Becoming a Physician at UM SOM - Recommendations
It is clear to me that to emphasize the importance of our interest in this area, this program must be seen as Dean Wilson's initiative and must be well publicized. Specifically, I recommend that:
The Program should be primarily identified as the Dean's initiative.
It should carry his name and his imprimatur; he is willing and he should initiate the first patient contact that the medical students have on their first day of medical school by interviewing a patient in a White Coat (see Appendix 4: Section on the First Day and Orientation); and he should continue to be visible as the program continues throughout the four years including reviewing its progress and evaluating its outcome.
The Program should have as its head a highly respected and humanistic physician.
Dean Wilson should name a respected humanistic physician to be the coordinator for the entire four years under his direction. To ensure that the Program is not perceived as “touchy-feely fluff,” this person should not be a psychiatrist.
The Program be given a title such as Becoming A Physician (HELPERS-PRO).
It is recommended that to "show case" the Program, it should have a brief but inclusive title such as Becoming a Physician: HELPERS-PRO (which stands for Professionalism, Respect for Patients, Families and Colleagues, Other (Death and Dying, Impairment, Sexual and Aggressive Behavior and Physician/Industry relationships), Families - Humanism, Ethics, Life-long Learning, Physicians subordinating themselves to their patients, Ethical behavior, Research subjects, Sensitivity to age, culture, disability, diversity and gender.
The general approach to the Program should be positive rather than "finger-wagging."
The approach (suggested by Dr. Mackowiak), should be, that for the most part, students are highly professional and ethical but that there is always room for improvement and we want to become known as a medical school that turns out highly professional and humanistic physicians. We should communicate that the professional and humanistic aspects of becoming a physician are as important as the academic ones; that we will assist everyone to attain these features by the time of graduation (as we do academically); and we will seriously evaluate them.
To that end we need to:
Bring about a culture shift.
It is clear to me that as a profession and as members of both an academic and medical center community we must bring about a cultural shift - from training doctors to be Aknow-it-alls and do-it-alls," in however narrow their subspecialty - to educating them to become team and community members who, working with others, put the patient first and strive to render the best treatment and care possible, while acknowledging their limitations. How we accomplish this, I have no idea, but unless we do, our patients and our profession will suffer. In addition, there needs to be a culture shift regarding why students are here and what we are all about; from a "practice and party" mode, as one faculty member put it, to one of being in a professional and academic teaching environment.
Although completely outside my mandate, I was asked by Dr. Schimpff to tell him “what I was doing these days,” and I am convinced from our conversation that the problem(s) is universal not only among medical schools and the medical and other professions but among all who work in a medical center. In this regard, then, eventually all persons working in the medical center should be exposed to these areas through staff and house staff development program and such seemingly trivial steps as those taken at Mt. Sinai Hospital in New York where the elevators have signs that say things like "Respect Patients Privacy - This is not the place for discussions." Sharing the hospitals' data on their findings from Quality Management and Patient Satisfaction surveys could help all in the medical center understand the issues.
Communicate the importance of the issues of HELPERS-PRO by having the subjects emphasized in all courses.
A four year emphasis on teaching and experiencing all the aspects and areas should occur in every course in the 4 years. For instance, cases in Informatics, PBL and elsewhere can be reworded to present opportunities for discussion of these areas and a tip sheet of subjects that can easily be discussed in each case, given to each preceptor/small group leader, etc. In addition, we must develop an outline and checklist of topics to cover for every course, rotation and experience. One faculty member suggested that if each preceptor were given 5 items to emphasize/touch on, it could achieve a huge multiplier effect.
Communicate the importance of HELPERS-PRO through a renaming of courses:
In addition to the above (#5) emphasis in every course, several venues, because of their subject and/or longitudinal nature, especially lend themselves to this effort. It is my recommendation that these be re-named with a preface of Becoming a Physician, so there would be listed in the catalogue and on every course outline, as, for example:
- Becoming a Physician I: Human Dimensions of Medical Education
- Becoming a Physician II: Orientation to the School of Medicine
- Becoming a Physician III: Principles of Human Behavior
- Becoming a Physician IV: The White Coat Ceremony
- Becoming a Physician V: Real World Ethical Issues (between HDID & P&T)
- Becoming a Physician VI: The Autopsy
- Becoming a Physician VII: Genetics and the Patient and Family
- Becoming a Physician VIII: Intimate Human Behavior
- Becoming a Physician IX: The Philosophy of Medicine through Literature
- Becoming a Physician X: Introduction to Clinical Practice
- Becoming a Physician XI: Physical Diagnosis
- Becoming a Physician XII: The Medical Humanities Hour
- Becoming a Physician XIII: A User's Manual (the ex-PBL time)
- Becoming a Physician XIV: The Student Clinician White Coat Ceremony
- Becoming a Physician XV: The Longitudinal Ambulatory Experience
- Becoming a Physician XVI: The AHEC Experience
- Becoming a Physician XVII: Electives/Selectives in HELPERS-PRO
- Becoming a Physician XVIII: Match Day
- Becoming a Physician XIX: The Final Week
- Becoming a Physician XX: The Humanism Award Ceremony
- Becoming a Physician XXI: Commencement
Develop a four-year developmental process of teaching/experiencing these areas and aspects.
