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Chapter 3: Professionalism with Physician Colleagues and Other Health Professionals

Chapter Authors: Adam A. Rosenberg, MD & Yolanda H. Wimberly, MD

The professional development of physicians involves experience and reflection; experience increases knowledge and skills, whereas reflection on that experience improves self-knowledge and insight. Providing learners with role models who use and promote the use of reflection in their daily work will create the kind of environment that embodies professionalism as a core value. Thus, the culture of the work environment has enormous potential to contribute in a positive way to the formation of physicians during residency.  Central to this concept is the ability of trainees to embrace the concept of the multidisciplinary team and a culture of patient safety and continuous quality improvement.  These attributes are inherent to the triple aim to produce improved outcomes for our patients, better health for populations and cost effective care.  This paradigm for care places a premium on team based care with coordinated services and appropriate stewardship of resources.

The two responsibilities outlined in the Physician Charter that are most relevant to this area of professionalism are:

  • Commitment to improve quality of care

Quality improvement requires that physicians “work collaboratively as a member of the health care team to increase patient safety and reduce error.”1 To accomplish this, physicians need to value interdisciplinary teamwork and contribute effectively to team function to ensure optimal care to patients. Equally important is the team’s responsibility to examine its system of care on a continuous basis, accept responsibility for shortcomings and failures, and work together to improve the system.  Part of this responsibility includes being acutely aware of patient safety in clinical practice and being willing to report events that might lead to preventable harm.  In addition, this must embrace a culture of searching for opportunities to improve on the system of care provided on a continual basis.  These qualities are extolled in the CLER Pathways to Excellence document from the ACGME (Jan 2014).

  • Commitment to professional responsibilities

As a member of a team, the physician must contribute to the overall functioning of the team by performing his or her share of the work in a way that builds on the contributions of other team members. Underlying this functional responsibility is a culture that values and embraces a genuine respect and appreciation of the skills of all team members. Such a culture can help to create a safe patient care environment in which conflicting opinions can be openly expressed and discussed in order to provide continuous improvement of care for patients.  Healthcare is delivered by multidisciplinary teams and quality issues need to be addressed within the team structure supporting a culture of continuous process improvement.

It is important to consider professionalism in the context of being both a member and a leader of an interdisciplinary team. Teamwork involves ongoing collaboration, mutual respect, cooperation, and information sharing to ensure that the care provided best serves the interests of patients and families.

When serving as a leader of a team, the trainee must demonstrate additional behaviors important to overall team functioning. It is critical to avoid abusing any power that may come with the title “physician” and instead use a leadership position to guide and facilitate team dynamics. Balancing supervision with independent decision-making is critically important for the safety of patients and the developmental growth of learners. The trainee should take responsibility for matching task assignments to the capabilities of the individual team members so as to optimize care of the patient. As a leader, it is important to set an example for others in order to create a culture and context for providing high value and quality care in a professional manner.  With leadership comes the added responsibility of teaching, supervising and evaluating colleagues and oneself. With regard to the latter, one must be truthful and accurate in order to provide others with meaningful feedback to guide practice improvement.

Accountability is a critical element for teams to function effectively. It begins with self-awareness. Engaging learners in guided reflection that fosters awareness of personal biases, stresses, and limitations is critical to fostering professional interactions in the work environment. Taking time to reflect on interactions and behaviors, whether positive or negative, is an important characteristic of a professional and necessary for continued professional development.

Physicians are also accountable to other members of the profession. Assisting colleagues with daily work, completing tasks on time, providing coverage in emergencies, and seeking help when the care required is beyond one’s scope are some examples of how this aspect of professionalism can be demonstrated. Furthermore, physicians need to demonstrate respect for all health care providers, across all disciplines. Negative comments made about others diminish the professionalism of all physicians and perpetuate problems.  It also gives a life to stereotypes and teaches all trainees unprofessional behavior.

Finally, physicians are accountable to each other. Professional responsibility does not stop with one’s own practice. With the opportunity to self- regulate comes the responsibility of taking the behavior of our colleagues seriously. When we witness unprofessional behavior, we have a duty to address this behavior so that it does not continue and if remediation is warranted, it can be implemented.  When working as part of a team, trainees may witness unprofessional behavior on the part of peers or colleagues. Whenever possible this should be addressed with the individual. There should be a safe process for reporting unprofessional behaviors of more senior colleagues so as not to put trainees in the uncomfortable position of addressing these issues directly.

