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Chapter 6: Professionalism After Training

Chapter Authors: Debra Boyer, MD & Richard B. Mink, MD

Throughout this Guide, we have emphasized that both general pediatricians and subspecialists must be committed to lifelong learning and ensure that they continue to have the skills necessary to provide high-quality care. Professionalism itself is not a competency to be achieved. It is a developmental process that continues throughout the life of a physician. Each and every day, in each encounter and at every decision-making point, the physician must confront the issue of the ideal professional behavior and try to achieve that ideal. Professionalism should not be focused just on the very unusual and serious unprofessional behaviors that are demonstrated by a few. It is a challenge for every physician to continue to improve his/her skills of healing and comforting patients and families. Although we begin to teach and shape professional behavior in medical school and during residency and fellowship, the lesson is never fully learned. After training, this task becomes more complex as individuals will be responsible for their professionalism without the constant vigilance of teachers and role models.

Two of the professional responsibilities in the Physician Charter related to clinical care are:

  • Commitment to professional competence
    • Achieving and maintaining competence involves a commitment to maintain the medical knowledge, clinical abilities and team skills necessary for the provision of quality care.   
  • Commitment to improve quality of care
    • Continuous improvement of care involves not only ongoing, informed review of the medical literature and maintenance of clinical competence, but also working with colleagues, health care systems, and other professionals to improve patient safety, reduce medical errors, improve accessibility and efficiency of care, minimize overutilization and underutilization of medical resources, and improve health outcomes.

As trainees begin to think about life after training, they will begin to see that professionalism issues will continue to arise throughout their careers. They will also likely realize that they need to self-monitor their behavior. When working through the material in this chapter, program directors may want to begin by asking the trainees to project their thoughts into the future and consider the following five questions:

  • How will you know that you are doing a good job?
    • Physicians should always continue to question whether or not they are doing a good job. This process of self-reflection and self-assessment is the critical step in maintaining professionalism. As physicians move from medical school, through residency or fellowship training, to an independent practice position, they will move from a situation where others reflect on their professionalism to an environment in which they are responsible for their own assessments and actions. These are hard questions: Am I doing a good job? How do I know? In an academic setting, there may be some system of performance evaluation and in a group practice, there should be efforts among colleagues to assess quality. Is the care being delivered up to-date? Is work being benchmarked? Are patients leaving care? How is the practice regarded in the community? There may be external benchmarks, but there must also be a system of internal measures. It is appropriate to ask your colleagues for feedback and help in identifying specific areas in which improvement is needed. In addition, many hospitals and practices have the capability to obtain specific information about your performance that can help guide improvement.Since patients and their families are the ultimate measure of effectiveness, physicians in practice can solicit their opinions as well. Distributing anonymous questionnaires to families can provide valuable information. Although it is a bit daunting to ask, their answers will likely be reassuring and may give some suggestions as to how to make your performance or that of the practice even better.
  • How can you find support for your professionalism?
    • There are many ways to find help with professionalism efforts. One way is to remain active with a local, regional, or national professional organization. Membership in the American Medical Association (AMA), Academic Pediatric Association (APA), American Academy of Pediatrics (AAP), subspecialty organizations and local pediatric societies are good ways to find peer support. It is also important for physicians to identify a mentor either in the community or from past professional contacts. This individual could be a former attending physician or program director. Discussing issues, problems, and positive and adverse events with a mentor is helpful in monitoring professionalism even without having daily contact. A few individuals may experience issues with their professionalism. Drug and alcohol abuse, unhealthy patient or peer relationships, or legal problems may emerge. In these cases, physicians may turn to hospital-based wellness committees or state-run programs for treatment and monitoring. It is always better for physicians to enter such a program voluntarily and seek help before there is an untoward effect from one’s actions that might affect the physician, his/her family, or most importantly, patients.
  • How do you maintain work-life balance?
    • As a trainee, duty hours are regulated by requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME). In practice, there are usually no such restrictions and it falls on the physician to monitor his/her time. Fatigue from sleep deprivation impairs performance and can compromise patient care.  Excessive work hours can also have a detrimental effect on family relationships and cause added stress. One should also not ignore the importance of maintaining good physical health through regular exercise and appropriate nutrition. These strategies can help the physician cope with stress. For those physicians having difficulty finding a good work-life balance, the advice of mentors and senior colleagues can be obtained and may be very helpful.
  • What if you change careers or enter a new type of practice?
    • Changing careers or reentering pediatrics after a significant break is a likely scenario for many pediatricians. This is a time when there must be an extra emphasis on professionalism. New roles require a retooling, not only in knowledge base and communication styles, but also in performance expectations. Again, the role of a mentor or advisor is critical. A senior colleague or a peer can be made aware of the need for feedback. Also, physicians should set aside time for self-reflection or even engage in keeping a journal that describes the transition and the difficulties that might be faced.
  • How does professionalism change as you become a more senior physician?
    • As previously noted, professionalism is a developmental process that continues throughout the life of a physician. Life-long learning and keeping “current” is a professional responsibility that may be more of a challenge for those in private practice. Nonetheless, with added experience, the physician will have gained skills to better cope with stressful situations, more effectively utilize self-reflection to improve care and have developed efficient systems to communicate with other providers. As a senior physician, he/she can serve as a role model for junior colleagues, helping them to understand the need for self-assessment and life-long learning and serving as a resource for issues that arise.