From discussions with faculty and students, as well as from focus groups conducted by Dr. Thomas O’Toole of the Sorus Foundation's Community Service Project, it is clear to me that there should be (1) a developmental process throughout the four years and (2) that this process should take into account the different aspects of HELPERS-PRO of concern to students at different stages in their education, e.g. students in their preclinical years are most interested in "dealing with patients, global concepts, principles, rules of the road, access to care, inequities in care, systems, etc.;" whereas students in their clinical years are most interested in Adealing most effectively with other professionals and the doctor-patient relationship, and as house officers, professionalism in the workplace and professional societies, etc. It is desirable that there be a grid or checklist of phase-specific areas to cover at each stage in the student's education. Students noted that there was a need to present issues when they are appropriate (e.g. clinical ethical issues should only be presented in clinical years/settings.)
Add or alter the content in most courses, rotations and experiences to emphasize these areas.
In Appendix 4, I have recorded the suggestions from each course director as to what more they could cover, to which I have added some of my own. In addition to the renamed "Becoming a Physician" courses, we can add material found to be useful elsewhere: e.g., a discussion of what to expect in the 3rd year, a team-building exercise (just before the 3rd year), a presentation by a physician with an illness, a session on how to include spouses in their lives and projects on ethics and professionalism, etc. Several schools (specifically Stony Brook) have 2nd and 3rd year courses not unlike our ex-PBL and ICP ones and we could benefit from a look at their material.
Ensure that all faculty to whom the students are exposed early-on are our best role models.
The students, not surprisingly, report that faculty members they observe in their first year become the most powerful role models as they move through the next 3 years and their selection should be well thought through.
Encourage each clerkship director to continue their individual emphases/techniques but expand on the areas of HELPERS-PRO covered.
Each Clerkship Director has his/her own approach to these efforts (e.g. Dr. Englander's query about good and bad role/models, Dr. Jarrell's emphasis on how students can be seen as "good," Dr. Mackowiac's on how being a professional is special and carries both rights and responsibilities, etc.) Each of these course directors, plus others, could, however, expand on their presentations to reinforce all the areas of concern. Indeed, the students I met with were convinced that spending more time during each clerkship's orientation on these issues would have a tremendous pay-off. Also, during each clerkship, patient-student interactions must be directly observed and evaluated by the end of the rotation. Students report a lack of orientation to their ward and clinic rotations, except at the VAMC, that gives then the impression that the other members of the clinical team are not valued.
Capitalize on the decentralized ambulatory medicine and AHEC experiences by adding a centralized discussion and feedback process.
One of the seeming weaknesses of the ambulatory medicine and AHEC experiences, their decentralization, could become a strength if we provided all students in their clinical years a structured luncheon discussion of professional issues, role models and ethical dilemmas.
Improve the admissions process.
It has been shown that attitudes and behavior demonstrated before and during medical school, including aspects of professionalism such as volunteerism, predict such future factors (O'Toole, T.P. et al: Experiences and Attitudes of Residents and Students Influence Voluntary Service with Homeless Populations, JGIM: 14:212-216, 1999). Dr. O'Toole is convinced that during the Admissions Interview, it would be relatively easy to identify which applicants have had such positive experiences in the past as well as the quality of such experiences, which would allow the Admissions Committee to better select such individuals. Thus I recommend that we ask more specific questions about aspects of Professionalism such as community service, in the interview. In addition, Dr. Schimpff noted that the Ritz-Carlton hotel chain has determined the 10 top attributes for each type of employee (e.g. concierge) screens applicants for attitudes for each job; there is no reason why Medicine, Medical Schools or we should not try to do the same. This will mean that interviewers will have to receive specific training/orientation on how to evaluate these areas in the seminars Dr. Foxwell holds for interviewers.