The Pediatric Competencies that are most relevant to this area of professionalism are:

  • Systems-based Practice
    • Work in inter-professional teams to enhance patient safety and improve patient care quality.  
  • Personal and Professional Development
    • Provide leadership that enhances team functioning, the learning environment and/or health care system/environment with the ultimate intent of improving care of patients.  
  • Professionalism
    • Professionalization 
    • Professional Conduct 

Behavioral Statements

The components of professionalism with physician colleagues and other health professionals discussed above provide general goals. It may be helpful to identify specific behaviors or practices that would exemplify professional conduct in this domain and some that would represent lapses of professionalism.

Examples of Expected Professional Conduct:

  • Follows policies and procedures
  • Demonstrates self-awareness and the ability to be self-critical in reflecting on practice
  • Accepts feedback from others and develops goals for practice improvement
  • Participates in hospital patient safety training around issues of preventable harm and reports events that could potentially result in patient harm
  • Works collaboratively and cooperatively as a member of a health care team
  • Leads with respect and fair treatment of colleagues and provides appropriate guidance to team members
  • Accepts responsibility for negotiating conflict and bringing about conflict resolution at the appropriate time and in the appropriate setting
  • Ensures the safety of patients by not allowing oneself and/or team members to go beyond their limits of knowledge and skill in delivering care
  • Accepts the responsibility of teaching colleagues by developing the knowledge base, skills, and attitudes necessary to be a competent teacher
  • Gives appropriate feedback to peers regarding improvements in behavior that will enhance professionalism and is willing to report lapses through the proper institutional channels
  • Arrives on time for scheduled activities and appointments and in the event of an emergency arranges appropriate coverage

Examples of Lapses in Professional Conduct:

  • Fails to engage in self-reflection and disregards feedback from others that would be helpful in practice improvement
  • Fails to notify supervisors of inability to work in a timely manner and does not take responsibility for ensuring proper coverage
  • Fails to ask for or address patient input (to the extent possible based on individual patient needs and clinical circumstances) in making decisions
  • Does not demonstrate the required leadership when running a team to create a supportive learning environment or a culture of safety and balancing workload by neglecting to define the roles of each team member
  • Avoids responsibility to negotiate conflict among team members and/or report lapses in professionalism
  • Ignores the opportunity to acknowledge and incorporate the expertise of other team members in enhancing patient care
  • Does not expend the effort to acquire the knowledge, skills, and attitudes that are necessary to be an effective educator of trainees and families
  • Fails to take part in patient safety training, shirks the responsibility to report patient safety concerns and does not embrace quality improvement efforts to improve patient care
  • Does not demonstrate respect for all team members at all times

Teaching Professionalism

Learning Objectives for Trainees

  • Trainees will advocate for collaboration to improve care, reduce medical errors, increase patient safety, and optimize outcomes of care.
  • Trainees will identify the elements of professionalism that contribute to the effective functioning of a team, including physicians, other health professionals, and students.
  • Trainees will be able to identify lapses in professional behaviors in the work environment and mechanisms for addressing these lapses.

Reflective Exercises

These reflective exercises can be used for individual reflection on professionalism issues or can be modified and discussed as a part of a larger group meeting.  Where applicable, related competencies/milestones are indicated.  After holding a discussion about professional responsibilities of physicians, ask learners to describe, in one page or less, an incident in which they were challenged with a decision that involved professionalism in relationships with other physicians or health care personnel.

  • Using any of the vignettes below, ask learners to describe a similar real-life situation. Ask them to identify the conflicting values and what they learned from the situation.

Vignettes

The vignettes that follow were developed for use with an individual, or in a small group or noon conference setting to help stimulate discussion about issues of professionalism.  Program and clerkship directors are encouraged to expand upon these to reflect local issues and experiences.  Where applicable, related competencies/milestones are indicated.
 

Chapter 3 Vignettes - Professionalism with Physician Colleagues and Other Health Professionals

Vignette 1 - Sick call

The resident on sick call is called by the chief resident and told that she needs to come in and cover for a sick colleague. The sick call resident explains that she cannot come in because she has not arranged a baby-sitter for her own children. She says that it is impossible to keep a baby-sitter on alert for the whole month in case she gets called in. She asks the chief resident to call in somebody else and says that she will cover next time provided she has ample warning.

