 Our speaker today, speaker today is is an old friend David Stern I've known David for a long time. We even made a trip to China under the auspices of the China Medical Board ten years ago quite a while ago David The the brochure or the announcement that was sent out says that David is the vice chair for professionalism In the Department of Medicine at Mount Sinai in New York Those were the good old days I've learned that because a new chairman came in at Mount Sinai a new chair of medicine David is now not only the vice chair for professionalism, but also for Correct me if I'm wrong faculty affairs finances Promotions in tenure junior faculty development strategic planning and compensation sort of And professionalism And remains an adjunct professor of medicine at the University of Michigan Where he worked for many years? David is president of the Institute for International Medical Education An independent nonprofit Institute the goal of which is to get is to get curricular materials Delivered to developing countries so that countries that may have one or two pathologists in the country can have teaching materials to work from Dr. Stern received his bachelor's degree in anthropology from Harvard his medical degree from Vanderbilt and a PhD From Stanford where he worked closely with Kelly Skeff in medical education He served as the director of standardized patients the co-director of the doctor-patient Relationship course and the founding director of the International Office for Global Reach all at the University of Michigan David is a practicing Internist with a long-standing commitment to taking care of patients And a commitment to improving patient outcomes and to ensure the professional behavior of physicians He'll talk to us as you can see Reflecting on 20 years of scientific study on promoting professionalism He'll talk to us about what he describes as his three phases of work in professionalism the middle one of which is the one you probably know him best for Which is the psychometric part on measuring outcomes in in professionalism? I I gather that's part two of the three-part presentation and that book called measuring medical professionalism was published in 2006 by Oxford. I Think you'll join me in welcoming David Stern telling him how happy we are to have you at the University of Chicago and Look forward to continuing interactions David Thanks Mark and and thanks for having me here. I'm Honored to be one of the speakers for this series, which is really When I got the when I was invited first first I was invited and I said of course I'll come and he's you said I'm holding a seminar series on professionals I thought that's great. I didn't realize that I think just about everyone who has published in professionalism is Either has been here or will be here in one way or another So it's a real honor to have been invited and a great opportunity to be here I'll have to I'll tell you that that This is impressive. I it was saying to you just before when this thing started that there are so many people here Interested in ethics and professionalism We often I do a lot of medicine grand rounds and surgery grand rounds and things like that and there people show up because It's grand rounds and they have to Your commitment and interest in this is really wonderful so I Welcome you Really the reverse if I'm not speaking loud enough. Let me know in the back because I can I can project and and will more if I need to I Was I was thinking and I'm reminded that most of the of the scholars just came from a seminar Something philosophy of professionalism or for philosophy of ethics or I'm reminded of Something I was strangely invited to about 15 years ago. It was the first ever it may have been the last two meeting of the deans of Colleges of rabbinic education in the United States for those of you who know much about the Jewish Education world or that there are many different sects of Judaism the orthodox the conservatives the reforms and In general, it's very difficult to get two people even within the same group to sit down at the same table So to have all of these people sitting around the same table deans of the conservative and very religious groups sitting down with the very ultra modern ultra A non-religious group sitting down talking to one another was really interesting and they invited me there because they were interested in The development of professionalism the development of apprenticeship and that sort of thing in the clergy particularly the Jewish clergy and We got to arguing about a variety of things based on some of the work that I had done very early on and came down to the Realization and and you know, they really pushed that they really pushed us and they and I said to them Do you care more whether? one of your rabbis is good in the heart or behaves appropriately and And they argued and argued and said we really care about the soul. We really care about what's inside and I said that's fascinating because You can have in my in my view you can have all the evil thoughts you'd like if you behave well I think you're doing good enough So that's my introduction to tell you that I am a blatant behaviorist This is very different Knowing the people who have spoken and people who will speak Very different in some ways than the some of the people in ethics and philosophy. You may have heard of I am an empiricist I I look for data. I am a scientist I have always felt that the world of professionalism has been far too bereft of real data on and only with real data will we be able to Get time in the curriculum of medical schools will we be able to demonstrate that professional behaviors are at least as important in the care of patients as cognitive behaviors and Without this data we can stand up and and you know dress well and look great and inspire confidence But ultimately we won't be able to prove our points in a world particularly of science and medicine where data comes first So 20 years ago I started on a scientific Inquiry into professionalism and as a scientist Let's say you you you could view professionalism as a unwell say unprofessionalism as a disease Okay, unprofessional behavior. That's a disease What would you do like any scientist with any disease? The first thing you do is try and understand something about its natural history The second thing you do is you try and create some sort of a diagnostic test for it If you went to treatment before you created a diagnostic test, you'd never know whether your treatments worked, right? So it really works in a logical way to do to understand something about the condition to find some Diagnostic tests and then to figure out what to do about it and That divides my 20 years in this field into equal parts of six or seven years apiece For me there's been a constant tension between Always wanting to do something about it when you see unprofessional behavior as a practitioner as a care provider as an Educator as a teacher as a mentor as a