In addition, experts such as Dr. Lawrence K. Altman (The Proper Time to Tell Doctors What Will Be Expected of Them. New York Times Tuesday Oct 3, 1989 p C2-3) stress that we do not put medical school applicants on notice as to what the profession demands. Dr. Foxwell suggests we include information on HELPERS-PRO in the Admissions Packet as was suggested in Dr. Altman's article which mentions misconduct, obligations to treat, traditions, ethical obligations, cheating, fraudulent research, drinking alcohol on duty, drug abuse and sex with patients.
Also, we can alert prospective students in pre-interview material as well as our own faculty about the high value we place on of the issues of HELPERS-PRO and highlight our interest in the areas and aspects of entering our humane, caring profession by obtaining a (1) certification of professionalism from their college, as well as printing highlighted, boxed and bulleted features in the (2) catalogue and (3) Website, the packet for (4) interviewers and (5) interviewees and the (6) evaluation form.
At least one school provides a certain number of admissions slots to students who need not take science courses or the MCAT's, which encourages those persons with strong humanities backgrounds to apply.
Senior students have suggested that during the tour of the campus and subsequent luncheon discussion, conducted by senior students, they could focus on aspects of HELPERS-PRO. In addition, some visits include Davidge Hall, passing the dissection areas that long ago were secret and hidden. This could be made a routine stop, during which an initial discussion can begin concerning physicians adherence to high ethical and moral standards, caring and compassion, altruism and empathy, respect for others, a continuing commitment to excellence, a commitment to scholarship and to advancing their field and aspects of human experimentation.
Finally, the experience accumulated by the Advancement Committee should be analyzed (1) to see if there were any intimation of problems that showed up later in the admissions interviews and (2) to communicate to the Admissions Committee the results of both their analysis and search for intimations.
Prepare students for a new role before school begins.
In addition to repeating the about the high value we place on HELPERS-PRO in mailings, we should send a list of recommended summer readings (Appendix 5) to be covered before medical school begins. These readings would become the subjects for small group discussions in HDME and the Orientation.
Modify the Faculty Development Program.
Currently, the process consists of (1) basic teaching skills, (2) leadership of academic elements and (3) research skills. However, since the faculty are the most powerful repositories of and communicators of the values of HELPERS-PRO, a major effort must be made to influence every contact they make that involves medical students since most faculty agree that to merely cover these areas in the curriculum but not emphasize them during other faculty-student encounters is insufficient. All the faculty I talked with think we can improve our ability to do this by "weaving in" elements of the areas of HELPERS-PRO in every faculty-student contact and communicate the ways and means of doing so through the faculty development process. Unfortunately, one problem noted by some was that those (especially clinical) faculty most pressed for time and as a result least able to provide good courteous, humanistic role-models, were those who are probably the most in need of faculty development but unable to take advantage of it due to their clinical burden. Some solutions, therefor, will have to be found that involve: (1) a compelling reason to participate and (2) a web-based or similarly flexible learning tool.
Implement house staff development.
As, if not more, important than the faculty, is the development of the house staff in each Department since they have the most direct influence on the development of the medical students’ attitudes and behaviors regarding all the areas and aspects of HELPERS-PRO. Therefor, it is my strong recommendation that each Residency Program develop a day or half-day program at the beginning of each year focused around case examples and small group discussions on these issues. In addition, one faculty member suggested that one grand rounds a month in each specialty should be devoted to these areas.
Develop a more substantial ethics program.
I met with several individuals in the University with an interest in medical ethics (Professors Karen Rothenberg, Diane Hoffman and Susan Dwyer as well as Dr. Henry Silverman), who told me of their very specific activities in medical ethics on this campus. Prof. Dwyer is eager and willing to supply graduate students for elements of an ethics program. But it is clear to me at this point after hearing the subject introduced by many, many faculty members, inside and outside the institution, that we are in need of (1) A medical ethics program and (2) A Professor of Medical Ethics. The reasons are many: no real concentration/attention/etc., to this critical area of medical education; the necessity to put together the scattered small elements of an ethics curriculum, the pressure on the IRB's, our public image, etc. (Interestingly students were also eager to do much more in the area. One student suggested that between 1st and 2nd year each student be assigned a topic on an ethical issue on which to write a paper; an exercise that could be repeated in the 4th year "when things aren't so hectic." Another student felt that it was extremely helpful to have physicians talk about their ethical experiences rather than lecture in the abstract.)
