICAL CONSIDERATIONS

The children's and their parents' integrity was preserved through measures taken to protect patient identity during ethics case reflection sessions. The study was approved by a regional ethical review board.

FINDINGS

Consolidating care by clarifying perspectives emerged. Consolidating care entails striving for common care goals and creating a shared view of care and the ethical concern in the specific case. The inter-professional perspectives on the ethical aspects of care are clarified by the participants' articulated views on the case. Different approaches for deliberating ethics are used during the sessions including raising values and making sense, leading to unifying interactions.

DISCUSSION

The findings indicate that ethical concerns could be eased by implementing ethics case reflection sessions. Conflicting perspectives can be turned into unifying interactions in the healthcare professional team with the common aim to achieve good pediatric care.

CONCLUSION

Ethics case reflection sessions is valuable as it permits the discussion of values in healthcare-related issues in childhood cancer care. Clarifying perspectives, on the ethical concerns, enables healthcare professionals to reflect on the most reasonable and ethically defensible care for the child. A consolidated care approach would be valuable for both the child and the healthcare professionals because of the common care goals.

Ethical competence

Background:

Exploring the concept of ethical competence in the context of healthcare is essential as it pertains to better quality of care. The concept still lacks a comprehensive definition covering the aspects of ethical expertise, ethical knowledge and action of a health professional.

Objective:

This article aims to report an analysis of the concept of ethical competence.

Method:

A modified strategy suggested by Walker and Avant was used to analyse the concept.

Results:

As a result, the concept of ethical competence can be defined in terms of character strength, ethical awareness, moral judgement skills and willingness to do good. Virtuous professional, experience of a professional, human communication, ethical knowledge and supporting surroundings in the organisation can be seen as prerequisites for ethical competence. Ethical competence results in the best possible solutions for the patient, reduced moral distress at work and development and democratisation of society.

Conclusion:

The results of the analysis establish a basis for an instrument to evaluate health professionals’ ethical competence. It will guide educators, as well as managers in healthcare, to support the development of ethical conduct in healthcare.

Postgraduate training in medical professionalism

Medical professionalism receives little attention in postgraduate medical education, despite its importance in producing clinically and professionally competent specialists. Guidance for translating professionalism from postgraduate curricula into practice is lacking. This is the challenge for every postgraduate training programme.

Assessing professionalism: summary of the working group on assessment of observable learner performance

Professionalism is one of the six Accreditation Council on Graduate Medical Education (ACGME) core competencies on which emergency medicine (EM) residents are assessed. However, very few assessment tools exist that have been rigorously evaluated in this population. One goal of the 2012 Academic Emergency Medicine consensus conference on education research in EM was to develop a research agenda for testing and developing tools to assess professionalism in EM residents. A literature review was performed to identify existing assessment tools. Recommendations on future research directions were presented at the consensus conference, and an agenda was developed.

Combined formative and summative professional behaviour assessment approach in the bachelor phase of medical school: a Dutch perspective

BACKGROUND

Teaching and assessment of professional behaviour (PB) has been receiving increasing attention in the educational literature and educational practice. Although the focus tends to be summative aspects, it seems perfectly feasible to combine formative and summative approaches in one procedural approach.

AIMS AND METHOD

Although, many examples of frameworks of professionalism and PB can be found in the literature, most originate from North America, and only few are designed in other continents. This article presents the framework for PB that is used at Maastricht medical school, the Netherlands.

RESULTS

The approach to PB used in the Dutch medical schools is described with special attention to 4 years (2005-2009) of experience with PB education in the first 3 years of the 6-year undergraduate curriculum of Maastricht medical school. Future challenges are identified.

CONCLUSIONS

The adages 'Assessment drives learning' and 'They do not respect what you do not inspect' [Cohen JJ. 2006. Professionalism in medical education, an American perspective: From evidence to accountability. Med Educ 40, 607-617] suggest that formative and summative aspects of PB assessment can be combined within an assessment framework. Formative and summative assessments do not represent contrasting but rather complementary approaches. The Maastricht medical school framework combines the two approaches, as two sides of the same coin.

