A fundamental goal of our curriculum is to ensure that every student develops a profound understanding of the personal attributes that are essential to the practice of medicine and that these attributes mature and deepen as they progress.
Teaching students about important attributes of professional behavior begins with the admissions process. In the technical standards for admission to the school—which all students must sign before matriculation—the following paragraph is the very beginning statement of expectations of professional behavior:
“A candidate must possess the emotional health required for full utilization of his/her intellectual abilities, the exercise of good judgment, the prompt completion of all responsibilities attendant to the diagnosis and care of patients, and the development of mature, sensitive, and effective relationships with patients. […] Compassion, integrity, concern for others, interpersonal skills, interest, and motivation are all personal qualities that shall be assessed during the admissions and education processes.”
Articulation of what is meant by “professional behavior,” guidance and assistance in achieving this behavior, and recognition of excellence in this arena continues throughout the four years of medical education.
Orientation week includes multiple events to ensure of professional behavior. During the White Coat ceremony, students read the Hippocratic Oath and share in a reflection on professionalism by a faculty physician. A session on the Honor Code includes scenarios in which the Honor Code can be at issue. At this session, the students read and sign the UPSOM Honor Code, which is then placed in their permanent file. A second large-group session features senior students who portray dilemmas in professional behavior, along with expectations and avenues for redress. During orientation, the Vice Dean gives a one-hour talk on professionalism during orientation. Part of the message to our students is published as the September 2010 editorial in Academic Medicine: “An Open Letter to New Medical Students”; this editorial has been distributed to a number of first-year medical school classes in the US and around the world.
Finally, there is a session on the last day of orientation entitled “Navigating the First Year of Medical School: Academics, Behavior, and Evaluation,” during which students are introduced to the Behavior Concerns Reporting form and procedures, as well as to the “Learning Environment” questions that will be on every course and clerkship evaluation form. These questions and related comment fields ask the students whether they and others associated with the course were treated respectfully.
There is formal instruction in expected aspects of professional behavior as students progress through the curriculum. At the beginning of the Medical Anatomy course, students are oriented to the dissecting laboratory and to their assigned cadaver as their “first patient.” Issues of respect for the bodies of the human donors, dealing with the stress or discomfort on first exposure to the lab, and appropriate behavior are addressed by the course director and several of the second-year students. In the Ethics, Law and Professionalism course, there are two sessions specifically on medical student professional behavior, with true scenarios as the basis for discussion. This course also has sessions on physician professional behavior, the impaired physician, medical errors, and physician-industry relations. Each of these topics is handled with a large didactic session followed by small group discussion sessions designed to encourage exploration of issues raised.
The Behavioral Medicine course, which runs in the 2nd half of first year, focuses on human behavior and its integration into the clinical care of patients. The importance of integrating individual behaviors is presented as a professional value and skill. The core value and skill set is emphasized both for the sake of the patients as well as for our students as future practitioners. Critical goals of this course include “Employ a respectful and compassionate attitude towards patients, families, and other health professionals from diverse backgrounds, to allow for culturally competent care of patients/families” and “Communicate sensitively and effectively with patients and families around issues of pain, suffering, addiction, and weight.” (From the Behavioral Medicine course syllabus)
Attention to issues and professional behavior is also emphasized in Medical Interviewing and Introduction to Physical Examination. These issues range from punctuality and appropriate attire, to the many relevant considerations that need to be attended to in the performance of a sensitive, thorough, yet respectful physical exams and medical interviews. The two interviewing courses, in particular, emphasize the critical importance of empathy, courtesy, and respect during patient encounters.
A week-long Preclerkship Course is designed to prepare students for entry to the clinical years. Part of this week is designed by the Honor Council Representatives who, with senior students, dissect and discuss Honor Code scenarios that are relevant to the clinical teaching environment. The week finishes with a pinning ceremony, at which the students are encouraged to consider the responsibilities of patient care (again, presented by a practicing clinician) and to acknowledge that their clinical teachers are also human—and may not be perfect. They are encouraged at this event to think more immediately about the world they are about to enter at a new and enhanced level from that of the first two years.
All clerkships establish the above professional attributes through course objectives and incorporate professional behavior into the performance evaluation for the clerkship grade. Recognition of student excellence in professional behavior is recorded as part of each clerkship evaluation. In addition, UPSOM has a chapter of the Gold Humanism Honor Society for which students are nominated by their peers for exemplary professionalism. This recognition occurs in a ceremony, is announced in a school-wide email, and appears in the graduation program. Students are also nominated by their peers for excellence in small-group work during the first two years, an honor that indicates respect for their fellow students and excellence in collaborative learning and teamwork.
Formal Evaluation of Professional Behavior in Students occurs on multiple levels in many venues throughout the four-year curriculum.
Most observed, standardized clinical exams include evaluation of professional behavior and communication skills. Deficiencies noted on an OSCE are remediated either by the relevant course or clerkship director, or by the Director of Performance-Based Assessment. Remediation involves identification of the problem behavior and work with a simulated patient and faculty member to reach an acceptable standard. These examinations occur at intervals throughout the curriculum, including during the clerkships.
Medical Interviewing and Advanced Medical Interviewing
Formative feedback focuses on empathy, courtesy, affect, and respectful treatment of fellow students as well as medical content issues. Students are given immediate written feedback after each session. The final grade includes a narrative on strengths, weaknesses, and improvements. Demonstration of professional behaviors constitutes about half of this evaluation.
There are many opportunities to observe student interactions with each other, with faculty, staff and standardized patients. Individuals who witness concerning behavior by a student, are encouraged to report such behavior. These reports are used to provide formative feedback to the student as well as to track patterns of behavior across courses and years. The mechanism for such reporting is described below.
A Behavior Concerns Observation form may be submitted to the Office of Medical Education by anyone who witnesses inappropriate or concerning behavior by a student. The reporter can deal with the concern and just report the interaction, or can request that faculty designate a meeting with the student about the incident. These faculty can determine the level of necessary intervention which can range from a conversation with the appropriate faculty member, referral to Honor Council, medical (psychiatric) referral, or referral to the Associate Dean of Students or Vice Dean of UPSOM for serious issues. Such incidents, if minor and if there are no recurrences, are kept in the student’s file until graduation, at which time the file is destroyed. Unless these issues rise to the level requiring disciplinary action, they do not become part of a student’s permanent record.
The purpose of this form is to track patterns of behavior without putting a student in jeopardy of “labeling,” as well as to optimize opportunities to assist the student in remediating behaviors that have the potential of negatively impacting their effectiveness as a physician.
In all clerkships, there are expressed, written goals of professional behavior; a significant element in each clerkship evaluation form addresses behavior and communication skills – both with the clinical team and with patients.
UPSOM students learn in an environment that promotes development of behaviors and attitudes that will help them be effective and compassionate clinicians and team members. The combination of admitting superb students, curriculum content, role modeling and support for improvement has led to a program that continues to graduate exemplary physicians.