 Good afternoon. I'm delighted to welcome you to today's seminar in the professionalism series. We're delighted and honored that Dr. Holly Humphrey is able to join us and speak to us today. Holly and I go back a couple of years to today's where we were both medical students and interns and residents and not at the same time. We were separated by a generation, but it does go back a ways. As you know, Dr. Humphrey is the Dean of Medical Education at the University of Chicago, highly regarded nationally as one of the leading medical educators in the United States. Here at Pritzker, Holly took the lead in developing the Pritzker initiative, the curricula reform for the 21st century, and Holly has also launched the roadmap to professionalism initiative with colleagues. Nationally, when Dr. Humphrey was the head of the program in internal medicine, she also was the president of the program directors in internal medicine. And since then, as she moved from there to the Dean's office, she's become the chair of the American Board of Internal Medicine. So it's hard to think of anybody who has received more acknowledgement and recognition for contributions to the field of medical education than Dr. Humphrey. Today, Holly will talk about case studies in medical professionalism, a view from the front lines. Holly was so glad you're here. Thank you. Thank you, Mark. Thank you very much for that wonderful introduction. I'm glad you clarified that we weren't in the exact same medical school class. In all honesty, Mark was one of my teachers when I was a medical student here. And I have continued to learn from him over the years since I was a student as we all have. I wanted to say at the outset a thank you to Dana Levinson, who helped put this presentation together. There are a number of different angles that I could have taken with the presentation today. But I thought I would try to build on what we have learned as a group, beginning with the fall seminar series that I thought was very elucidating and interesting. And you'll see that some of what I'll present will touch on some of the conversations that we had in the fall. Let's get started. I do intend to address this question of the definitions of professionalism. And then I'd like to share with you what some very important accreditation expectations are in this domain of professionalism. Because I think in many ways the accreditation expectations force a lot of not only the conversation but the behavior that medical schools and residency programs are engaged in today in 2012. And then to try to make the point and drive the point home, I'm going to ask you to engage in some problem solving experiences through a few case studies. And I will conclude those case studies by posing what I believe are some unanswerable questions. However, it's possible that as a group, you will persuade me that there are in fact answers to some of what I'm posing as unanswerable. And then I will conclude by inviting you to think about the impact that mentoring can have in helping us solve some of the questions. And I think that everybody in this room has an opportunity to be engaged in a mentoring relationship on one level or another. I won't go into that topic in great detail given some time constraints. So I think early in this seminar series in the fall, we had an opportunity to think about the major principles of medical ethics that in fact form the foundation for the whole conversation and all of the published literature on medical professionalism. And I know that many of you who are real experts in the field of medical ethics may be content to leave this topic of medical professionalism right there with those four basic principles of medical ethics. You also know, given the presentation that Laney Ross did in the fall, that a more contemporary definition of medical professionalism was done by the American Board of Internal Medicine Foundation and the American College of Physicians through the physician charter. And that charter is based on the three principles which we covered in the fall as well as the professional responsibilities that the charter calls each physician to adhere to. Now, as I have listened to the conversation in the fall and being well familiar in particular with the physician charter, it gave me an opportunity to ask myself the questions of why is it that this topic of medical professionalism creates so much controversy and so many questions and conundrums. And I've certainly had the opportunity to think about that when our own medical students have pushed back on instruction related to medical professionalism. I think that the lofty goals of medical ethics and the lofty goals of the physician charter are in fact aspirational in what they intend to invite us all to aspire to. But I think the real essence of this conundrum gets back to the fundamental definition that we would find in any major dictionary. And that fundamental is that the professionalism is focusing on the conduct or the qualities that characterize or mark a profession or a professional person. And it's in trying to set expectations for conduct that I think we run up against some real dilemmas because I think they can very often stray a long way away from those fundamental high minded ethical principles as well as the principles of the physician charter. I also think that today this concept of professionalism is often applied to groups that would not historically have been thought of as representing a profession such as athletics according to Miriam Webster uses athletics as the example. And if you were to look in the literature you would find that a whole host of groups are using the term professionalism to describe the work that they do and the group that they happen to be a part of whether it's veterinaries or nurses or individual employees at Walmart. Now Herbert Swick published in academic medicine a set of expectations for physicians that he believed incorporated the contemporary definition of professionalism and we've had