Bad apples spoil the barrel: Addressing unprofessional behaviour

Given the changes in society we are experiencing, the increasing focus on patient-centred care and acknowledgement that medical education including professionalism issues needs to continue not only in the residency programmes but also throughout the doctors career, is not surprising. Although most of the literature on professionalism pertains to learning and teaching professionalism issues, addressing unprofessional behaviour and related patient safety issues forms an alternative or perhaps complementary approach. This article describes the possibility of selecting applicants for a medical school based on personality characteristics, the attention to professional lapses in contemporary undergraduate training, as well as the magnitude, aetiology, surveillance and methods of dealing with reports of unprofessional behaviour in postgraduate education and CME.

Professionalism beyond medical school: an educational continuum?

Given the changes in society we are experiencing, the increasing focus on patient centred care and acknowledgment that medical education needs to continue not only in the residency programmes but throughout the doctors career, is not surprising. This article describes the attention currently paid to professionalism in the residency programmes, differences in perception of professionalism between patients, faculty, students and residents, differences in professionalism issues in the different educational phases, as well as their consequences for training and assessment regarding professionalism. Continuous medical education in professionalism is thereafter briefly discussed.

Assessing professionalism in the context of an objective structured clinical examination: an in-depth study of the rating process

INTRODUCTION

Professionalism is fundamental to the practice of medicine. Objective structured clinical examinations (OSCEs) have been proposed as appropriate for assessing some aspects of professionalism. This study investigated how raters assign professionalism ratings to medical students' performances in OSCE encounters.

METHODS

Three standardised patients, 3 doctor preceptors, and 3 lay people viewed and rated 20 videotaped encounters between 3rd-year medical students and standardised patients. Raters recorded their thoughts while rating. Qualitative and quantitative analyses were conducted. Comments about observable behaviours were coded, and relative frequencies were computed. Correlations between counts of categorised comments and overall professionalism ratings were also computed.

RESULTS

Raters varied in which behaviours they attended to, and how behaviours were evaluated. This was true within and between rater type. Raters also differed in the behaviours they consider when providing global evaluations of professionalism.

CONCLUSIONS

This study highlights the complexity of the processes involved in assigning ratings to doctor-patient encounters. Greater emphasis on behavioural definitions of specific behaviours may not be a sufficient solution, as raters appear to vary in both attention to and evaluation of behaviours. Reliance on global ratings is also problematic, especially if relatively few raters are used, for similar reasons. We propose a model highlighting the multiple points where raters viewing the same encounter may diverge, resulting in different ratings of the same performance. Progress in assessment of professionalism will require further dialogue about what constitutes professional behaviour in the medical encounter, with input from multiple constituencies and multiple representatives within each constituency.

Teaching and evaluating professionalism for anesthesiology residents

The Accreditation Council for Graduate Medical Education Outcome Project requires teaching and evaluation of 6 core competencies, one of which is professionalism. Because of this initiative, anesthesiology residency programs are obliged to teach and evaluate professionalism for anesthesiology residents. We decided to create a system that would allow the teaching and evaluation of professionalism in the specific context of anesthesiology.

Responding to the professionalism of learners and faculty in orthopaedic surgery

Recent developments in assessing professionalism and remediating unprofessional behavior can curtail the inaction that often follows observations of negative as well as positive professionalism of learners and faculty. Developments include: longitudinal assessment models promoting professional behavior, not just penalizing lapses; clarity about the assessment's purpose; methods separating formative from summative assessment; conceptual and behavioral definitions of professionalism; techniques increasing the reliability and validity of quantitative and qualitative approaches to assessment such as 360-degree assessments, performance-based assessments, portfolios, and humanism connoisseurs; and systems-design providing infrastructure support for assessment. Models for remediation have been crafted, including: due process, a warning period and, if necessary, confrontation to initiate remediation of the physician who has acted unprofessionally. Principles for appropriate remediation stress matching the intervention to the cause of the professional lapse. Cognitive behavioral therapy, motivational interviewing, and continuous monitoring linked to behavioral contracts are effective remediation techniques. Mounting and maintaining robust systems for professionalism and remediating professional lapses are not easy tasks. They require a sea change in the fundamental goal of academic health care institutions: medical education must not only be a technical undertaking but also a moral process designed to build and sustain character in all its professional citizens.