Maintenance of Certification (MOC)

The medical profession must work to ensure that all of its members are competent and exhibit professional behavior. The mission of the American Board of Pediatrics (ABP) is to assure the public that pediatricians have the knowledge and skills necessary to provide quality care and that they maintain these skills over a lifetime of practice. At the time of completion of pediatric residency and fellowship training, program directors are asked to attest to the clinical competence and professionalism of their learners. Once the trainee passes his/her initial General Pediatrics Certifying Examination (and for those who pursue fellowship, their Subspecialty Certifying Examination), there are mechanisms to ensure that he/she continues to act in professional ways worthy of the public’s trust.

In order to maintain certification by the ABP, a diplomat must demonstrate that he or she has a valid, unrestricted medical license (this is Part 1 of MOC). If a license is restricted in any way by a State Licensing Board due to a disciplinary action taken against the license holder, the ABP certificate is subject to revocation. Certificates have been revoked by the ABP on the basis of disciplinary actions, the majority of these revocations falling into three categories: impairment due to chemical or substance abuse; incompetence/negligence; and sexual misconduct and violations of appropriate physician/patient boundaries. Other, less frequent, causes of disciplinary action include conviction of a crime, inappropriate prescribing, Medicaid/Medicare fraud or other fraudulent misrepresentations.

MOC also involves an assessment of two of the professional behaviors related to patient care: a commitment to competency and a commitment to improve quality of care. The MOC process involves measures of knowledge building to assess the physician’s commitment to life-long learning (Part 2), and measures of quality improvement to evaluate performance in practice (Part 4). MOC also includes a measure of cognitive expertise, that is, completion a recertifying examination (Part 3).

Professional Behavior and Practice Requirements 

There are several other places where professionalism is included in the assessment of physicians. If there are serious lapses in professionalism, the physician may be prohibited from obtaining the approval needed to work as a general pediatrician or subspecialist. These areas include:

  • State Licensing
    • In the United States, all states and the District of Columbia have the authority to issue medical licenses.The states set the requirements for licensure, the penalties for practicing without proper authorization and the criteria for suspending or revoking a license. The Federation of State Medical Boards of the United States (FSMB), an organization comprised of the individual state medical boards has an electronic notification system that alerts state boards when one of their physicians has received disciplinary action in another state.  Through this, the ABP is quickly informed about any license suspension or revocation.
  • Hospital Credentials
    • Every hospital is required to establish bylaws that codify qualifications for staff membership and areas of practice. A graduating trainee will need to apply for staff privileges at every hospital in which he/she provides patient care. The application usually includes questions about any unprofessional behavior, and character references are also routinely sought. As specified in their bylaws, hospitals have the right to revoke staff privileges.
  • Liability (Malpractice) Insurance
    • When seeking liability or malpractice insurance, insurers will also assess a pediatrician’s professional conduct through a series of questions in the application. Insurance may be declined due to past episodes of unprofessional behavior. Insurers and hospitals must report adverse information to the National Practitioner Data Bank (NPDB). In addition to other information, the NPDB collects reports of liability payments made on behalf of health care professionals regardless of whether the payment was the result of a verdict or a settlement.  In addition, some states require reporting of settlements to their medical boards.
  • Third-Party Payers
    • Most practicing pediatricians and pediatric subspecialists will need to contract with third-party payers. As a part of the process, the third-party payers will ask program directors and training institutions to verify the resident or fellow’s completion of training as well as identify any past episodes of unprofessional behavior, lapses in training, instances of program modification, or special oversight that was required.

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

  • Interpersonal and Communication Skills
    • Communicate effectively with physicians, other health professionals, and health-related agencies 
  • Professionalism
    • Professionalization
    • Professional Conduct
    • Humanism 
  • Personal and Professional Development
    • Use healthy coping mechanisms to respond to stress
    • Manage conflict between personal and professional responsibilities 
  • Systems-based Practice
    • Work in inter-professional teams to enhance patient safety and improve patient care quality 
    • Participate in identifying system errors and implementing potential systems solutions 

Behavioral Statements

The components of professionalism beyond residency and fellowship listed above provide general goals. In discussions with trainees, it may be helpful to identify specific behaviors or practices that exemplify professionalism in this domain and some that would represent lapses of professionalism.

Examples of Exemplary Professional Conduct:

  • Participates actively in maintenance of certification
  • Constructs and participates in a lifelong learning plan
  • Surveys peers and patients about the quality of care bring delivered
  • Participates in hospital-based, commercial, or organizational continuing medical education activities
  • Maintains hospital staff privileges
  • Participates in community-based child advocacy activities
  • Completes clinical documentation and communication in a timely fashion
  • Continually strives to improve care

Examples of Lapses in Professional Conduct:

  • Engages in unethical or illegal practices
  • Promotes the business of medicine above duty to patients
  • Engages in discriminatory hiring practices
  • Conducts practice without regard to monitoring quality or safety

Teaching Professionalism

Learning Objectives for the Trainees: 

  • Trainee will describe the dimensions of professionalism beyond the period of residency training.
  • Trainee will explain the many ways their professionalism will be tested and how to maintain high standards.
  • Trainee will describe the implications of professionalism lapses.
  • Trainee will explain methods for evaluating their own professionalism throughout all stages of their career.
  • Trainee will be able to develop a lifelong professionalism plan to enhance their lifelong learning.
  • Trainee will identify techniques to find help and support with issues of professionalism into the future.

Reflective Exercises

These reflective exercises can be used for individual reflection on professionalism issues or can be modified and discussed as part of a larger group meeting.

  • After holding a discussion about professional responsibilities of physicians, ask trainees to describe, in one page or less, how they will monitor their professionalism in the future.
  • Using any of the vignettes below, ask trainees to describe a similar real-life situation. Ask them to identify the conflicting values and what they learned from the situation.
  • Hold a teaching session to review the state licensing regulations and obtain, review, and discuss a list of reasons for license revocations. The American Medical Association publishes these in State Medical Licensure Requirements and Statistics, and each state has license revocation information on its Web site.
  • Hold a meeting with trainees to discuss what form of professional misconduct requires the   program director to report unprofessional behavior to the ABP. What is a minimum threshold?
  • Perform a confidential written exercise that requires trainees to describe an unprofessional behavior they have seen in an attending and indicate what they would have done in a similar situation.
  • Gather a group of senior faculty for a discussion about the professionalism challenges they face in an effort to serve as role models for trainees.
  • Observe physician-patient interactions from movies or television and discuss the issues of professionalism that are raised.