colleague You really want to do something about it So I've as a practitioner felt that tension but always also tried to keep my head in okay Wait a second if we can study this how will we study it? the studies that that I talk about and I will talk about some are are are Sociological and educational in nature. We don't really get the opportunity to do In vitro studies in in professionalism, although I've had some great conversations over the years with people about how to do them There's some great ways that you could trick people and lie to them and make them behave in certain ways and see Dr. Milgram wherever you are How people would behave We've not been able to do those I haven't had the stomach for them And I don't think they'd make it through the IRB anymore anyway So I'll talk about each of these things and then I'll talk a little bit about Where I see the future of research in professionalism going and I'll try and do that all before one o'clock As as Mark mentioned, I will talk some about assessment. I I Honed down I can talk for hours on assessment if you'd like I honed down that piece down to very little you'll see I'll mention a couple things about it If you'd like to know more we can talk for ages The the first thing I did and the reason I got into this game was not at all because I cared about professionalism I I Not that I don't care about it It's just that that's not the reason I got into the business the reason I got into the business is because I cared about teaching I was finishing residency and decided I wanted to go on and and And and and and continue in medicine and I wanted to be in an academic medical center And the reason I wanted to be an academic medical center is because the one thing I really loved was not any particular organ But was that I love teaching and at the time this was 88 or 89 you couldn't Continue in teaching of course unless you have students the only places you had students were in academic medical centers The only thing that you had to do in an academic medical center other than teach and take care of patients was do research So what in the world was I going to do research on I was going to do research on teaching? and this This this troubled my chair of medicine to no end Shelly Wolf There's a wonderful man, and he said you should go back and think about rheumatology, which I did But I said I really want to I really want to do research on education He said there's no NIH Center for that I don't I can't guarantee that you'll have a career But if you do it do it with people who are doing it well And I found my way to Stanford really to study education and my mentor Kelly Skeff there said go to the education school learn whatever you can have fun take the courses from the best professors, which I did and Find your way into something that interests you about education. Don't do what I'm doing It was doing improving the the quality of bedside teaching, which is a wonderful work and I and I walked into the classroom of a University of Chicago Grad and I think he was professor at the education school and also worked at the lab school Elliott Eisner a brilliant professor at Stanford who's really the heir of much of the work of of Dewey and Elliott one day in his classroom was talking about the three curricula that all schools teach and the three things that he says all schools teach he was talking about elementary schools are The explicit curriculum. That's the stuff that's written in the syllabus The null curriculum and that's the stuff that's not anywhere in the curriculum It's not taught anywhere and if we don't teach it people will think it's irrelevant. He's an art educator so he was making the argument that if you don't teach art people will learn that it has no value negative value and the hidden curriculum and Here I was having finished my residency In a fellowship in general medicine out at Stanford thinking what in the world is the hidden curriculum of Medicine this was 91 and I realized at that time that it was probably going to be something about professional values or professional behavior or something that what gets taught in this what I now call the interstitial space of the day is all about how we behave as physicians and Started looking into this hidden curriculum when I first heard it. It was from Philip Jackson who said it's this Represented by the three Rs But not the familiar ones of reading writing and rhythm tickets instead the curriculum of rules regulations and routines of things That teachers and students must learn if they're to make their way with minimum pain in the social institution called the school or the Jackson was here, too, right? Yeah, still here. Yeah, still here emeritus and Whether it's the school or the hospital or or the medical school It is it is the other things that teachers teach that get you to this hidden curriculum So in my first phase of looking at professionalism at trying to understand the sociology of it I clipped on a tape recorder and a couple of research assistants and started walking around the hospital following teams of Medicine residents and attendings and medical students days nights weekends for about six months doing an observational study of Of The teaching of values I was trying to figure out where they were being taught why they were being taught which ones were being taught how they were being taught And collected these you know two three hundred hours of tapes and then went back through them listening for Episodes where we thought values could be being taught We found that they were taught in some interesting places. First of all, this is in a q4 call schedule and Most of the values look like they were being taught and this is on a per hour basis about one an hour But most of them are in the long and post-call period and most of them are in the evening Okay, so most of the values are being most of these kinds of values are being taught late at night on call okay and if you look at at How many of those are in the formal curriculum and formal in internal medicine is really about 50% of the day there's work rounds and attending rounds and chief rounds and and and noon conference and Lectures and all that most of it is formal, but still by about a two-to-one margin Values get taught in this hidden curriculum, which is walking down the hallway. It's in the elevators. It's in the cafeteria It's in the call rooms. It's in the conference rooms It's all of these other times that are informal Now the values that were taught in those settings Some of them I think were taught very well some values that we would like to be taught In the profession were taught well like responsibility and confidentiality Responsibility is taught fairly directly. This is not a new finding. This is a very old finding Renee Fox talks about this Back as far as 159 to do that right close enough As responsibility is a key function of learning to be a physician Where you Where we tell medical students that they are responsible