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

As part of efforts afoot to improve the overall quality of physician training, the Accreditation Council for Graduate Medical Education (ACGME) has endorsed a set of competencies that will be the blueprint for outcomes-based graduate medical education for years to come. While the spirit of this new law is taking shape, the letter remains largely unwritten. To bridge this gap, administrators of programs from all specialties must determine how the core competencies will be taught, evaluated, modeled, and enforced within their respective programs. This paper summarizes these challenges, in particular for surgical programs, and focuses constructively on the modeling/enforcement approach, describing key characteristics that programs should pursue and cultivate (virtues) as well as the signal prohibitions (vices) that both trainees and trainers must avoid. Regardless of specialty or programmatic particulars, virtues and vices may be used to define a context in which general competencies may be understood, and yield operational guidance upon which ultimate discussions of evaluation, remediation, and graduation may be predicated.

Teaching professionalism during anesthesiology training

Recently, there has been a focus on the teaching of professionalism in postgraduate medical education. Many discussions and studies have been performed to help in teaching professionalism and in the evaluation of the effectiveness of this teaching process. Unfortunately, many anesthesiologists are unaware of the literature and the discussions that have taken place. This review article serves as a primer for those individuals faced with the task of instilling the concepts of professionalism, not only in trainees but also in anesthesiologists practicing today.

How to conceptualize professionalism: a qualitative study

The aim of this study was to clarify which themes and elements constitute professionalism in medicine. Three consecutive steps were taken: (a) a systematic search of the literature to identify constituent elements of professionalism mentioned in definitions and descriptions of the concept; (b) analysis of these elements using the constant comparison technique to reveal possible themes covering these elements; and (c) validating the results using an expert panel. A total of 90 separate elements of professionalism were identified in the 57 articles included in our study. Three themes within professionalism were uncovered: (1) interpersonal professionalism; (2) public professionalism; and (3) intrapersonal professionalism. These themes were considered accurate by the expert panel which supports the validity of the results. Our findings show that the concept of professionalism is multidimensional and should be conceptualized as such.

Improving medical care of persons with Alzheimer disease through clinical teaching: the IMPACT program

The purpose of this project was to develop, implement, evaluate, and disseminate an educational program on ethics and the primary care of patients with dementia for residents. Pre/post-rotation self-confidence measure, a post-rotation assessment of the importance of and achievement of the program's goals, and a post-rotation evaluation of the program were administered. Significant increases in residents' confidence in performing the programmatic clinical goals and in overall confidence were found. Program goals were met, and components of the program were rated highly. We found that a well-designed ethics curriculum can be successfully implemented within a clinical rotation for medicine residents and have a positive impact on the quality of the educational experience as well as on their confidence in performing relevant clinical management behaviors.

Assessing professional behavior: yesterday, today, and tomorrow

PURPOSE

The author interprets the state of the art of assessing professional behavior. She defines the concept of professionalism, reviews the psychometric properties of key approaches to assessing professionalism, conveys major findings that these approaches produced, and discusses recommendations to improve the assessment of professionalism.

METHOD

The author reviewed professionalism literature from the last 30 years that had been identified through database searches; included in conference proceedings, bibliographies, and reference lists; and suggested by experts. The cited literature largely came from peer-reviewed journals, represented themes or novel approaches, reported qualitative or quantitative data about measurement instruments, or described pragmatic or theoretical approaches to assessing professionalism.

RESULTS

A circumscribed concept of professionalism is available to serve as a foundation for next steps in assessing professional behavior. The current array of assessment tools is rich. However, their measurement properties should be strengthened. Accordingly, future research should explore rigorous qualitative techniques; refine quantitative assessments of competence, for example, through OSCEs; and evaluate separate elements of professionalism. It should test the hypothesis that assessment tools will be better if they define professionalism as behaviors expressive of value conflicts, investigate the resolution of these conflicts, and recognize the contextual nature of professional behaviors. Whether measurement tools should be tailored to the stage of a medical career and how the environment can support or sabotage the assessment of professional behavior are central issues. FINAL THOUGHT: Without solid assessment tools, questions about the efficacy of approaches to educating learners about professional behavior will not be effectively answered.