Points to consider during discussion:

  • Assume that you are the chief resident. How would you respond to this resident? What if the resident were male? What if this is the first time? What if this is a chronic problem?
  • If you decide that efforts to get this resident to come in at this point in time are futile, what do you say to the next resident that you call to come in when they ask why the sick call resident is unavailable?
  • Issues with a double standard (such as having a child versus not) come up frequently. What strategies can one use to even the playing field?

Vignette 2 - What's the prescription?

A respected and well-liked division chief approaches one of your peers for a prescription for meperidine for his headaches. He explains that he has been too busy to get to his own physician for a new prescription and today his headaches are particularly bad. When the resident sheepishly says that she would rather not write the prescription, the faculty member nervously withdraws the request and apologizes.

Points to consider during discussion:

  • Imagine that your peer comes to you for advice about what she should do. Do you get involved or steer clear of the situation?
  • If you feel it is part of your professional responsibility to become involved, how would you proceed?

Vignette 3 - Covering for a colleague

You are assigned to a subspecialty team with four junior residents who rotate call and cover each other’s patients every fourth night. The morning after one specific colleague takes call is always chaotic and stressful. He says the night is too busy for him to follow up on labs, imaging studies, etc. You and the other two trainees have been coming in earlier and earlier to compensate so that rounds still go smoothly. You are halfway through the rotation and decide it is easier to continue to cover for the other resident than raise concerns.

Points to consider during discussion:

  • What is the role of the residents, if any, in addressing this behavior?
  • Suppose the subspecialty fellow is unaware of the situation because the residents have done such a good job of covering. One morning, toward the end of the rotation, a student on the team makes the fellow aware of what has been happening. In addition to confronting the problem resident, he confronts the other three residents for their unprofessional behavior, saying that they are accountable for addressing professional lapses of their colleagues. Are the remarks of the fellow justified?

Vignette 4 - Angry evals

One of your fellow residents returns from his semiannual review of evaluations with the program director and is quite upset about the interaction. According to the resident, the program director told her that her professionalism was in question because she did not engage in required learning activities to improve quality of care, such as creating a learning plan or participating in her clinic quality improvement project. The resident feels that she has done a good job of taking care of her patients and that the program director is judging her on things that “don’t really count.”

Points to consider during discussion:

  • What is your definition of professionalism?
  • Do the incomplete assignments constitute a lapse of professionalism? If so, how would you respond to your colleague?
  • How do you as current residents make time for these types of activities?

Vignette 5 - Seeking advice

As the senior resident on the ward, you are asked by the department quality improvement committee to help address the issue of timely patient discharges. They inform you about an upcoming meeting and ask your advice about which key players should be invited to the meeting.

Points to consider during discussion:

  • Who would you invite if there was a similar problem on your ward team and why?
  • Identify the attributes and behaviors of your group that will be important in effecting positive change to address this issue

Vignette 6 - Yes, nurse?

You have been called by a nurse about a patient care issue. This nurse has a history of calling you quite a bit for what you deem are non-emergent issues. You are concerned about this as it disrupts your other duties.

Points to consider during discussion:

  • What are your next steps?
  • Who should you involve in the discussion?
  • Have you done all you can to satisfy your professional responsibilities in this circumstance?

Vignette 7 - Hostility from nursing staff

You have noticed there are issues between the nursing staff and the residents. Residents feel they are disrespected by the nurses on a daily basis and feel it is a hostile work environment and definitely not the best for patient safety.

Points to consider during discussion:

  • How would you address this issue?
  • What resources would be needed to help improve this situation?
  • Who would you involve to help solve this issue?
  • How does it affect patient safety?

Vignette 8 - Exceeding capacity

As an intern on your night ward rotation, there have been several nights where the acuity on the service as well as the number of new admissions has exceeded the capacity of yourself and the supervising resident to continue to provide safe care for the patients on the team. On each occasion you have persevered until the final night, after which you send an extensive communication to the chief resident describing several potential patient safety concerns.

Points to consider during discussion:

  • Is it a breach of professionalism to not report through hospital channels the patient safety concerns?
  • Is it a breach of professionalism to have not prospectively called for help (eg, from the attending)?
  • How should the chief handle this circumstance and counsel the intern?
  • Who else should be involved in the conversation?