for every single piece of data on every single patient that walks in the door Right, they have to know absolutely everything and God forbid the attending ask them a question They don't know it. They know who their patients are. They know everything about them This is something that we teach naturally as part of the way that we The way that we care for patients confidentiality is taught in a much more implicit way There are some positions here I remember because I put my dad was a doc and I followed him around the hospital when I was a kid I I do remember when charts. I mean charts now, right? They're double password encrypted and on computers that only certain people can get access to They used to be Back in the day, where do they used to keep the charts? The chart rack before the chart rack foot of the bed Charts used to be at the can you imagine charts nowadays in the world of HIPAA to have charts hanging off the end of the bed But that's where they were they would hang off the end of the bed You go by and you pick it up and you look at it Well, we teach confidentiality not because we stand up when we say there's HIPAA rules and there's laws You have to sign we teach it in some ways structurally We we teach it by making it impossible to get at the data in any other way than in a secure fashion So I think we do those things pretty well some things we ignore completely and this was this this is now old data This is 19. This is 10 12 years ago, but some things that I think we ignored I Then public service and self-policing two values of the profession that are fundamental values of professionalism in medicine Which were completely ignored public service and self-policing? I would say in the last decade public service has really come to the fore in other places in the curriculum and Self-policing is still almost entirely absent Even though it is a fundamental characteristic of professions and I mean professions like medicine law clergy Any of the professions not just medicine the whole concept that we are self-regulating Is a real challenge and did I see there's one of the somebody's talking about self-regulation? Someone coming up is talking about self-regulation. It's a wonderful thing because it's a it's a huge gap in in in what we're doing in In making sure that we maintain our professional stance and then some things I saw were frankly completely inhibited Taught as the reverse of what we would like And the best example of that is that we espouse we talk about interprofessional respect Oh, yeah, we work in teams and all this stuff and that was frankly seen more in the breach than in the than in the practice and Just an example there's and I and I have lots and lots of them about doctors disparaging nurses and and other people but here's a here's a nice one I heard in morning report about internists Dising on surgeons. Well, you know what they say about surgeons that they've seen one They've clearly seen it happen if they have to they have a lot of experience with it And if they've got three then they've got an extensive series, right? so What I learned in in in listening to these tapes and watching professional values being taught In the context of clinical medicine Was a few things number one. These are rare events It doesn't happen often. It's maybe once an hour and you really have to be listening for it and you got to be there and The second is that when people demonstrate their professional behavior it is in a specific context and That context is most often one in which there is some kind of conflict and you watch them resolve it The About this time a colleague of mine at University of Toronto Glen reger invited me up to give a talk and he said tell me He said you can talk about anything. I said, how about I talk about what the ideal? Assessment tool would be for professionalism and he said that'd be great as I have no idea what it is I still don't know what the ideal assessment tool is for Professionals and despite years of looking at it and writing books and all sorts of stuff But I'll tell you I said, you know, I may not know what the ideal assessment tool is But I know what that characteristics of that tool would be That is that they would assess professional behavior in context That they would watch people that it would be able to observe people resolving conflicts Because it's easy to say I mean it's easy for all of us today to stand up and swear to the Hippocratic oath or some other List of values that we want to us that we want to behave in that way Because it's an abstract list Are you going to be honest today or dishonest? Well, that's easy. I'm going to be honest Are you going to be efficient today or inefficient? I'm going to be efficient But if I ask you if you're going to be honest or efficient And I put you in a real world context Sometimes you'll choose one thing and sometimes you'll choose another And it's the nature of that decision that I would love to get at As someone who's trying to study how people make these decisions and the kinds of behaviors that they have I am not the first person to say this The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy If you want to know whether someone is behaving professionally or not professionally and I'll talk about that in a second Put them in a stressful situation challenge them make it real life and you'll begin to see the Character of that character that individual now I Used a couple of words that I'm that make me very nervous one of them is character and the other is professional and unprofessional About this same time Along with colleagues from the University of Toronto particularly Schiffer Ginsburg We began to talk about the stigmatization that occurs with the word professional unprofessional and the concept of character Which is not my business. I there are people who do that far more than I do But for many reasons Many of us in the world of measuring professional behavior have tried to adjust our language to talk about lapses in professional behavior as opposed to unprofessional behavior or unprofessional character The reasons are many number one professional character sounds like a fixed characteristic Number two professional behaviors, you know your or unprofessional Again is a label that sticks. There is no gray zone and Both the observational work that I've done and I think everyone your own personal experience will tell you that we all make mistakes Nobody's perfect. Nobody should be expected to be perfect. We all have lapses in professional behavior Things that on retrospect I wish I wouldn't have slammed the phone down on that nurse at two o'clock in the morning when she called me for a Tylenol order Which was really idiotic, but I still shouldn't have hung up the phone on her But I was tired and I was upset and I was whatever So Thinking of lapses in behavior rather than unprofessional character or unprofessional behavior is both helpful for me as an Individual thinking about it and also