Vignettes

The vignettes that follow were developed for use in a small group or noon conference setting to help stimulate discussions about issues of professionalism. Program directors are encouraged to expand upon these to reflect local issues and experiences. 

Chapter 6 Vignettes - Professionalism After Training

Vignette 1

You are on the Credentials Committee of your hospital. You read in the local newspaper that one of the members of the hospital staff has been arrested for child pornography. There has not yet been a hearing or sentencing.

Points to consider during discussion:

  • What should you do?
  • Do you bring this to the attention of your Credentials Committee?
  • Do you contact the physician to get their side of the story?
  • Do you contact the state licensing board or the ABP?
  • Do you have an obligation to protect a colleague or potential child victims?

Vignette 2

A physician in your town is in a pediatric practice and advertises that she is a board-certified pediatrician, but you note on a routine check of credentials that she is no longer certified because she did not recertify. Nonetheless, she seems to be a competent pediatrician and good colleague.

Points to consider during discussion:

  • Is this a problem?
  • Should you contact the ABP?
  • Is it important to let parents in your community know?
  • Do you approach the physician to discuss this issue?

Vignette 3

3. You refer your patients to a busy pediatric gastroenterologist, but you never receive any written reports or consultation notes for your files. This makes it difficult to know what treatment plan needs to be followed. You have mentioned this to the gastroenterologist, but he just does not respond.

Points to consider during discussion:

  • Is this an issue of professionalism?
  • What should you do about it?
  • Should you change consultants?
  • Will complaining to the hospital CEO help?

Vignette 4

You note that one of your partners prescribes oxycodone very liberally by your standards. You are not sure if he just has more patients with pain or this is his practice “style.” You are concerned but feel on one hand that this is not your business. On the other hand, some of his patients come to you for refill prescriptions and that makes you feel uncomfortable.

Points to consider during discussion:

  • How will you deal with this?
  • Is this a quality of care issue?
  • Is this a possible variation in style?
  • Should you mind your own business?
  • How can you handle this situation as a group practice?

Vignette 5

You notice that one of your colleagues in your Pediatric Critical Care group has been showing up late to work, calling in sick not infrequently and seeming much more on edge lately. This is very unlike her. You notice that when she comes in to work sometimes she is slurring her speech a bit and seeming a bit confused. You are concerned that she might have developed a drug/alcohol problem.

Points to consider during discussion:

  • Is this any of your business?
  • Do you discuss this initially with your colleague? Your Division Chief? The Hospital Medical Staff? The local Board of Medicine?
  • What is your responsibility to the patients in your unit?
  • What kinds of support might exist that you can suggest to your colleague?

Vignette 6

It is your 35th birthday and you have plans to go out for a really nice dinner with your husband after clinic. Since having children, you haven’t been out for a really special dinner in a long time. During the day, one of your Oncology patients gets transferred to the PICU in respiratory failure. You run off to the unit immediately after clinic finishes to speak with her family. At this point, it is 5PM and the family wishes to speak with you about whether they should redirect care. You look at your watch, realizing that your dinner reservations are for 6:30PM.

Points to consider during discussion:

  • How do you explain this situation to your husband?
  • Are you obligated to stay?
  • Could this situation have been avoided?
  • What other resources can you call upon in this situation?

Vignette 7

You are now 2 years out from your Pediatric Gastroenterology fellowship and have joined a private practice of six individuals in your hometown. You enjoy your practice group very much but realize that you actually miss the tradition of sitting down twice a year with your program director to review your evaluations. You think that you are doing a good job, but honestly realize that you have no idea how you are doing both personally and as a practice.

Points to consider during discussion:

  • How can you get feedback on your performance?
  • Who would be helpful to get this feedback from?
  • How can you improve your own performance and that of your entire practice?

Vignette 8

You have just joined your new practice and are very excited. You are somewhat surprised by the long hours seeing patients and doing patient follow-up. You find yourself getting in earlier and earlier and staying later each day to catch up. After a few months, your spouse comments that you are not sleeping much, you seem grumpy most of the time. You feel like you are starting to make some “silly mistakes” in terms of your patient care. It dawns upon you that you actually miss the days of “duty hours” in residency where you were limited in how much you could work.

