Abstract
The existing medical education paradigm is not structured in a way that prepares future physicians with knowledge or the skill set to excel in professionalism. The authors provide information in the form of a case study of a professionalism competency development program that was undertaken in the Duke University Medical School Division of Head and Neck Surgery and Communications Sciences, barriers found that impede development, and offer five reforms that are necessary in order to bring about the movement toward high-value care. The authors propose to 1) prioritize professionalism competency training in medical education, 2) make curricular revisions to promote professionalism competency training across the continuum, 3) revise selection criteria for entrance to the profession that deals with basic professionalism skills, 4) institute new prerequisite requirements for entrance to the profession centered on professionalism competency, and 5) require professionalism competency training as part of certification and re-certification processes.
TopIntroduction
As the authors discussed in Chapter 10, medical education has arrived at a critical stage in which circumstances are demanding reform in how future physicians and residents are trained. Rising costs, an aging patient population, physician shortages, and reliance on an outdated education paradigm are some of the things that are structurally standing in the way of high-value care outcomes. As Marcotte, Moriates, Wolfson, and Frankel (2019) suggest, high-value care will not find its greatest potential through policy or payment reforms, but through professionalism reform. The existing medical education paradigm is not structured in a way that prepares future physicians with knowledge or the skill set to excel in professionalism. This chapter intends to provide information in the form of a case study of a professionalism competency development program that was undertaken in the Duke University Medical School – Division of Head and Neck Surgery and Communication Sciences (Duke – HNSCS) called: Leadership Lived Out® (LLO®), barriers found that impede development, and five reforms that the authors believe are necessary in order to bring about the movement toward high-value care.
In 2013, the authors of this chapter began a program designed to improve professionalism competence in the Duke University Medical School – Division of Head and Neck Surgery and Communication Sciences. The program concept began as a proactive endeavor to bring about a division-wide commitment to excellence in patient care.
The first step in creating the program was to identify a set of virtues that the division agreed would guide those involved in patient care. They chose: integrity, initiative, self-discipline, responsibility (later changed to: compassion), and accountability (Lee, 2013). In a sense, all thoughts, actions, engagements, and decisions are judged, or guided through these shared virtues. Without these fundamental virtues guiding behavior, it would be impossible to grow or learn as individuals or as an organization. These shared virtues provide a definable set of standards that in essence are the worldview from and through which all interact and are held accountable.
So, Duke – HNSCS values: integrity, initiative, self-discipline, compassion, and accountability, while another institution or department might value: honesty, competence, respect, grace, or justice. What matters most is that there is an established set of virtues moderating or guiding action and setting the standards for professionalism competence. The purpose of these virtues is to set a standard of greatness, a goal for all to achieve which results in better people, teams and organizations. With these virtues as guiding principles driving how one thinks, feels or acts, others are able to determine through observation whether one is truly thinking, feeling, or acting from an intrinsic perspective or from one imposed (or expected) by others. The underlying motivation matters for intrinsic-based actions outlast those which are extrinsically imposed (Pink, 2011). So, by identifying Duke – HNSCS virtues, the authors were able to establish the foundational principles against which all division employees’ behaviors could be evaluated.
Key Terms in this Chapter
Leadership Lived Out® (LLO®): Leadership Lived Out ® is a program developed in the Duke University Medical School – Division of Head and Neck Surgery and Communication Sciences to improve professionalism competence as members engage with patients and fellow team members. The program began as a proactive endeavor to bring about a division-wide commitment to excellence in patient care. The LLO ® program is based on the concept that behaviors are conditioned by how one thinks and feels and guided by a certain set of virtues ( Doublestein, Lee, & Pfohl, 2015 ).
Shared Virtues: They are the fundamental guiding principles that support all thoughts, actions, engagements, and decisions through which team members are judged or guided as they go about their patient care activities. Without these fundamental virtues guiding behavior, it would be impossible to grow or learn as individuals or as an organization. These shared virtues provide a definable set of standards that in essence are the worldview from and through which everyone interacts and is held accountable.
Hidden Curriculum: The hidden curriculum is a socialization process that transmits norms and values that undermine the formal message taught during the medical education continuum. The hidden curriculum disrupts training in that its message (as it is practiced by others in authority) implies that what is formally taught as best practices is less important than what is practiced. It causes students (residents included) to move from being open-minded to closed-minded; move from being intellectually curious to narrowly focused on facts; from empathy to emotional detachment; from idealism to cynicism; from civility and caring to arrogance and irritability; and, an erosion of ethics ( Mahood, 2011 ).
Social Economy: Every interaction with patients or team members occurs in a social construct. One might be gaining excellent personal professionalism competence yet fail to achieve desired high-value care outcomes. The practitioner must gain understanding and competence of social intelligence skills in order to fully gain high-performing status. Professionalism competence is fully achieved when practiced in the social construct.
Learning Opportunities: The process of professionalism competency development requires that people within the organization are committed to learning. One purpose of medical education is to take people from novice to expert ( Miller, 1990 ). The process of moving people along this continuum is often fueled by failure, the very thing that physicians hope never happens. But it is often inevitable, and as such, it is important to process every failure, large or small, in a way that maximizes learning opportunities ( Edmondson, 2012 AU57: The citation "Edmondson, 2012" matches multiple references. Please add letters (e.g. "Smith 2000a"), or additional authors to the citation, to uniquely match references and citations. ). Organizations or institutions that maximize learning opportunities are those that leverage their failures and seek the best in their people and processes ( Senge, 1990 ).
Social Intelligence: Social Intelligence refers to one’s human aptitude for relationship. It is comprised of two distinct categories relating to social engagement: social awareness, and social facility ( Goleman, 2006 ). Social awareness refers to a variety of abilities that run from being able to instantaneously sense another’s inner state, to understanding their feelings and thoughts, and finally to understanding complicated social situations. Social facility builds upon social awareness to allow smooth and effective interactions and it involves: 1) s ynchrony – interacting with others smoothly at the nonverbal level; 2) self-presentation – presenting oneself effectively as they engage with others; 3) influence – being able to shape outcomes of social interactions; and, 4) concern – caring about others’ needs and taking actions that demonstrate concern ( Goleman, 2006 ).
Professional Competence: The term used to define the skills necessary to deliver high-value care . Professionalism competence is a set of high-performing, non-technical actions practiced with skill as one engages with patients, peers, and members of the healthcare team. People operating in accordance with these high-performing actions result in highly-competent humanistic, ethically vigilant, reflective, socially responsive and responsible, resilient physicians (Weld, 2015 AU58: The in-text citation "Weld, 2015" is not in the reference list. Please correct the citation, add the reference to the list, or delete the citation. ). These skills transcend the traits, trappings, and traditions of being a physician.
Professional Competency Cycle: The professionalism competency cycle is a learning process which moves people from novice to expert status. While the term ‘expert’ is an ever-changing target, the cyclical process provides structure to the learning process. The cycle consists of self-assessment, self-awareness, self-analysis, self-improvement strategy development, and evaluation. The first three steps are about discovery, with the final two about active application and learning.