de-stigmatizes it so we can begin to talk about it right So how do you get at those? How do you get at people's? Grappling with these kinds of of behavior a grappling with these these these values in their head How do you get them? How do you watch them do it? How do you watch them evidence their professional? Stance Well, you can do what I did you can observe them You can observe the results of these behaviors I'll show you about how to observe the results of these behaviors Outcomes of behaviors that you might do you can observe the actual behaviors themselves, which is again what I did in this observation work You can simulate behaviors. That's standardized patients. You can perform surveys of those behaviors ask people How you might behave in certain situations or have you done this or will you do that or have you seen these things? And then you can ask questions that about the behaviors Seven-year-old boy is on his fourth round of chemotherapy all hope is lost The parents want to take the child home You want to do further chemotherapy? What should you do a let the patient go home? B sign them out AMA C call the police D. You know chain them to the bed There's a there's a multiple-choice question Modified from the national board of medical examiners actually it actually is a modification of a real question that they gave me Actually, that's a quick story for for a long time and people at the national board First of all, they're there if you don't know them. They're brilliant They are there they really know their stuff the questions that they ask are quite good at getting what they want to get at and At these national meetings on assessment and and medical education there or they're there I hang out with them sometimes and I used to have these long arguments about whether you could measure professionalism using a multiple-choice exam And we argued about it for years and finally Susan case who is now the head of the national board of legal examiners Said said to me one day will take that case of the chain the kid to the bed, right? Give it to sixteen thousand students, which is how many they give it to every year and she said two things She said first of all Some people are going to answer that question Chain the kid to the bed. Okay, and then it's not going to be a mistake Okay, half the people that say it are going to think I'm doing so well on this test That this is a stupid question, and I'm just going to circle that anyway just to show them And the other half the people are going to actually think it's the right answer And I think you want to know who both of those people are right? So multiple-choice questions as I say are a good way to potentially catch outliers But not a great way to measure professionalism in general Not going to talk about all these different ways to measure professional behavior, but I will talk about two Just to show you some of the data that we've collected and presented over the years One of them is what I call administrative data and these are the results of behaviors and the other is faculty evaluations Which is observations of behaviors The first is administrative evaluations and the original data collection that we did on this although it's been validated in a couple of different settings since then was because I was in this business and Sitting in with the is anyone here a clerkship director No clerkship directors in third-year clerkships in medicine the clerkship directors routinely get together for lunch once a month at most Medical schools and they sit around and they talk about problems that are going on and then they chat about a few students and It's usually about March or April of the third year when the clerkship directors are getting lunch and about to sit down And they say oh you heard about Joe Smith. He's on my service, and they say oh, yeah He was on my service, you know two months ago. There's something weird with this guy And then they all sit down and they say wait a second There's someone in the March or April of the third year of medical school, and we are just now sitting down talking about this person My Discussion with those individuals was wait a second We've just wasted your time this kid's money and a lot of effort on not finding someone sooner So there's got to be something that we can do to find students earlier than the end of the third year or the fourth year Because at least we give them a chance to remediate or if we don't remediate at least we give ourselves a chance to dismiss people Because once you've found a student at the end of the third year there is virtually no way you're going to dismiss them from medical school So I took an entire class of students at the University of Michigan Because Michigan likes to test the heck out of their students and keep all the data So I took a whole class of entering students from 1995 And I asked what predicts professional behavior in the clinical years three years later So take students who are just enrolling and ask what what makes a difference three years later First of all, there was absolutely nothing from the admissions packet that made any difference I went to the dean at the time and I said if you want to save money fire the admissions director Use the MCATs just like your current and GPAs like you're currently doing and there's no way that you can I can show you that You're gonna get a better class than you currently have There was absolutely and we looked at I promise you everything We did a qualitative analysis of admissions essays. We looked at who did sports We looked at who had a parent with illness. We look at who had a personal experience with illness We really looked for just about everything we could hoping there was something there and found nothing What we did find is that in the first month of medical school Two things happen number one there's students everyone's required to get immunizations tetanus flu mmR Hepatitis B for immunizations And you're required to report it to the dean to the student affairs office Even if you didn't get it even if you refuse to get it you still report that you didn't get it Okay, some people reported it and some people didn't There's no real penalty for not reporting it that the school can't hold you accountable in any way in addition Students are required and this was the process the University of Michigan to complete course evaluations for every course A quarter of the class at a time would be required to fill out there Nobody's nobody had to do it But some students did it and some students didn't And it turned out that students who got there who documented their immunizations and students who got there Who filled out their course evaluations were three years later less likely to be identified as quote unprofessional by faculty Now this was fun because because then you have to say why I mean is it just because Neurosis is good which It is Uh, I I did a I helped the surgeons to create a Evaluation form on professionals and for surgery