The Professionalism Committee - Professionalism and SSOM Curriculum

Professionalism and the SSOM Curriculum
Recommendations of the Ad Hoc Committee on Professionalism

The Ad Hoc Committee on Professionalism has been asked to make recommendations regarding the development, implementation, and evaluation of an integrated curriculum on professionalism. The initial step in the process was to catalog topics currently in the undergraduate medical education curriculum as well as identify the organized clubs/activities, volunteer projects, and service commitments that students participate in across the four years of medical school. A review of the curriculum, both formal and informal, provided the basis for the following observations:

There is distinctiveness yet overlap in topics spanning end-of-life, ethics, professionalism and spirituality.
Stritch curriculum (formal and informal) is rich in content and experiences fostering professional development of students; a hallmark of the medical school.
There needs to be a clear set of measurable objectives to guide curricular development in professionalism. Currently, decisions regarding professionalism content and experiences are made by course directors rather than having institutional goals and objectives guide curricular development.
There must be better methods to assess the outcomes of the curriculum. It is possible to make the assessment a motivator in developing a curriculum that relies heavily on role modeling, reflection, and that combines self-, peer-, and mentor-assessment.
The curriculum targets medical students only; the scope should be broadened to involve residents and faculty as all contribute to the environment which either fosters professionalism or discourages it.
A challenge is applying content to practice. Classroom sessions are an important part of education in professionalism. However, the closer to the delivery of services these lessons can be conducted, the more obvious will be their relevance.

I. Recommendations

1. Curricular Objectives

Recommendation: Develop objectives to guide professionalism curriculum development. Review LEEP objectives and re-write in measurable terms the global objectives related to professional development in the Ideal Graduate report.

2. Portfolio Assessment

Recommendation: It is the sense of the committee that a professional development program that is driven by a portfolio assessment technique holds the most promise for utilizing the strengths of the SSOM formal and voluntary curriculum. A portfolio assessment should (a) require the annual setting of student goals across a variety of dimensions of professionalism such as service, interaction with peers, interaction with mentors, interaction with residents and attending physicians, interaction with nurses and other health care professionals, interaction with patients, balancing of conflicting demands in the classroom and/or clinic (b) encourage the collection of narratives that include mistakes from which the student has learned as well as the successes s/he has achieved, and (c) include formative evaluation from the variety of sources with which the student has interacted, and (d) be supervised by a mentor who models the process of goal setting and shares his or her portfolio. Portfolio assessment provides the flexibility to adapt to any additional objectives that become a part of the SSOM curriculum.

This process will make thematic the many things that a large percentage of SSOM students already do so well and will provide a forum in which students are challenged to improve areas in which they have not shown sufficient achievement. In other words, this process will build upon the strengths that have developed in the formal and informal curriculum at SSOM.

3. Topics on Conflict of Interest

Recommendation: Add topics regarding conflict of interest to the curriculum, including areas such as: taking gifts from pharmaceutical companies, taking money to recruit patients to clinical trials, and having stock options in companies supporting research. Currently, IPM I has a small group discussion case on pharmaceutical company relationships. We recommend that these topics be expanded in the IPM curriculum (I, II, III) and there may be an opportunity to build these topics into some standardized patient teaching and evaluation scenarios used throughout the curriculum.

4. Topics and Experiences in Cultural Diversity

A curriculum proposal has been developed by the Design sub-committee of the CCA, (attached). The proposal will be acted upon by the CCA.

5. Clinical Education

Recommendation: Identify professionalism/ethical issues/topics currently being discussed or presented in clerkships that may not be reflected in the course objectives. Clerkships provide the laboratory for applying education to practice. There are opportunities to observe and act to assist in patient care dilemmas (e.g., conflict resolution, communicating bad news, demonstrating respect for diversity).

Provide ethics/professionalism cases as part of the core curriculum in each clerkship. Facilitate more opportunities for discussion of health care issues that may create conflict of interest for the physician (e.g. payer issues, patient autonomy). The biopsychosocial project in Family Medicine is an excellent method to explore the dynamics of illness on the patient and could be adapted for other clerkships. The student performance evaluation needs to be revised to assess professional development.