Vignette 9 - Second guessing

You and a colleague are rotating in the intensive care unit on a team with 2 second year pediatric residents, a 4th year medical student, an intensive care fellow and attending. It has become a regular occurrence on rounds to second guess and outwardly criticize patient care decisions made by the more junior members of the team. In particular, the 4th year student has been frequently handled in this manner; on a few occasions bringing her to tears after rounds. The ICU fellow has been the main culprit with the attending mostly in the background. You have spoken with the fellow on more than one occasion to not be so hard on the student who you feel is doing a nice job and would someday be a good resident in the program. You fear the student is having a negative experience that will impact her willingness to train further in the program. The fellow, when you have spoken, just shrugs his shoulders and says “this is how you learn”.

Points to consider during discussion:

  • Is this type behavior ever acceptable within the construct of the care team?
  • What do you think of the attending’s behavior in this circumstance?
  • Having been rebuffed by the fellow and put off by the attending’s apparent indifference about the fellow’s behavior, how would you proceed?
  • What should be the outcome in this circumstance?

Assessment Tools

“A true evaluation of professionalism must focus on the reasons for a behavior, rather than just the behavior itself. Professional behavior assessment tools must take into consideration the contexts in which unprofessional behaviors occur, the conflicts that lead to lapses in behavior, and the reasons choices were made.”2 This approach clearly cannot rely on one tool and/or one source of input. Input needs to be provided by faculty, peers, nurses, families and other ancillary personnel. Other options also include multidisciplinary simulations or use of standardized patients.  Some examples of available tools include:

  • The 360-degree assessment instrument for PM&R residency programs3
  • The professionalism mini-evaluation exercise4

These tools do not specifically assess a trainee’s role as a team leader or ability to work within the team, nor do they assess their role in creating a culture of patient safety and continuous process improvement. Most current assessments of teamwork focus on high acuity rather than low acuity situations.  It would seem that items could be added to existing tools to specifically address leadership and performance within the multidisciplinary team structure or could be inferred from comments on global or specific professionalism assessment tools.  As for  the quality improvement/patient safety piece, one could consider using a curriculum checklist as suggested by Nagy et al5.

References

  1. ABIM foundation. American Board of Internal Medicine, ACP-ASIM Foundation. American College of Physicians- American Society of Internal Medicine, European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med 2002;136:243-6.
  2. AAMC. Assessment of professionalism project. www.aamc.org/download/77168/data/professionalism.pdf
  3. Musick DW, McDowell SM, Clark N, Salcido R. Pilot study of a 360-degree assessment instrument for physical medicine & rehabilitation residency programs. Am J Phys Med Rehabil 2003;82:394-402.
  4. Cruess R, McIlroy JH, Cruess S et al. The professionalism mini-evaluation exercise: a preliminary investigation. Acad Med 2006;81(Suppl 10):S74-S78.
  5. Nagy CJ, Zernzach RC, Jones WS et al. Common core curriculum for quality and safety: a novel instrument for cultivating trainee engagement in quality improvement and patient safety. J Grad Med Ed 2015;7:272-274.

Other sources:

  • Clinical  Learning  Environment  Review.  Pathways  to  Excellence.  Accreditation  Council  for  Graduate  Medical Education.  Chicago, Ill, January 2014.  
  • Miles  PV,  Conway  PH,  Pawlson  LG:  Physician  professionalism  and  accountability:  the  role  of  collaborative improvement networks. Pediatrics 2013;131:S204-S209.
  • Myers JS, Nash DB: Graduate Medical Education’s new focus on resident engagement in quality and safety: will it transform the culture of teaching hospitals? Acad Med 2014;89:1328-30.
  • Amalberti R, Auroy Y, Berwick D, Barach P: Five system barriers to achieving ultrasafe health care. Ann Intern Med 2005;142:756-764.
  • Hickman RS, Raman A. Medicine’s continuous improvement imperative. JAMA 2015;313:1811-1812.
  • Berwick DM. Postgraduate education of physicians. Professional self-regulation and external accountability. JAMA 2015;313:1803-1804.
  • Van Schaik SM, O’Brien BC, Almeida SA, Adler SR. Perceptions of interprofessional teamwork in low-acuity settings: a qualitative analysis. Medical Education 2014;48:583-592.
  • Wilkinson TJ, Wade WB, Knock LD. A blueprint to assess professionalism: results of a systematic review. Acad Med 2009;84:551-558.

Index of Pediatric Competencies addressed by learning activities:

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