students and one thing they one item they wanted on there was good soldier You know you follow orders you do right We we bubble in the circles in the multiple choice things with a number two pencil without any stray marks and completely, right? That's that's actually a good thing about being I mean, I'm a general internist if I don't Follow up on every lab test if I don't call every patient back bad things happen, okay? So compulsivity or thoroughness is probably not a bad thing mark I'm going to tear my back a little bit. I I have a colleague here at the university Who says that That that the admission standards or the selection standards In industry are are so much better than they are Let's say in medical school that that if industry is looking for certain kinds of character traits or personality traits There are very well validated instruments to To assist them in in making those kinds of choices at the middle to high levels And and that they can't afford to be wrong too often And so psychologists and sociologists have validated many such instruments They're quite different from a standard medical school application And he wonders why we are so far behind I mean if we're looking for whatever empathy compassion responsibility Compulsivity, I mean whatever whatever those features are that you think are desirable He says there are ways to do that and there are groups doing it Currently, but that the medical education line has not been Part of that process. So are there any medical schools to do it better than others? Yes. Yes There are now I think And this is I'll mention this again at the end of the talk we talked about at the beginning You've got somebody who's applying to medical schools over here and has experienced this the There's something called so let me a little background first I The reason that we are so good at measuring knowledge Is because the national board and others have learned how to ask really good questions and biopsy knowledge base 500 times using really good questions that differentiate levels of knowledge And because you sample enough You're able to actually get gradations of This construct called scientific knowledge. Okay, which I think they do a pretty good job of about 20 years and 30 years ago now Ron Hardin out of scotland and a number of other people Develop what's called the oski the objective structured clinical exam a multi-station exam looking at mostly communication skills And in any measurement there are always three types of variants The case the student and the examinee There's always three sources of variants and it was his view that if you eliminate two sources of variants You'd be left with the student variants, which is what you're looking for So I have to do is standardize the case and standardize the evaluator and you get yourself a good assessment of even something as potentially variable as communication skills And that's precisely what we've done over the past 30 years. I don't know how much oskies are in use here at the University of Chicago Yes, nodding of heads They usually it usually takes about eight stations Students pass from room to room to room Patients individuals are trained to act as if they are patients Students go in and interact with them. They're graded on a variety of scales The the patients are trained to act in exactly the same way with every student They're trained to grade the students in exactly the same scales. They are And and this is a very valid way of measuring communication skills I've often said that measuring professional behavior is more like More like accounting than rocket science It's it's really a sampling issue Again, if you can sample with enough discreteness in the domain, you might be able to get it So what are we doing in admissions? They took the idea of the oski for communication skills and professional behavior in medical schools and took it to a pre-medical setting so Kevin Eva, sorry. I forgot his name. Kevin Eva and Jeff Norman at McMaster developed a multi-station admissions examination Eight stations you did six stations seven stations. She did seven state I was just talking beforehand. She did the multiple medical interview for admission to a medical school It's happening more and more around the country. It was a huge conversation double mc this year. I heard With good reason it is a multi-station exam of communication skills Communication skills overlaps with professional behavior in many ways Um, I I usually say communication skills are the means through which professional behavior is enacted That is if you can't communicate Professionally, no one's going to perceive you as professional right, so This multi-station exam Is if you count doctors hours and time at, you know, whatever 200 300 an hour, whatever we get paid depending on its Medicare or Medicaid or Blue Cross The cost of this is not substantially more than the cost of the of the sort of standard admissions process where various faculty members meet with students And in the canadian example, and they've done it in a bunch of schools now in canada It's predictive of the equivalent of the us mle part two clinical skills Okay, it predicts Whether students are going to be good communicators or whether they're going to be able to communicate now now that's a better thing and What's still unclear to me about it is it is yes, it's picking up professionalism. I'm sorry. Yes, it's picking up communication skills Wendy Levinson is thrilled The the question is whether it also picks up on people's Propensity to behave professionally When under stress, um, this is my Hippocratic temple of professionalism Um, uh, professionalism is is in my view and this is a definition for the purposes of assessment It's not for any other reason than assessment Um, is based on three foundational elements that you just absolutely have to have without which you cannot be a professional um clinical competence Um communication skills and ethical and legal understandings You know, you you you can't practice as a physician unless you have these things I mean that you would never be a professional without them. There's mother Teresa was may have been a Wonderful selfless. She may have been a saint. She may be a saint. She's not a saint yet, right? She is a saint She may be a saint. Um, she is a saint. She is a saint. Sorry. She is a saint, but she's not a But I don't know that she's a professional because she doesn't have a knowledge base That makes her fit into the category of professional as we talk about professionals So it's based on these foundational elements upon which are built some principles that we look for And I have four up here, but you could have six. You could have two different people cut them up in different ways. Okay Um, let me talk quickly about, uh, faculty evaluations because that's that's also another thing that we found that's got some good predictive validity Um, and and then I'll I'll finish up quickly. Um Um, one of the things that we