a chance to talk about these multiple times over the fall what in fact physicians do they subordinate their own interest to the interests of others they adhere to these high ethical and moral standards they respond to societal needs they events core humanistic values they have accountability for themselves and their colleagues they demonstrate continuing commitment to excellence they have a commitment to scholarship and advancing their field they deal with high levels of complexity and uncertainty and they reflect upon their actions and the decisions that they make that's a very long list. So with all of this background one reader who posted his comment on the internet said that that list actually read like a combination of the Boy Scouts code the Ten Commandments the Golden Rule and the Pledge of Allegiance all lovely and legal yet impossible to adhere to and enforce platitudes and pedestals warm the cockles but reality is chilly. I think in many ways we have heard that point of view in this seminar over the course of the fall but now let me show you what in fact physicians say when they have a chance in focus groups to talk about what they think of as professionalism and what I'm showing you is basically a word cloud that was developed by the American Board of Internal Medicine Foundation after doing a series of focus groups with practicing physicians largely in small and mid-sized group practices when they talked about their work as physicians in the community. This is the word cloud and one thing that gives me a great deal of a reassurance is that the very center of the word cloud is the patient. So when physicians talked about their role as professionals it was really their interaction with patients that drove their conversation in the focus groups as well as these qualities of compassion and honesty everything that you see on the word cloud in smaller font and lighter text are things that were mentioned in the focus groups but to a less extent. Okay so with that background let me show you what the accreditors expect medical schools to do. I'm going to talk about the LCME which is the accrediting group for medical schools and then the ACGME which is the accrediting group for residency and fellowship programs. So the LCME has several standards that are going to be very much related to this topic of professionalism. One of those standards is ED23 related to the curriculum. A medical education program must include instruction in medical ethics and human values and require its medical students to exhibit scrupulous ethical principles. They go on to say that the medical education program should ensure that medical students receive instruction in appropriate medical ethics, human values and communication skills and adherence to ethical principles should be observed, assessed, i.e. evaluated and reinforced through formal instructional efforts. Okay that's ED23. The phrase scrupulous ethical principles implies characteristics that include honesty, integrity, maintenance of confidentiality and respect for patients, their families, other students and other health professionals. The next standard is a relatively new standard and it applies to the learning environment. The standard 31. A medical education program must ensure that its learning environment promotes the development of explicit and appropriate professional attributes in its medical students, their attitudes, behaviors and identity. It is expected that a medical education program will define the professional attributes it wishes its medical students to develop as part of their formal training. Medical students should learn the importance of demonstrating the attributes of a professional and understand the balance of privileges and obligations that the public and the profession expect of a physician. Keep this in mind when we get to case study number one. The medical education program should also regularly evaluate the learning environment to identify positive and negative influences on the maintenance of professional standards and conduct and develop appropriate strategies to enhance the positive and to mitigate the negative influence. And then there's a standard related to outcomes. A medical education program must collect and use a variety of outcome data including national norms of accomplishment to demonstrate to the extent to which we meet these objectives and that we should collect that outcome data on medical student performance. The kinds of outcome data that could serve this purpose include assessments by graduates of the school by residency directors of the graduates preparation in areas related to the medical education program objectives including the professional behavior of its of its graduates. Now the Association of American Medical Colleges which is one of the two main parents of that accrediting body the LCME convened about a decade ago a task force to to provide guidance for medical schools on how we should report the performance of our students to the outside world specifically how we should report the performance of our graduates to the residency programs that they're applying to. That report is called an MSPE the medical student performance evaluation and it's the report is about 50 pages long and it has a whole series of recommendations for schools. I'm going to focus on only one of those recommendations right now and that is the recommendation that medical schools should provide a comparative performance of professional attributes of all of our graduates in this MSPE previously known as the dean's letter so no longer a letter of recommendation today a letter of evaluation and the recommendation from the AAMC is that medical students should be reporting on the performance of our graduates as exemplary adequate or below average compared to their peers that's what this arrow means how does this particular student compare to their peers in the domains that were put forward by the AAMC do they treat patients compassionately are they exemplary adequate or below