6. Introduction to the Practice of Medicine III

Recommendation: Expand IPM III to provide more opportunity for presentation and discussion of third year core curriculum topics, including professionalism. Increase the number of sessions from 5 to 10 (monthly sessions). IPM III is a third year course using a conference format to present a series of topics that expand on the IPM I and II curricula with particular focus on clinical applications. A variety of presentation methods are used, including lectures, panel discussions, and small group sessions. Small groups are organized by clerkship (Medicine, Peds, etc.) providing opportunity to discuss patient cases and apply concepts to patient care. Students learn very early the work ethic of medicine, but are not encouraged to problem solve the vast array of issues in patient care. Team building and communication skill development are additional benefits of group interaction. Discussion groups should include students, residents and faculty.

7. Resident/Faculty Development

Recommendation: Provide opportunities that integrate education for all learners, i.e., students, residents and faculty. Observing and participating with professionals at different stages in training reinforces principles of becoming a professional. In order to succeed in promoting professional development, faculty and resident efforts that will be reciprocal and complementary to those expected of the students must be promoted. The medical students will only learn appropriate ways to set professional goals and self-monitor their progress in they observe this behavior in their mentors. In particular,

Faculty should partake in any portfolio assessment technique that is implemented in the SSOM curriculum. Faculty will be needed to serve as advisors who oversee the development of a student's goals at the beginning of the academic year and review their progress with them at the end. It would be highly beneficial to the students if each advisor would develop and share his or her goals related to scholarship, service, and improving interaction with colleagues and students. In the case of clinical faculty, goals should include ways to improve relations with residents, patients, families, nurses, pastoral care and other related professions. It is important that a "critical mass" of teaching faculty be enlisted into this effort in order for the ethos of professionalism to be promoted.

Faculty will need to be oriented and trained to participate in the portfolio activity and other professionalism education efforts. This training should include insight into the reciprocal responsibilities of faculty to which they are invited by the student honor code. Some annual orientation and training session should be developed.

Clinical faculty who participate as student advisors should also be responsible for implementation of a professionalism education session on their service for faculty and residents. This session can be structured in a variety of ways, e.g., didactic, case discussion, etc.

The professional evaluation of faculty and residents by their superiors should include evaluation on the professional treatment and mentorship of students. Excellence in this area should be clearly recognized and respected. Failure to achieve excellence in this area should be occasion for constructive criticism and formative evaluation.

II. Implementation

The recommendations should be forwarded to the CCA for discussion and action. It is important to survey existing course/elective directors to determine if professional development is an objective of courses.

III. Evaluation

Suggestions for assessing outcomes:

Portfolio - This was highlighted above. In sum, a portfolio is a collection of material made by students that records and reflects key events, learning experiences and processes in their professional development. A record of service activities, critical incidents in-patient care, ethics paper, standardized patient videotapes, etc. are included. Portfolio is reviewed by "mentor/advisor" periodically, and students may present information from their portfolio at certain times over the four years. It is important that the student be mentored early in his or her medical school career to set goals for his or her development in various areas of professionalism and then provide evidence for those goals.

This evaluative instrument fosters self-reflection and does not penalize the inclusion of negative incidents that are learning experiences. If mentored properly, the mentorship becomes a kind of role modeling.
360° evaluation - performance feedback from all members of a patient care team. The limitation of this tool is timeliness of feedback and administration of the system. However, some version of it can be incorporated into a portfolio assessment program.
Intern survey - Solicit feedback from interns at the end of the year as a measure of their preparation and patient care knowledge/skills/attitudes.
Graduation Questionnaire - Association of American Medical College survey of medical school graduates has items on professionalism.
IPM III - conduct a recap of activities/sessions at the end of the year to assess achievement of course objectives and discuss student development of clinical competence in the third year.
Clerkship student performance evaluation - strengthen the assessment of professional development in the clerkships. This could include improving the evaluation form and incorporating items on an end-of-third-year competency exam. Self-assessment is also an important component of the evaluation process.

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