Abstract
Background To better standardize the teaching of professionalism, the American Board of Internal Medicine and the Accreditation Council for Graduate Medical Education established competency-based training milestones for internal medicine residency programs. Accordingly, professionalism milestones served as the basis for a faculty development program centered on providing feedback to postgraduate year 1 residents (interns) on their own professionalism behaviors during preceptor-resident sessions in the internal medicine continuity clinic.
Methods To determine the level of faculty (n=8) understanding and comfort in providing feedback, surveys listing 12-month professionalism milestones were distributed to core internal medicine teaching faculty. Current interns (n=10) also rated their understanding of the same milestones. The faculty development program included interpersonal communication education, role-plays of difficult situations, and pocket resources, as well as direct feedback on videotaped sessions with residents. At the end of the intervention period, participating faculty completed a postdevelopment survey, and the current 6-month interns completed a follow-up assessment.
Results Average ratings between the pre- and postintervention teaching faculty surveys fell approximately 0.25%-0.50% on all measures of understanding, but increased slightly on measures of comfort. Conversely, average ratings between the pre- and postintervention 6-month intern surveys generally increased 0.25%-0.50% for measures of comfort and understanding.
Conclusions The faculty perceived the intervention as helpful in teaching them to focus on behaviors that change the context of overall feedback delivery. However, the study results showed that the system in place was not conducive to implementing such a program without modification and the introduction of resources.
INTRODUCTION
The American Board of Internal Medicine (ABIM) has described professionalism as “constituting those attitudes and behaviors that serve to maintain patient interest above physician self-interest.”1 The professionalism competency is quite possibly the most difficult one to teach but one of the most crucial to develop. Assessments of professionalism can be limited because the qualities of professionalism need to be integrated into who we are as physicians.2 In fact, because this aspect of being a physician is so challenging to define and teach, a prior study proposed using emotional intelligence (EI)—defined as the ability to understand and manage oneself and to understand others and manage relationships—as a successful way of developing a curriculum to teach professionalism.3 Components of EI, such as teambuilding and negotiation, have been found to enhance leadership skills in medical education, thus contributing to the professionalism development of residents.3 Finally, perhaps the most crucial method for instruction in professionalism lies in mentoring and exhibiting role model behaviors.2
In November 2007, the ABIM and the Accreditation Council for Graduate Medical Education (ACGME) developed and implemented 6 core competencies for internal medicine training programs.4 Additionally, these 2 organizations recently released milestones associated with the 6 competencies to define in more detail the specific objectives targeted.4 The competencies and milestones guide curriculum development, assessment strategies, and national standardization in evaluation. Additionally, the competencies have been used for faculty development in past studies and were successful in guiding residents to develop core competencies.5-7 Despite its importance as a key competency, professionalism is a difficult concept to assess compared to other competencies such as patient care and medical knowledge. In fact, deficiencies in this area typically are not brought to a resident's attention until a problem arises.8 Furthermore, additional guidance and structure seem to exist regarding feedback on other competencies than feedback on professionalism. As a result, feedback regarding the professionalism competency appears to be inadequate because of a lack of comfort with the concept and an established structure.8
Accordingly, the objectives of this qualitative assessment were to evaluate faculty understanding of the professionalism competency and their comfort with feedback delivery on the competency, to provide faculty development based on the preliminary assessment, and to evaluate understanding and comfort following the faculty development.
Specifically, the professionalism competency milestones served as the basis for a faculty development program focused on providing education and feedback to postgraduate year 1 (PGY1) residents (interns) on their own professionalism behaviors during preceptor-resident sessions in an internal medicine continuity clinic. We hypothesized that a faculty development course that included, among other interventions, reflective experiences of videotaped feedback sessions with interns would assist faculty members with skill development for the purposes of teaching and providing feedback on professionalism milestones to interns.
METHODS
The institutional research board granted this qualitative assessment an exemption because it was classified as a quality improvement project. All attending physicians and PGY1 residents consented to being videotaped for quality improvement purposes. We distributed the presurveys in May 2012, implemented the faculty development program in June 2012, videotaped the sessions beginning in fall 2012, and distributed postsurveys and held several meetings to discuss the impact of the sessions in January 2013. The setting for this project was an internal medicine continuity clinic where 8 core faculty members serve as preceptors to residents onsite and where 10 PGY1 residents see patients 1 afternoon per week in an outpatient setting. During the first 6 months of training at the continuity clinic, the PGY-1 residents undergo direct observation by faculty during patient encounters. The typical patient encounter flows as follows: The intern sees the patient, obtains a history and physical information, and asks the reason for the visit. Then the intern and the preceptor discuss the case and formulate the appropriate assessment and plan in the precepting room. Afterward, the intern returns to the patient. The average length of interaction between the preceptor and PGY1 resident during the first 6 months of onsite training is approximately 30 minutes per patient encounter.
To assess the level of understanding and comfort in providing feedback on select 12-month professionalism milestones, teaching faculty (n=8) completed preintervention surveys scored using a Likert scale (Table). For questions related to comfort, 1 represented very uncomfortable, while 5 represented very comfortable. For questions related to understanding, 1 meant unsure and 5 meant the respondent could teach it. Additionally, current preintervention 6-month interns (n=10) rated their understanding of and level of comfort with the same milestones at the same time as the attendings, which indirectly measured the effectiveness of faculty teaching and feedback on the selected topics.