Points to consider during discussion:

  • How can you better adjust to your new role as an attending?
  • What resources are there to help you?
  • Are there things that you can do during residency/fellowship to help you prepare for your life as an attending?

Cases

Chapter 6 Cases - Professionalism After Training

Case 1: A Patient Lost

Bill comes into his office early to find a desk covered with messages, charts, and forms. This is a typical Monday morning for him, with one or two hours to clear his desk before starting on the next round of patients. It has been particularly tough this month because of winter viruses that have filled the office with acutely ill patients in addition to the usual well-child checks. One of these viruses has affected him, and he too is feeling a bit ill.

Bill sorts through a stack of lab reports, circling abnormal values and writing notes to the nurse about how to follow up. Next, he signs off some forms and prescription refills. One and half hours into his day, he already feels that he has done a day’s work.

Next, he shuffles through messages and finds a note from Mrs. Jones, the mother of a 3 ½-year-old Anna, whom he has cared for since birth. There have been many well-child checks, minor illnesses, and some behavioral problems. He is surprised by the message, which states that “Mrs. Jones called on Friday and asked that we transfer little Anna’s records to the practice of another pediatric group.” “I wonder why they are transferring,” he muses sadly. He thinks back to interactions he has had with the child and parents and cannot come up with anything out of the ordinary. Was there a conflict about a bill or an interaction with a nurse? Bill writes a note to his office staff; “Please copy the records of Anna Jones and send to Dr. X” yet he can’t help but wonder why the family wishes to transfer.

Time is passing and there are many more messages to get through before the office officially opens and many more families that want to come to him. Nevertheless, the Jones request bothers him and he asks the nurse to pull the Jones chart. Should he call the mother? Time to move on.

Guiding Questions:

  1. What is your duty to patients who are leaving your practice?
  2. Why is Bill troubled by this situation? Should he be?
  3. Is this something Bill should look into further or should he write it off as an issue of patient autonomy?
  4. Is there a threshold for the number of patient transfers that you would find unacceptable?

Case 2: Professionalism After Training

Dr. Mike White, a 34-year-old general pediatrician, was trained at the local children’s hospital prior to joining Starr Pediatrics Practice. Starr Pediatrics enjoys an excellent reputation and is located in the affluent suburbs with an outstanding payer mix.

Dr. White typically sees twenty patients per morning session and last week noted after a single morning session that three patients seen that morning had been referred to Dr. Johnson, the new chief of pediatric gastroenterology at the children’s hospital. Dr. White notes that each of the three patients seen by Dr. Johnson had undergone some sort of endoscopic procedure with biopsies. He only knows this because the pathology reports of normal biopsies are in the record. He has not received any follow-up letters from Dr. Johnson. Ironically, as Dr. White was reflecting upon these facts, Mrs. Reyes called to thank Dr. White for the timely referral of her daughter Selma to Dr. Johnson.

Mrs. Reyes was very impressed with the care and attention her daughter received at the recent visit. She also reported that she was especially impressed that she got an appointment within the week, because she had been told that the wait time is normally greater than six weeks. “You must have a great connection with Dr. Johnson,” Mrs. Reyes told Dr. White.

Dr. White thinks “how timely” and tells his partners that Dr. Johnson seems to be serving their practice well; patients are satisfied and seem to get almost preferential service.

Three weeks pass when Shirley, Dr. White’s most experienced nurse, asks for a referral for her 3-year-old son Charlie, who has had ongoing constipation issues despite medications. Dr. White thinks the problem is probably compliance and control issues but agrees to refer Charlie to Dr. Johnson. After Charlie sees Dr. Johnson, Shirley calls and requests a second opinion because she doesn’t want Charlie to have to undergo the recommended colonoscopy. Shirley says, “It is just constipation. I was only looking for an easier laxative to use.”