Preparation for the White Coat Ceremony.
Several medical schools now have some build-up to the white coat ceremony by discussing issues such as "entering a profession," "what taking an oath means and what oaths already exist (e.g., the Oaths of Maimonades, Hippocrates and the League of Nations)," and actually go over the oaths line by line. Therefore, I recommend that we move the ceremony to the end of the orientation week and include in the small group discussions held during orientation week some preparation for the ceremony.
Initiate a Clinical White Coat Ceremony between the 2 & 3rd years.
To reinforce the initial White Coat Ceremony, as well as introduce areas of HELPERS-PRO more relevant to their entry into the Clinical Years, a second (Clinical) White Coat Ceremony, entitled by the Gold Foundation a Student Clinician Ceremony should be held. Both ceremonies should not be scheduled during times when any students and faculty are unable to attend due to their religious obligations (e.g. Friday-Saturday sundown).
Taking as an example the "Medicine through Literature" elective, create 15-20 electives in "HELPERS-PRO" so that each student can/should have one such opportunity during the four years.
What Dr. Henry Silverman in the School of Medicine and Prof. Alan Hornstein in the School of Law do, can be a model of electives that can be offered so that all students can participate in at least one such discussion group during their four-year curriculum. Discussing the literature allows the group to discuss tough humanistic/professional issues with a bit of distance. They can be tailored to faculty & student interests and carry titles such as "Death and Dying in the Literature," "Ethical Dilemmas in the Literature," "Socio-Cultural Issues in the Literature," "Professionalism in the Literature," etc.
Promote greater sensitivity to reporting, sanctioning and remediating deficiencies in professional behavior noted in courses and rotations.
I was struck by the fact that there seems to be not enough communication to the Course Directors of experiences/deficiencies in professional behavior that were noted but may not rise to the level of reporting to Disciplinary Bodies, the Advancement Committee, Dean's Office, etc. I think each Clerkship or Subinternship Director must alert the Directors in the next few rotations to ascertain if such behavior was a one-time event or represents a chronic problem. In addition, problems posed by the use of new technologies should be covered in some blanket statement at the beginning of the year (this year's example is the use of the Palm Pilot). Also, students, especially, commented that they were never observed 1-1 with patients, were not rated on these areas despite our expectations they would be, and were never sanctioned for irregularities (as opposed to sanctions for academic underperformance.) Students also noted that there also did not seem to be sanctions for residents and faculty exhibiting unprofessional behavior (e.g. not showing up for lectures, being "mean" to students, talking in front of patients, showing disrespect for other specialties, etc.) Rather than a dependence on sanctions alone, though, a remediation system that emphasizes bettering professional skills through the "professionalism-equivalent" of Asst. Dean Judy Emery or assigning a "tutor," as some schools do, should be pursued. In addition, it was felt that until we applied sanctions for unprofessional behavior equal to those of academic failure (e.g. suspension, dismissal), none of this would be taken seriously.
Better evaluate the HELPERS-PRO areas.
There are several parts of evaluating these areas. First, as stated above, the faculty has to take the evaluation of these areas seriously as seriously as evaluating cognitive aspects of medical school, as does the ABMS where two of the six competencies are communication and professionalism. Second, students need to be advised before each course/rotation that these areas will be evaluated and existing forms (such as those used by Toronto, UCD, UCSF, U South Carolina) utilized after each course/rotation (Papadakis MA et al: A Strategy for the Detection and Evaluation of Unprofessional Behavior in Medical Students. Acad Med 74:980-990, 1999). Third, since research has shown that this is necessary but not sufficient, there should be a separate evaluation and process for dealing with critical events (see #21 above) of unprofessional behavior (Ginsburg S et al: Context, Conflict and Resolution: A New Conceptual Framework for Evaluating Professionalism. Acad Med. 75:S6-11, 2000). Fourth, the introduction of OSCE’s into the evaluation process offers a fine opportunity to evaluate all the areas and aspects of HELPERS-PRO that have been introduced in each segment (Donnelly MB et al: An Objective Look at OSCE's: Assessment of Residents' Interpersonal Skills by Family Proctors and Standardized Patients: A Psychometric Analysis. Acad Med 75: S93-95, 2000). Finally, since the evaluation of many areas rests on direct observation of student interactions with patients, each clinical experience must incorporate opportunities for such direct observation.
Better evaluate the faculty.