average are they honest do they have integrity again exemplary adequate or below average do they respect others what is their ability to communicate do they advocate for patients do they put others first and let me remind you that we are one of a growing number of schools in the country that is a past fail competency based school so for us this this promotes an extra conundrum and I will tell you that we do not currently adhere to this recommendation okay but keep that in the back of your mind okay now what about the ACGME what about the group that accredits resident season fellowships they also have accreditation standards on this topic and they say that they must integrate the following ACGME competencies into the curriculum and one of those competencies is professionalism residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles residents are expected to demonstrate okay here we are the conduct of the profession compassion integrity and respect for others responsiveness to patient needs that supersedes self interest respect for patient privacy and autonomy accountability to patient society in the profession and sensitivity and responsiveness to a diverse patient population including but not limited to diversity and gender age culture race religion disabilities and sexual orientation so that's the expectation from the ACGME now with that background i want to invite you to come with me to the front lines let me say at the outset that the cases i am about to present are based on real incidents which have occurred in our own medical school and medical center however i have changed some of the details in order to protect the privacy of the faculty and the students who may have been involved in these okay so let me take you to rounds on the general medicine service and a commonly encountered conundrum of the pressure to discharge a patient so the patient is an 85 year old woman with end stage renal disease on parent neal dialysis she had a fall at home and came to our emergency room where it was determined she needed to be hospitalized for placement over the course of the hospitalization the team noted that there were several other diagnoses including high blood pressure diabetes and glaucoma and that she lived alone in a second floor apartment and had no known family members so the team caring for this patient needed to not only evaluate and care for her but then work on this issue of placement and as they tried to do that without family support in place and the need for the patient to be on parent neal dialysis which the patient wished to continue the team began to feel a lot of pressure from the utilization review committee to discharge this patient i'm sure that some of you in the room have found yourself in this situation and i'd be interested to know if you have found yourself in this situation how you have handled that in my experience nine times out of ten you know that it is the case the patient needs to be in the hospital but it's not been documented clearly and so with some easy an easy fix is to just make sure that your team is documenting clearly that the patient needs to be in the hospital according to the guidelines set forth by the utilization review committee i just think that it highlights that actually being able to advocate for your patient is such a key part of professionalism in the sense of knowing the ropes and unfortunately that does mean knowing a lot about coding these days and and the different sort of requirements of managed care that i think maybe none of us like but is a real reality okay excellent point from the oh just from the other side on utilization review they also have a you know sort of an obligation societally and into the institution as a whole as well as sort of to all the patients and i believe a lot of them as vini said are very amenable to negotiations and understanding sort of how to do things so okay great my first question is have we discussed with the 85-year-old that we're talking placement and are we removing her from her home and does she know this and is she consenting to this and how much does she have a say in everything that's going on i understand why it's hard for her to live on a second floor apartment but she's been doing it for weeks and months and years with all of these other comorbidities and what's pushing us and does she really agree to it yeah that's an excellent point and i know that the team was actively engaged with this patient and the patient actually did wish to return home with some extra supports in place if that could be arranged however 48 hours was not enough time to get all that in place okay well what ended up happening is utilization review was literally placing a lot of pressure on this team in fact involving the department chair to move the patient out of the hospital we talked about how the attending physician might manage the patient we didn't necessarily think about the role modeling aspect for residents and students about the highest standard of care however i think the comments that you shared were very much applicable as positive role modeling experiences what happened in this particular patient is that the patient was worked up for a pulmonary embolism there was potentially episode of shortness of breath overnight and while the index of suspicion for a pulmonary embolism did not seem to be very high it wasn't completely unreasonable but i just invite all of us to think about the cost implications when we're ordering tests so the patient got one extra day for being worked up for a pulmonary embolism and then the second thing that happened is after the pulmonary embolism was ruled out once again utilization review had made arrangements for the patient to go home however in the evaluation of the patient the team discovered that the patient was actually severely malnourished and the team was also working this patient up for whether or not there was a swallowing disorder whether or not there were other issues in terms of caloric intake etc and in the