did is looked at what faculty think about students and and this was some work that I did with Maxine Papadakis and John Velosky Maxine's at UCSF, John's at Jefferson All schools that keep all the records on all their students, which is why we selected those schools Um, and we identified from the federation of state medical boards Sanctions for unprofessional behavior from graduates of those three medical schools. This is tip of the iceberg behavior This is really bad stuff. You lose your license for it fraud sexual abuse Uh, um, serious misconduct. This is not malpractice. This is not technical malpractice. Okay. This is not Wrong site surgery leaving us bunch in this is uh, really unprofessional behavior And we selected two controls for each case and then went back into our records as far as 1964 um And looked for any grades or indications or evaluations that might indicate professionalism and what we found Uh, was this uh, it didn't matter if you're male or female Uh, knowledge does make a little bit of difference the population attributable risk of one on MCAT scores um And uh fail passing or failing courses again Was significant. So there is a knowledge component A minute ago. I said a foundational element of professionalism is knowledge I also think another one is communication skills Okay, if there was a measure that we had in here for communication skills I think it likely would have come up as well. And I think uh Again the work of wendy leavenson and deb roder would would confirm that the communication skills are another reason They talk about in terms of malpractice, but I think it's also probably true in terms of unprofessional behavior But the real thing that came up was unprofessional behavior during medical schools And this sent the shiver through the spines of deans at at the double mc meeting When when we started talking about this because what this says Is that behaviors of medical students in medical school can be Predictive of loss of licensure years later Um, and that's a scary thought if you're a dean And letting people pass through the way that we had been not anymore for many years the kinds of professional behaviors that we saw That were particularly predictive Here they are the big ones are right here irresponsibility Remember this uh, uh, thoroughness attention to detail all that stuff We think this is probably the same concept that's coming through Not following through and a second one Which I didn't show you some other data on which I think is very important Which is the diminished capacity for self-improvement. These are two characteristics of students Not following through being irresponsible and uh a diminished capacity for self-improvement that Look like they are predictive of in the future being losing your license This state has been very helpful to to student affairs deans It medical schools around the country because they can begin to say look, you know I called you in here once before to tell you this Kind of behavior towards your colleagues or towards your nurse towards nurses is inappropriate Uh, you said you were going to correct it. You haven't you're back again You fall into this category of diminished capacity for self-improvement We're very concerned that it may lead to loss of license. You may do something. It really hurts patients So what do we learn as part of this approach to assessing professionalism? The first thing I learned is that testing is treatment Testing identifying what is important does set expectations Simply by saying guess what folks we really care about this stuff. Here's the stuff we care about Particularly the people who are really good anyway are going to behave the way we want them to The second thing and and we do that in other ways as well So we set those expectations in white code ceremonies and orientation Sessions and mission statements. We do that all the time The second thing is that students always learn to the test So if you start testing it students will start behaving in a way that you'd like them Excuse me to behave Right And that's why I think uh, that's how I ended up in this Uh, you see I like things in threes Expectations experiences and evaluation. I also like alliteration That three ways to promote professionalism are number one to set expectations to talk about them to profess as Matt Winnie would say To evaluate because evaluation is to teach And the third way is through experiences um, and If you ask me What's the best way to measure for the purposes of rewarding people? I would say you probably should ask their peers because peers know best If you ask me what's the best way of identifying people who are really at the low end and should be dismissed I'd say it really doesn't matter because they get picked up on pretty much anything that you do Uh, they're really so egregious everybody knows about them. It's just a matter of documenting And dismissing and this is true for medical students or Residents or what i'm doing now, which is with faculty faculty you misbehave misbehave in a variety of ways. It's not hard It's just uh, it's just accounting Um, and finally the people in the middle What do you do to promote professionalism for people sort of the whole rest of us in the middle who? Usually act well, but occasionally we lapse and the answer in my view from that is is experiences Um, and what do I mean? Well, there are some formal experiences that we create for students and trainees and practicing docs Lectures and seminars like this one doctor patient courses and standardized patients Experiential learning And i'm going to focus on that last one because I really think it's one of the most important The reason I think it's one of the most important is that I did a study Funded by the gold foundation a few years ago with seven schools I'm sorry with 20 different medical schools over a thousand students And we asked them What promotes humanism? What is it that happened during your career that promoted humanism? And what they said and this is in order of importance for them Personal experiences with illness getting to know patients Participating in the care of terminally ill or dying patients for those in palliative care positive role models volunteer experiences and international experiences now What's common about all those things? Again the gold foundation actually had a had a symposium here in chicago about four years ago And we invited Schools to submit to us things that they thought were they were doing that promoted humanism And the three common themes in that Were that each of the kinds of activities that promote the kinds of behaviors we're looking for Do these three things number one it puts doctors in situations that require you to Require you to see things from a different perspective To walk in the patient's shoes for a mile and see what that really feels like The second is that it allows for time for reflection and the third is that reflection is mentored Okay, you can't do it well with