Dr. White also feels a bit uncomfortable about the recommendation for what may be an unnecessary procedure. He remembers that Dr. Spect, who was a resident with him and, who subsequently went across the state to the prestigious gastroenterology fellowship program at the University Children’s Hospital, has recently joined Dr. Johnson’s group. Dr. White thinks that she is the best resource to get the true story. He calls Dr. Spect, but she is on family medical leave. He also calls Dr. Kerwin, another friend from residency, who practices in the community health center in the poorer section of town. He asks if Dr. Kerwin has any similar concerns about Dr. Johnson. Dr. Kerwin reports that Dr. Johnson is not a good communicator and seems reluctant to endoscope his patients. Dr. Kerwin has started to use another private pediatric gastroenterologist for his referrals.

Guiding Questions:

  1. What is your duty to know the practice of the physicians to whom you refer?
  2. After receiving multiple normal biopsy reports, what options, if any, should you pursue? Internal chart audit? Call the referring doctor? Call the department chair?
  3. What if you learn that the numbers of endoscopic procedures exceeds the standard of care?
  4. Should Dr. White be concerned about the lack of follow-up correspondence?
  5. What if you perceive that the pattern of endoscopies correlates with patient insurance?

Case 3: Lifelong Learning

Dr. Susie Jones gathers up her belongings and copies her pediatric journals from her office on the way out to the car to drive home. It has been a long day and is now 8:00 pm. She stopped seeing patients at about 5:30 pm. From 5:30 to 8:00 pm, three of the four members of her practice group gathered together over a pizza for their biweekly journal club. The topic of tonight’s session was “Review of Asthma Guidelines” recently published by the American Academy of Pediatrics. While driving home Susie reflects on how lucky she was to find the practice in which she is currently working. After finishing residency training two years ago, she interviewed at a number of different practices and made a decision to choose her current practice because the group was relatively young and they seemed committed to keeping up to date and practicing high-quality pediatrics. They were collegial group and went out of their way to share new information that they learned with one another. When Susie arrives home at about 8:30 pm, she has to put the final touches on packing for her family, which includes a 7-year-old and a 5-year-old. They will be accompanying her and her husband to Orlando for the annual AAP meeting, the first she has been able to attend since beginning practice two years ago. She is excited about the meeting, the setting, and the chance to spend some fun time with her husband and children. It is also important to acquire 25 CME credits, as her state medical license is due to be renewed soon.

Susie plans to attend as many sessions as possible and is particularly interested in the Red Book Committee session on New Immunizations; however, the Red Book meeting conflicts with a beautiful, sunny day and 7-year-old Sam wants to go to Disney World. There is also an evening session scheduled on cultural competence and Susie plans to attend this, as a number of immigrant families have recently joined the practice. Her husband, however, surprises her with an invitation to dinner for just the two of them and has made arrangements for their children to be cared for by an on-site babysitter. And so it goes for the rest of the meeting. Susie is able to attend several hours of sessions, but not nearly what she had originally planned.

On arrival back in the office several days later, Susie accesses PediaLink online and enters her hours of attendance at the AAP conference, 25 CME credits as is required for her to maintain her license.

Guiding Questions:

  1. How does one balance personal and professional obligations?
  2. If Susie is keeping up with the medical literature with her practice journal club and providing high-quality care, can claiming the CME credits be justified?
  3. What if Susie consciously sets aside time to read about new immunizations and cultural competence after returning from the AAP meeting?
  4. What other opportunities can a physician in practice use to maintain their competency and their CME credits?

Index of Pediatric Competencies addressed by learning activities

  • Interpersonal and Communication Skills
    • Communicate effectively with physicians, other health professionals, and health-related agencies

  • Professionalism

  • Systems-based Practice
    • Work in interprofessional teams to enhance patient safety and improve patient care quality.

    • Participate in identifying system errors and implementing potential systems solutions.

  • Personal and Professional Development
    • Use healthy coping mechanisms to respond to stress

    • Manage conflict between personal and professional responsibilities. 

    • Demonstrate trustworthiness that makes colleagues feel secure when one is responsible for the care of patients.

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