end the patient actually had a feeding tube placed which got the patient another additional day in the hospital so this case obviously has a whole host of avenues that we could pursue about patient management about the role modeling for physician for students and residents who are on this team and about really ultimately doing our best to take care of patients ultimately this team was able to find outpatient peritneal dialysis and a home healthcare nurse and the patient was in fact discharged home now I want to invite you to think about how should the attending physician grade the student for professionalism on this rotation because professionalism is one of the the domains that the attending physician is going to need to complete at the end of this rotation now I haven't really shared with you any of the data points for what the students role in the care this patient was but certainly as an observer the student had an awful lot of data points of their own to see what transpires in a hospital when a patient with this condition gets admitted given what you heard transpire during the management of this patient do you think as an attending physician you would be in a position to evaluate the student in the way that the WMC is asking us as medical schools to evaluate our students if you were strongly advocating to get the patient out as quickly as possible and the medical student was coming and telling you that he thought that wasn't a good idea and that the patient's not ready then you would probably give him maybe a higher point for advocates but then maybe a lower point for well the reality of the situation I mean I mean the fact of the matter is it has a lot to do with the attending's own perspective on what would be the ethical approach to doing this and I think a lot of how we end up evaluating medical students is how well they you know how well they fill their role in sort of living up to our expectations of what we think they should do in any given situation which is always going to be different depending on our perspectives about it and so the smartest medical students the best medical students I think are the ones who are able to perceive what it is the attending has in his mind about the best the best way to be and connect that way unfortunately in some ways but I think you know if the if the attending was you know advocating you know was more like Javad and saying we're not going to listen and the medical student you know went along with that you know I think that would be fine if the medical if the attending was saying we got to get this patient out as soon as possible and the medical student really gave them grief about it then I think there may be a problem that if the student begins to ask questions from my perspective they're going to get higher grades on professionalism so if they say ask a question should we be gaming the system is that what advocacy for our patients really means well well then you know honest has integrity becomes something significant and I think that's a real serious professional question raised by this case that hasn't been so far and if a student raised it I'd give them high high points so one thing that you should know is that feedback that the medical school receives from the students is plentiful and very constructive almost all of the time but one of the common themes that is a part of that feedback over many many years is that the students often feel the evaluations in the clinical arena are very subjective and so to the extent that you and I work together to make our evaluation of the student as explicit and known in advance so that they have less a feeling of the subjectivity the better okay let me move on and tackle case number two this particular case involves a student an interaction of a student with a nurse this is a third year student who was in the operating room during the surgery clerkship one of the surgical nurses believed that the student had become contaminated during an operation and asked the student to step out of the OR and to scrub in again the student disagreed and in fact an altercation ensued a verbal altercation ensued between the student and the nurse in fact the student gave the nurse the finger in the OR and at that point the attending physician asked the student to leave the operating room there were a few other factors which came to light multiple other students had actually complained of mistreatment specifically bullying by this same nurse in the past and the student had earlier reported comments made by this nurse regarding the student's religion which was Islam which were felt to be disparaging okay so this is a complicated situation and I'd like to ask you first of all how should the medical school respond to the incident holding the student accountable to the highest standards of professional behavior that might be the first thing we try to tackle here aside from the background issues that may have you know gone on in the past between this student and the nurse I guess my sense is the nurse is the boss in the operating room and if the nurse has the impression that the that the student contaminated herself that's a patient care issue and I think that the student has to abide by that even if she believes that it didn't happen because you know I think that the the nurse in the OR is trained to be on the lookout for these sorts of things and you know it may be that she was wrong or maybe she really does have it in for the student but we don't really know that and I think that that she's the boss and the student has to comply even aside from what background there may have been okay good Jeannie we can't control others behaviors but we can only control our reactions to their behavior and regardless of what the whatever the motivation was for the nurse's behavior clearly the students lack in judgment in the way that he or she responded really is something that is sort of in complete contrast to this professional behavior expectation okay I would just I think echo