Students give ample examples of poor faculty role models (e.g. faculty calling patients “dirtballs, scum or FSK's” (funny short kids); faculty denigrating people with addictive disorders or with psychosocial problems, etc.,) it is clear that several methods of faculty evaluation need to be initiated or strengthened. First, all students should be debriefed after all courses or rotations after grades are made. Second, all students should be asked specifically on faculty evaluation forms if there was anything offensive/unprofessional/etc said/done by faculty members. Third, students on highly decentralized, often isolated or distant ambulatory experiences should be offered/required to fill out monthly evaluations (like those done for Professor Hoffman’s highly decentralized placements in her Law School course) to both correct current problems and avoid future assignments to unprofessional faculty. To repeat what was said above (#21): "Students also noted that there did not seem to be sanctions for residents and faculty exhibiting unprofessional behavior either (e.g. not showing up for lectures, being "mean" to students, talking in front of patients, disrespect for other specialties, etc.)".
Reward good role models.
Several schools have implemented a Humanistic Honor Society (equivalent to that of AOA) and I know that we intend to do so here as well – which I fully support. Some schools honor only "exemplary" students, while others select a few 3rd year and all 4th year students. At these ceremonies, exemplary house staff officers selected by the medical students, as well as faculty members, can also be so honored.
Utilize the new mentoring and advisory systems to promote HELPERS-PRO issues.
Work with the faculty leadership and implementers of the new mentoring and advisory systems to ensure that students are cognizant of HELPERS-PRO issues and assist them in becoming highly professional, humanistic physicians.
Integrate the clinical correlates of genetics into all the years.
The type of clinical correlates that Dr. Miriam Blitzer offers in Cell and Molecular Biology represent a model for the sorts of integration that can involve the presentation of many HELPERS-PRO issues into this very "hot" and topical area (genetics).
Provide an experience of disability/disease for each student.
Dr. Rooks noted that some schools enable all their students to have an experience as a patient (as an example, the Physical Therapy and Rehabilitation Science students at UMB all spend a weekend in a wheelchair.) We should seriously consider something similar.
Provide a final week(s) experience.
There is a strong sense among the faculty to have some sort of utilization of the final period of the fourth year for Amore than partying," e.g. as a “capstone” to their 4 years and for some wrapping-up and discussion of the “commencing” part of this transitional phase from student to house-officer and from paying learner to paid learner-teacher. The subject(s) chosen for focus could be centered on a variety of subjects such as Entering the Profession, Death and Dying, Sensitivity and/or Ethical Behavior.
Better promote the community campus project.
Dr. O’Toole’s Soros Foundation project, the goal of which is to promote Professionalism through community service, professional ethics, advocacy and leadership, which affords students in their preclinical years the opportunity to spend 7 weeks in a well-supervised community experience and students in their clinical years to take a sub-internship in community service, should be better promoted to all our students.
Work with the hospital on new initiatives.
In addition to helping the hospital initiate house staff development (recommendation #16) support the hospital in its pursuit of improvement in the way we handle end-of-life issues as well as work with them to implement a Palliative Care Team. As I stated above, we need to work with the hospital so that all persons working in the medical center would be exposed to these areas through staff and house staff development and such seemingly trivial steps taken as that at Mt. Sinai Hospital in New York where the elevators have signs that say things like "Respect Patients Privacy - This is not the place for discussions." Sharing the hospitals' data on their findings from Quality Management and Patient Satisfaction surveys could help all in the medical center understand the issues.
Consider other suggestions offered by faculty and students:
- Consider revising/publicizing an expanded Statement of HELPERS-PRO.
- Have more interdisciplinary experiences, like Prof. Diane Hoffman's in the Law School, outside the ward-experience, which allows for better discussion/understanding than the ward situation.
- Provide a website devoted to these issues, including resources for consultation (especially regarding ethical issues) and more information (including links to the "virtual ethicist" at Virtual Mentor).
- Bring back a dining room.
- Publicize the HELPERS-PRO outline.
- Seriously tackle the attendance problem.
- Design a better way to pick up problems in the first and second years.
- Have Dean's Office level briefings & debriefings for Clerkship & Longitudinal Ambulatory faculty.
- Appendix 1 - Definitions of HELPERS-PRO
- Appendix 2 - Survey
- Appendix 3 - What is currently taught
- Appendix 4 - What could be taught
- Appendix 5 - Readings
- White Coat and Pre-Clinical Ceremonies/Honor Society
- Gold Foundation