only one I used to run global health at michigan if you just send students to Ghana for a month and send them to the obi ward and there are women Two to a bed lying on the floor dying and bleeding out. They will say what a horrible place I never want to go back. God forbid. I'm glad I was born in america And that's how they walk out of it if they don't have the opportunity to reflect on it and that have that reflection as a mentored experience then The experience fails the really good ones do all of these and you guys probably have either done some of these or are running these things or have these things already A couple of quick examples of these kinds of disorienting situations International health. I think is one of the best I think it's one of the reasons students like I think they used to come back when I ran these programs And they look at me in the eye after like four years of medical school at the university of michigan and they say I got it I understand what it is to be a doctor now It's not about the technology or the this or the physical exams the histories the lapses whatever I sat there with a mom of a kid who was hit by a lorry and You know clearly going to be brain dead. They tried to hyperventilate the kid to save us All I did this sit there all night and hold her hand and it was an awesome experience. I get what it is to be a doctor All right You don't get to have that so much here sometimes you do Another disorienting experience can be palliative care. It's very hard for students But as you saw from the survey they get great benefit from it and a third Just as an example Metsana has a visiting docs program We have doctors who carry a black bag and go visit patients in their homes care for patients who are home bound From 79th street to 125th street In Manhattan And students go along and it's really the most incredible experience for everyone because it is disorienting you you see patients not in your office but in their home Here's my Needs gone I've used this slide for years because it's a great picture of what a small group looks like That happens to be a small group here. I don't I don't see david. He's not here. No, he's not here Tell him he was seen But reflection and mentoring can be done in a variety of ways and there's some really interesting stuff that's going on now Again, you may be doing some of these mindfulness work narrative medicine appreciative inquiry reflective practice These are all things that in my view promote the kinds of values we're looking for So I talked about four things then it's a little bit about natural history a little bit of diagnostic testing a little bit of What I think works to promote professionalism Let me tell you where I think this world is going in terms of the research on professionalism The really promising places for those of you who are looking for for for good research work to do The first one is exactly what we talked about. Can this multiple many interview predict professionalism? I don't know yet. I'm not convinced it certainly gets communication skills Whether it's getting at professionalism whether it could get at professionalism. I'm not sure But great work to be done The second is something I haven't talked about but but hopefully I've Bitten around the edges of it here enough for you to realize that I care enough about it Is this concept of identity development Students as they go from being college students to doctors have to make a transformation and They make a transformation from not doctor to doctor. So this this professional development They're also making a personality development from adolescence to adults And there's an intersection that happens here And sometimes hopefully people Ideally you would have people mature into adults and then layer on a professional identity I think I have no data, but it would love to see What happens to students who do not complete personality development and then try and layer on a professional Identity on top of that It's like building a house on a weak foundation I'm concerned that students who are still immature And then try and act like a doctor may be in real trouble The psychologists and psychiatrists in medicine really need to bite into this And I really wish they would because I think we can start to track and and evaluate students in terms of where they are In terms of identity development And then I and and measure them where they are in professional development and begin to look at that intersection The next aspect of that is what is the effect of mindfulness or narrative or appreciative inquiry on this process of professional identity development can we promote it through the use of those tools Remediation what do we do with these people once we find them and finally Um a back to context are there environments that promote professionalism are there Back to milgram. Um, are there are there are there places are there spaces that we could create? That would engender the kinds of behaviors we're looking for You know, I I still see the the world of practicing either students or residents or practicing physicians as having this group of amazing well-meaning morally set Individuals I get the highest ends of professionals and who are our role models who are our guides who we aspire to become And they are 10 20 30 40 percent of the doctors out there And there's one or two percent who are really bad and probably shouldn't be doctors But the vast majority of us in the middle I put myself there If we're put in the right environment if we're put in a place that promotes the kinds of professional behaviors We're looking for are likely to behave in that way. And if you put in a horrible environment, they're likely to behave in Not so much that way Can we think about what it would look like to have a hospital? That promotes professionalism that promotes the kind of humanistic behaviors you're looking for I'll stop. Thank you Yeah 20 25 percent of physicians who are foreign medical graduates Right. So some of the things that you've made comments you've made might not apply to them Uh, specifically one of them about about the professional identity. Actually, they go to medical school quite a lot younger than than medical students Do in the United States And sometimes those people have are my limited experience have a lot of embodied ideals of professional behavior That our medical students here don't have So, uh, where do you what do you see commentary on that? so The first time I looked at the national practitioner data bank, which is the federal registry of Of mal of lawsuits and things against doctors Um, I sorted them by professional professional behavior versus malpractice and then looked at the medical school of origin There are some There are some non u.s. Medical schools that are Far Overrepresented in that group um There are a couple in mexico and a couple in the philippines in particular um, where I can tell you that the rates of Uh of misconduct are not one percent Of the