what others have said I think that one important thing that Dr. Hoffman point out which is that you know you have to know sort of who's the boss of what and although it's a team effort I think that this concept of what's sterile and what's not sterile is largely the nurse's responsibility and I think that it is it's absolutely the case that there may be other issues there may be issues of bullying those are all important things but ultimately everything should go towards benefiting the patient and no matter how upset the student would have been their response in no way benefits the patient and so I think that that to me would make that particularly problematic great so one thing to just keep in the back of your mind in as we think about the next question is to consider the mitigating factors and the impact of the institutional action on this student's future career so I already explained to you that the medical student performance evaluation is this comprehensive assessment composed by the medical school faculty regarding a student's performance it's supposed to compare him or her to their peers in achieving the educational objectives of the school it's neither a letter of recommendation nor our prediction of the student's future performance in a residency program and so one of the things that we are asked to report as a medical school is was the student the recipient of any adverse action by the medical school or its parent institution okay so that's the expectation we complete these these letters for all of our students when they're applying for for their residency program and so I'd like to share with you what the medical school actually did the committee on promotions actually put this student on academic probation for three quarters remember the student was a third year medical student so the student was put on probation for basically the remainder of the third year of medical school and the first quarter of the fourth year of medical school and the when a student is on academic probation the faculty committee on promotions would have an opportunity to discuss any students on probation at each of those meetings so student doesn't just go on probation and then they get forgotten about they go on probation and they get discussed at every meeting with updates on how are they performing have there been any other incidents in any of the other clerkships what what are we hearing from the faculty about their performance the student was actually removed from academic probation at the end of the summer quarter before the MSPE was released on November 1st based on the fact that there were no further incidents of unprofessional behavior I will tell you however that during this time that the student was on academic probation and before the committee took the student off of academic probation there were multiple meetings that the student had with me with lawyers and phone calls and meetings with this student's mother however the committee was independent of all of that activity and made the decision to remove her from academic probation for the reason that I mentioned the one of the deans in the medical school met with the surgery clerkship director to discuss the student's concerns related to the surgical nurse and provided mistreatment report data that we collect from the students in aggregate and that the WMC also collects from our students at the time that they graduate from medical school the surgery clerkship director implemented a mistreatment intervention in the department of surgery for faculty residents and clinical staff and I can now tell you several years later that intervention seems to have been very successful in that we have today much lower reported rates of mistreatment on all of our clerkships including the surgery clerkship one of the closest thing to an analogy happens in the first year what do you do and by that I mean that like here's the third year specific example it's easier to put a handle on in terms of well potentially unprofessional behavior although there were quite significant extenuating circumstances when I look at like the two cases and maybe what you're driving at a lot of us going to come back to those fundamental principles that have been sort of poo-pooed in the beginning and how a few people treat people as individuals but like in the first year they're clearly are going to be times when unprofessional behavior occurs but it's sort of it's somewhat harder to you know pitch and hold and say well okay you know we have a clinical example situation and we can then put this portion on probation but in some ways it's at least if not more important sort of address some of these issues early on and so how do you deal with the analogous situation when there may not be as easily formable structure to deal with it yeah that is an excellent question and in and of itself is a topic for an entire lecture but as a result of trying to find the right balance between these accreditation standards behaviors that we know take place in the classroom and in the clinical environment and trying most of all to promote the care of the patient as the highest priority and the proper professional development as a development in aspiring physicians several years ago with help from our students and faculty we developed a whole system of professionalism reporting and I see Shalini Reddy in the very back of the room Shalini led that task force and Shalini do you want to just stand up and say a word about how we would manage that today if we encounter an incident of unprofessional behavior in the first year or the second year whenever it happens but we are specifically trying to capture it in the first year so I sit in the back in the hopes that no one will call on me but so in the first two years if an incident occurs the clerkship director or the course director has the option to complete a form and on this form the particular individual the faculty member provides a description of what happened and refers to whether it falls in the