Survey Responses for the Presurveys and Postsurveys
A subsequent reflection exercise allowed teaching faculty to describe how they would address professionalism issues in various hypothetical situations and to identify situations they believe they have particular difficulty handling. The faculty development design was based on the information received from both preintervention surveys and the reflection exercise. The program included interpersonal communication education, role-plays between faculty preceptors portraying difficult feedback situations, and pocket resources to use as a reference in actual precepting settings. Videotaping occurred in the fall of the intern year and consisted of recording the preceptor-intern interaction in the continuity clinic. One session was recorded for each attending. In addition, precepting faculty reviewed videotaped precepting/feedback sessions with the institution's organizational ombudsperson to identify content, delivery style, and body language issues.
At the conclusion of the faculty development course, teaching faculty completed a postintervention survey that was similar to the preintervention assessment but added a section for open response. Additionally, the current postintervention 6-month interns—the group of interns engaged in the study—completed a follow-up assessment similar to the assessment the preintervention 6-month interns completed, the group used as a baseline who were not engaged in the study because they were senior residents by the time the study began.
RESULTS
The pre- and postintervention surveys evaluated 4 principles pertaining to professionalism that consisted of 15 different questions, 5 regarding understanding and 10 regarding comfort. The surveyed principles included adherence to basic ethical principles, providing timely feedback, maintaining accessibility, and demonstrating personal accountability. These principles were evaluated in regard to understanding and comfort using a modified 5-point Likert scale. The average rating for all principles on the intern presurvey was 3.4, and for the postsurvey the rating was 3.68. The average rating for all principles on the faculty presurvey was 4.30, and for the postsurvey the rating was 4.03. The table presents the detailed responses for each principle.
The results from the pre- and postintervention surveys trended in opposite directions for the interns and the teaching faculty. Average ratings from the 6-month intern survey generally increased 0.25%-0.50% for measures of comfort and understanding between the pre- and the postintervention intern surveys. Conversely, average ratings between the pre- and postintervention teaching faculty surveys fell approximately 0.25%-0.50% on all measures of understanding but increased slightly on measures of comfort.
DISCUSSION
Overall, the goal of this initiative was to educate faculty regarding feedback delivery, specifically regarding the competency of professionalism. Furthermore, after the education element, the aim was to increase the understanding and comfort of faculty and interns regarding professionalism. We found that the faculty did indeed feel more comfortable addressing this competency based on the faculty's postsurvey scores. On the other hand, we found that levels of understanding decreased on the postsurvey. However, these results do not necessarily reflect decreased understanding after the faculty development course but may reveal overconfidence that was unidentified before this exercise. Therefore, this initiative provided a learning experience for the faculty in that they determined that they did indeed need more instruction on providing feedback, reading body language, teaching about interpersonal communication skills, and addressing professionalism issues.
This quality improvement project led to several successes. First, the teaching faculty role-play exercise on providing feedback to various types of learners brought faculty out of their comfort zones and raised self-awareness about how they handle residents who process feedback differently. Next, videotaping actual feedback sessions raised faculty awareness of their own teaching styles, as well as of habits that affect how their message may be perceived. One of the respondents commented on the postsurvey (regarding what he or she took away from the experience), “Body language that I conveyed may indicate that I might be detached and/or impatient during the precepting process. Body language can be used to my advantage and may convey authority and give added importance to what is being said.” Finally, the faculty agreed when they convened for group discussion after the intervention that they may have been overconfident when they took the preintervention survey and that the professional development intervention allowed them to realize they had more to learn about professionalism milestones and feedback delivery. In fact, a faculty member commented, “It is always an eye-opener to see yourself on video.”
Additionally, we identified a few barriers during the course of this project that served as opportunities for improvement in other areas. First, we discovered that no standardized method for observing or providing feedback to PGY1 residents during the first 6 months of their internship existed. Essentially, each preceptor followed his or her own plan of observation. To remedy this deficiency, a tool will be developed to standardize the process of observation as well as feedback delivery during the precepting session. The faculty agreed that a more standardized approach to this process would be beneficial. Also, the faculty did not view the preceptor/resident setting in the continuity clinic as ideal for providing feedback on professionalism because they felt that professionalism intervention should be separate from clinical management mentoring. As a result, further education on the role of preceptors in the continuity clinic setting will be introduced. This training will include a component aimed at changing the faculty understanding to accept the continuity clinic as the best setting to provide feedback on professionalism.
CONCLUSION
This comprehensive faculty intervention was perceived as a helpful initiative because it taught the faculty to focus on behaviors that improved the quality of feedback delivery. The study revealed that faculty members were initially less comfortable with giving feedback on resident professionalism, particularly in the continuity clinic setting. The ABIM and the ACGME have recently released milestones associated with the 6 competencies to detail the specific objectives targeted. We will use this new information to develop a new assessment tool for the education process for professionalism.4 This situation must be addressed to ensure resident competency regarding professionalism milestones. Because we discovered that the system in place was unable to implement such a program modification to routinely address professionalism while giving feedback, we plan to develop resources to remedy this situation.
This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Interpersonal and Communication Skills and Professionalism.
Footnotes
The authors have no financial or proprietary interest in the subject matter of this article.
- © Academic Division of Ochsner Clinic Foundation
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