total physician population, but more like 10 Or maybe even 15 percent of all the graduates coming from that school Uh, I did a small study once. Um, it had some methodological issues But the fundamental data ended up being pre-published in the hartford karant as a news article um There are some medical schools that graduate higher and lower percentages Of students with unprofessional conduct even within the united states um Probably probably true The intersection here is hard to think about because there is both a communication issue And potentially a professional behavior issue um It's a great area for more study Because of the large percentage of u.s physicians who are from international schools and whether those Physicians are and in what context adopting Uh the norms of behavior that might be perceived as more professional in the in the u.s You have data on people who have been out three four five years to see whether Life experience the kind of sort of deliberative decision to go to medical school rather than gee This is just what uh, I've been floated into all my life. Um, and any of those things, um predicts one hopes uh, uh, uh a better cohort Harkins back to this other question about about Other schools it's going to take a multi institutional study to do that Because there's not usually enough students at one institution to figure it out I can give you a little bit hint of some data Um, it's actually from Sinai. I knew about it before I even moved there They have a program called humid humanities and medicine. They admit people to medical school After their first or second year of of of college and tell them to go major in humanities. Don't worry about the sciences Don't take the MCATs. We'll we'll take care of it We'll we'll we'll brush you up on that in the year before Those students traditionally do worse in the first two years of medical school and then outshine everybody else in the third and fourth years They end up at the top of the class It is that because they're smart and they were smart enough to get into the program or again or whether they really have the interpersonal characteristics That make them really super when they hit the wards and start talking to patients. It's not I'm not sure Yeah, I have a question about your methodology. Um, yeah with the students and With these data about the doctor's phone out. It looks like you're looking at the 1% that tip the iceberg And I think that there's there's good reason for that. I was interested in your gold study about the medical schools themselves You were looking at the opposite. You were looking at what promotes humanism Did you ask the the more traditional question for your data sets? Well, what stopped humanism? What was what what squelched it? What were the reasons I mean because that would get at the what you just mentioned about Mount Sinai now you now Now I'll have to go back and look now. I that's the more interesting question given all the rest of your data sets um I'll tell you the only the the piece of data that I remember I don't think we did but I'll tell you what I'll tell you what I know from um A study that was done a bunch of years ago was published in the New England Journal about student narratives on professional behavior and bad role models Were seen as bad and good They were bad because they They demonstrated these unprofessional behaviors, but they were good because they inspired students to behave never like that guy Well, that's if they don't succeed, but if they share the department it looks successful Uh, they still students still said I never want to be like that. I may be the chair of a department But I'm never going to be like that. I'm never going to treat students like that. That's um I'll remember his name in a few minutes at emory Somebody else will remember before I do Yeah question Professionalism and the development of medical students in residence. Yeah um as you're well aware there are some external Regulations specifically ours regulations that are coming into play and my particular question to you is about how you think that Affects professionalism in terms of the specific context as we know professionalism is contextual to some extent In which residents are now Moving more towards shift work Frequent handoffs of patients and how you think that affects their professional development The problem that it the the problem that it causes it and it's not It's just a worsening of the of the problems that have always been there Is that you can't be around 100 of the time when you have a patient in the hospital? So what does that do for the development of responsibility? And that's the key value that I think is a challenge here Um, so as I said, it's a it's a dilemma between two sometimes equally worthy values. So here's Here's responsibility And on the other hand is self health Okay, or or regulation. Maybe maybe you want to not take ownership of it. Um, but uh getting sleep and And taking responsibility for patients and it's just really bad now because there have to be so many handoffs So how do you engender? How do we how do we train? To responsibility When in that context one answer is you don't and you won't and now instead of like I felt on my first day of internship Suddenly i'm responsible You may not feel it until the first day you're out in practice Which is really scary, but maybe in fact true the first time you really have responsibility for wait I'm I'm I'm off this weekend. Who's who's going to see my patients? And how am I going to make sure these things get followed up and what if I'm sick and and you know all that stuff? um So one thing is it may delay it the other and this is my optimistic primary care general medicine view Um, is that the hospital has never been a place for continuity and of care in any way So continuity should be in the outpatient setting. So I would say More exposure to outpatient settings Continue to do the inpatient work, but understand that when you're in the inpatient setting You're going to see different doctors and when you're in the outpatient setting It's your responsibility to go see your patients when they're in the hospital So one of the things that we're doing at sign I what now we're struggling with is this discontinuity of care from the patient's perspective as they move from place to place to place And I just instituted because I can now a new policy That primary care providers must go visit or call Their patients when they come in the hospital And that's I made that a I made that a rule for the faculty first And then I'm going to make a rule for the residents next That either you or someone from your team has to come visit your patient in the hospital when they're there So that the continuity becomes the responsibility becomes related to your outpatient care And the the discontinuities handoffs or the discontinuities handoffs. Let's so be it You at least we won't lose the the value of responsibility in that Thank you Yeah, thank you