category of an egregious violation of professional behavior once that form is completed the student meets with the clerkship director or the course director goes through the form provides their input and then that goes on to further reporting in the in the medical school with one of the medical school deans and then what that determines whether there's a pattern of behavior or if this is an isolated incident with the knowledge that people are generally good good people sometimes behave badly and good people sometimes get put in bad situations so what's the proper form for evaluating these kinds of this kind of standard of professional behavior and the question is whether we want to sort of where to find out where students lie in a continuum between you know Dr. Wellby you know and you know some horrible person at the other end or do we want to simply be able to sort out those persons who fail to meet the professional standards and to flag those and to say that either they can be you know rehabilitated if you will that we can help the you know call those people out for special attention and try to get them to realize that their behavior needs to change or to say that that is incorrigible and that they don't meet the standards to be able to practice professionally and isn't that what you know more what we're after than saying you know you've got an A, B, C or D on professionalism on each of these I think that's a serious question for the profession and the evaluation of professionalism Yeah, I think actually that is very well stated and in fact in some ways I think at the root of the conundrum we find ourselves in because I think that the accreditation standards drove evaluation at a point in time when we were not prepared to be properly evaluating people and so I think that there's a lot of angst in the community about how we do this and do it right This was an opportunity for remediation I mean it was it was an outrageous behavior the patient was not taken into account and in fact was put at some risk with all this stuff going on lack of impulse control merely putting such a student on probation for two or three quarters without also offering some intervention in a constructive way even if it weren't done in the operating room but subsequently using all of the resources we've got to teach people about professional behavior I think would have been worthwhile and could be seen here as an opportunity missed that's one point my second point is that if I were the program director receiving this student for whatever residency I gotta tell you that I would like to know that this behavior happened I might not do anything about it and it might as you you fear put the student at some risk of not being selected but by for sure I'd keep an eye on this the student as they started the independence of a residency program yeah so mark those are two great points and let me say even though I didn't have it here on a bullet point on this slide this student had multiple interventions at a very high level oh really okay attempting to put this whole incident in the perspective of the patient on that table in the operating room I think I mean my own assessment is that the student over time did develop some insight I think the mother also helped now was it a perfect intervention I certainly don't say that it was but I can tell you that the student just did not get a letter from the committee on probation at promotions and we let it go there were multiple meetings with multiple people thank you for exactly that intervention the other thing that I want to say is that when we are thinking about the professional behavior of students and residents and faculty we're really looking for patterns of behavior and to the best extent of our ability to collect data and make observations we are after all a pretty small medical schools so we see our students in ways that other schools may not this was a single incident and so to report it to a residency program and I can guarantee you that if if that had been in the MSPE this student would not have matched now this student did not go into surgery in fact I will tell you this student did not go into a direct patient care specialty however this student did match in a non-direct patient care specialty but I know if this had been in the letter the student would not have matched now maybe this student really shouldn't have matched but my hypothesis is as a former residency program director is that the residency period is the period in which the number of data points will increase significantly and so if in fact there is a professional behavior problem it isn't going to go away it will come up again and again and again and the residency program then needs to be prepared to make the observations and intervene now the real issue is because we have this new system that Shalini Reddy described with we may well have students for whom we have a pattern of unprofessional behavior and if and when that happens we will I believe as a medical school need to include it in the MSPE and I think it will have very significant consequences on whether or not there will be a residency in that person's future how do you think about it from the perspective of maybe like an international medical student and because I know a lot of them don't match but I'm just thinking from their perspective they were you know hardworking and didn't have or had zero you know professionalism incidents it just seems a little concerning that maybe our student would get it over them I mean I understand the perspective that we don't want to harm our students career but there it's kind of an idea of a zero some game that there are other people not matching because our student is matching yeah I didn't know if there was any thoughts on that so for example we do share data very freely with a group of 12 other medical schools so we share numbers we share case studies we try to learn from one another so if if I were to get an MSPE from one of the peers with whom I share data and kind of keep an eye on how much our other schools revealing and in fact from time to time I ask our own residency programs if they can de-identify letters from other medical schools and let me look at them so I can keep a sense of what our other schools reporting in the MSPE I certainly don't have that kind of first hand data from the international community so I know what the numbers tell me but I don't know the quality of their evaluations or what would be in their letters of recommendation so I think while I want to keep that global perspective in mind without having the data I don't feel like I'm in a very good position to try to answer that okay I'm going to move past this third case but assure you that we actually have several cases that would be fun to try to ask and answer so what are some of the unanswerable questions what is moral behavior in an immoral system now there's a big one how do you learn to be professional in a broken healthcare system and in frequently in a broken society and what is more important in professional formation what we know or what we experience see or feel and I do think that these three questions would be questions perhaps for more than just one lecture but perhaps a series of conversations so it seems to me that in thinking about at least these two cases there is an intellectual response that we can have and we can base our intellectual response on hopefully some common basic principles there's also an institutional response which we try to follow and in fact do follow accreditation expectations and then there's an individual response and I want to put forward the idea that perhaps an individual response can be framed in this whole concept of memes and mentoring so what are memes well memes are a lot like genes this is a term coined by Richard Dawkins where the memes are the cultural analogues to genes and that they self-replicate and they respond to selective pressures and they are passed on from one mentor to mentee and actually two investigators Shurnoff and Nakamura make the case actually quite compellingly that memes and the cultural analogues are transmitted over generations I think we know about mentoring lineages from our day-to-day enjoyment but the work that's actually been published shows some very powerful mentoring lineages one of the most powerful being in the field of physics where the laboratory of JJ Thompson was the laboratory that first discovered the electron Rutherford the laboratory that first discovered radioactivity and every one of the persons in this mentoring lineage actually ultimately became the recipient of a Nobel Prize over now multiple generations so one of the frameworks that has been proposed by Daylos as a way by which adults learn is this framework of challenge plotted against support and Daylos proposes that when adults are in situations of very high challenge medicine and medical education would probably fit that definition the optimal is to have a support system in place that is also equally high and if that's the case then growth occurs if in fact the challenge is high but the support is low and or punitive stasis occurs if the challenge is high and support is low retreat occurs if the challenge is low and support is high it's confirmation of one's ability and then if the challenge is high and support is growth the most optimal so let's see if we can apply this to our student how should the medical school respond to the student incident in the surgery clerkship so if the challenge was low and the support was low we could blame the student we could ignore the nurses role we could hold the student accountable through academic probation and include everything in the MSPE as we've discussed if the challenge is high and the support is low we could blame the nurse absolve the student no adverse reaction okay retreat not much learning taking place there probably if the challenge is low and the support is high we could confirm address the student's concerns regarding mistreatment in the surgery clerkship and completely ignore the student's behavior or ideally if there's growth we could address the student's concerns regarding mistreatment but hold the student accountable through academic probation providing the student an opportunity to redress the issue now does this same framework work to work for case number one how should the attending explain his or her actions to those for whom he serves as a role model in managing the patient who's been admitted for placement in many ways I feel like this one is really hard and it's the kind of thing that we had a chance to talk about earlier stasis the attending could simply say to the student what can you do it's how the game is played we're gaming the system the attending could say to the student this is why I'm planning to leave academic medicine I'm joining a boutique medicine practice in Hindsdale the attending could say to the student I'm very troubled by the choices we were forced to make I base these decisions on the harm which might have resulted from an early discharge and several of you actually suggested that or we could try for growth and I have left growth as a question mark because I don't think it's obvious how to do the very perfect thing when the system itself is somewhat broken and and society is not all on the same page about how we should fix this system so that gives us opportunity I think for further reflection and further conversation and then we didn't have a chance to to talk about case number three but I wanted to show you that well actually given time I think I'm going to stop right there and see if there are any other questions or comments or areas that you'd like to explore before we wrap this up you make a compelling argument for not reporting this student as a single incident but then I think I heard you saying that in the case of repeated incidents which were not remediable that you would consider including it on the dean's dean's letter and I wonder if that's adequate or whether the school would be prepared to take the stand of saying this person doesn't meet the standards required to graduate from the Pritzker school with a medical degree and what it takes to do that and are we prepared to do that on the basis of professionalism? Yeah so I can actually answer that with two specific examples one example is of a student who had repeated evidence throughout medical school of serious issues of unprofessionalism and that student became very familiar with how serious those issues were and ultimately after six years in medical school was able to clear the hurdle the multiple hurdles for graduation however the details of the unprofessionalism were a big part I believe three paragraphs in the MSPE maybe two but it was definitely in the MSPE the student had an opportunity to see what was in the MSPE and the university lawyers also signed off on that you should know and the student ultimately had a very small number of interviews in what we would consider a less competitive field and at the end of the first year of training the student has done well I don't have the sense from that program director that the student is the star of that program but the student to my knowledge as revealed by the student and by that program director there has not been further evidence of the kind of difficulty that they had during the time that they were our students so that's example one example two is that we had a student get to the summer of the fourth year of medical school actually without any difficulties in the prior three years at least not any difficulties that were on our radar screen and for the radar screen yeah yes and in the summer of their fourth year they basically failed a their very first elective rotation and in digging into why that student had failed the rotation it was actually a combination of things it was a combination of intellectual preparedness as well as professional behavior the school quite honestly was a little bit surprised because they've made it through all the hurdles all the way to the summer of fourth year however failing an elective is a pretty serious issue so the student was given an opportunity to repeat that elective with a different team a different attending physician and the student received a marginal pass the student was then put on academic probation was required to do another series of rotations including a sub internship the student failed the sub internship and the student was dismissed from the medical school well i guess you know i'm going to just ask this group of people a really um pointed question and that question is one of the things that i have learned in um moving from the being the program director for a large residency program and going to the medical school beginning with applicants to the medical school who are between 18 and 22 years old is there is an awful lot of adult development that takes place in four years of medical school and i personally feel a lot more committed to being as far as i can to the right on that support access to support the proper adult development now the LCME says we think the environment in which students learn is so important that we're going to make a standard an accreditation standard about that and so one of the things that i feel and you've heard me say it at prior sessions of this group that i feel a real personal responsibility for is this environment that our 18 to 22 year olds are learning medicine and if you look at the literature on competencies as students are doing things and residents doing things for the very first time the anxiety level are extremely high the stress levels are extremely high and the way a physician develops proficiency and competency is that they practice those things over and over and over and as they practice the stress comes down the anxiety comes down and they're able to be an outstanding professional so i clearly don't want felons in the medical school i don't want people who can't hear feedback and change their behavior but i'm going to if i'm invested in somebody who we've admitted i'm going to do everything possible to help them through that professional development unless they're unteachable unless they're unable to hear that feedback as part of a residency program before i came as a faculty and residency program before i came here we had a student who had made the comment that my patient looks like xyz during a presentation during attending which that attending was very upset about the rest of the attendings might not have thought might have just joked right and not have said anything and there was a big debate of whether we should put that down on their evaluation as an off-service rotation we should say that you know they this was because one of it it was adamantly saying that i can't tolerate this at all but the rest of it like ah well you know he was making a joke you just took it the wrong way you had a bad day and so how far does that go back into what all of my peers are going to say as opposed to what i believe or someone else maybe it was a core ethical yeah that's an excellent point i'm really glad you raised it because we um that mspe is actually a document that stays with the student for life if they go apply for privileges in hospital xyz 20 years from now and they call the medical school for um an evaluation that's the document they get they get that and they get the university of chicago transcript that's it so it's a very summative document what you just described is what i put into the category of formative evaluation and feedback and without formative evaluation and feedback about the fact that that description of a patient was completely inappropriate and unacceptable and here are the reasons why and here's what i expect for tomorrow's presentation the student would would not have the opportunity to learn from their mistakes and to grow into the physicians that we can all be proud of so formative evaluation has a very important place equal to or bigger than the place of a summative evaluation