Medical Professionalism: Using Literary Narrative to Explore and Evaluate Medical Professionalism

Abstract

Demonstration and measurement of “professionalism” have become explicitly stated goals in medical education in recent years. However, these goals have proved elusive, as neither teachers nor students always have a clear and precise definition of the features and constituent parts of medical professionalism.  This chapter describes a “workshop” on professionalism in the field of pediatrics that uses literary narrative to explore and evaluate medical professionalism. In 2013, The Accreditation Council for Graduate Medical Education asked particular specialties in medicine to define and articulate particular “milestones” (i.e., observable activities) for “core competency” areas, including competency in professionalism. The chapter sets forth schemas of narrative—a useful delineation of “features” of narrative—and traces the use of Dr. Richard Selzer’s short story, “Imelda,” as the narrative basis for workshop members to identify and discuss the professional competencies in medicine in general and in pediatrics more specifically. The chapter concludes with the results from four workshops following the procedures set forth.

Appendices

Appendix 1: Suggested Texts

The following is a list of stories that work well to explore the professionalism of a medical provider.

Verse

Verse Anton Chekhov , “Enemies” Arthur Conan Doyle , “The Doctors of Hoyland” David Hilfiker , “Mistakes” (from Healing the Wounds) Jerome Groopman , “Unprepared” (from Anatomy of Hope) Stories included in the Medical Readers’ Theater: William Carlos Williams “A Face of Stone” “The Girl with a Pimply Face” “The Use of Force” (annotatd by Felice Aull and by Pamela Moore and Jack Coulehan) “Old Doc Rivers” Richard Selzer “Fetishes” “Imelda” “Whither Thou Goest” Susan Onthank Mates “Ambulance” “Laundry” Pearl S. Buck , “The Enemy” Arthur Conan Doyle , “Round the Red Lamp” Katherine Anne Porter , “He” Mary E. Wilkins Freeman , “A Mistaken Charity” Margaret Lamb , “Management”

Appendix 2: Pediatric Professionalism Milestones (Accreditation: Pediatric Milestones)

	Level 1	Level 2		Level 3	Level 4	Level 5
Empathy	Humanism, compassion, integrity, and respect for others; based on the characteristics of an empathetic practitioner
	Sees the patients in a “we versus they” framework and is detached and not sensitive to the human needs of the patient and family	Demonstrates compassion for patients in selected situations (e.g., tragic circumstances, such as unexpected death), but has a pattern of conduct that demonstrates a lack of sensitivity to many of the needs of others		Demonstrates consistent understanding of patient and family expressed needs and a desire to meet those needs on a regular basis; is responsive in demonstrating kindness and compassion	Is altruistic and goes beyond responding to expressed needs of patients and families; anticipates the human needs of patients and families and works to meet those needs as part of his skills in daily practice	Is a proactive advocate on behalf of individual patients, families, and groups of children in need
Duty	Professionalization: A sense of duty and accountability to patients, society, and the profession
	Appears to be interested in learning pediatrics but not fully engaged and involved as a professional, which results in an observational or passive role	Although the learner appreciates her role in providing care and being a professional, at times has difficulty in seeing self as a professional, which may result in not taking appropriate primary responsibility		Demonstrates understanding and appreciation of the professional role and the gravity of being the “doctor” by becoming fully engaged in patient care activities; has a sense of duty; has rare lapses into behaviors that do not reflect a professional self-view	Has internalized and accepts full responsibility of the professional role and develops fluency with patient care and professional relationships in caring for a broad range of patients and team members	Extends professional role beyond the care of patients and sees self as a professional who is contributing to something larger (e.g., a community, a specialty, or the medical profession
Boundaries	Professional Conduct: High standards of ethical behavior which includes maintaining appropriate professional boundaries
	Has repeated lapses in professional conduct wherein responsibility to patients, peers, and/or the program are not met. These lapses may be due to an apparent lack of insight about the professional role and expected behaviors or other conditions or causes (e.g., depression, substance use, poor health)	Under conditions of stress or fatigue, has documented lapses in professional conduct that lead others to remind, enforce, and resolve conflicts; may have some insight into behavior, but an inability to modify behavior when placed in stressful situations		In nearly all circumstances, conducts interactions with a professional mindset, sense of duty, and accountability; has insight into his or her own behavior, as well as likely triggers for professionalism lapses, and is able to use this information to remain professional	Demonstrates an in-depth understanding of professionalism that allows her to help other team members and colleagues with issues of professionalism; is able to identify potential triggers, and uses this information to prevent lapses in conduct as part of her duty to help others	Others look to this person as a model of professional conduct; has smooth interactions with patients, families, and peers; maintains high ethical standards across settings and circumstances; has excellent emotional intelligence about human behavior and insight into self, and uses this information to promote and engage in professional behavior as well as to prevent lapses in others and self
Self-Awareness	Self-awareness of one’s own knowledge, skill, and emotional limitations that leads to appropriate help-seeking behaviors
	Has a lack of insight into limitations that results in the need for help going unrecognized, sometimes resulting in unintended consequences	Shows concern that limitations may be seen as weaknesses that will negatively impact evaluations results in help-seeking behaviors, typically only in response to external prompts rather than internal drive	Recognizes limitations, but has the perception that autonomy is a key element of one’s identity as a physician, and the need to emulate this behavior to belong to the profession may interfere with internal drive to engage in appropriate help-seeking behavior		Recognizes limitations and has matured to the stage where a personal value system of help-seeking for the sake of the patient supersedes any perceived value of physician autonomy, resulting in appropriate requests for help when needed	Beyond recognizing limitations, has the personal drive to learn and improve results in the habit of engaging in help-seeking behaviors and explicitly role modeling and encouraging these behaviors in residents
Trust-worthiness	Trustworthiness that makes colleagues feel secure when one is responsible for the care of patients
	Has significant knowledge gaps or is unaware of knowledge gaps and demonstrates lapses in data-gathering or in follow-through of assigned tasks; may misrepresent data (for a number of reasons) or omit important data, leaving others uncertain as to the nature of the learner’s truthfulness or awareness of the importance of attention to detail and accuracy; overt lack of truth-telling is assessed in a professionalism competency	Has a solid foundation in knowledge and skill, but is not always aware of or seeks help when confronted with limitations; demonstrates lapses in follow-up or follow-through with tasks, despite awareness of the importance of these tasks; follow-through can be partial, but limited due to inconsistency or yielding to barriers; when such barriers are experienced, no escalation occurs (such as notifying others or pursuing alternative solutions)		Has a solid foundation in knowledge and skill with realistic insight into limits with responsive help seeking; data-gathering is complete with consideration of anticipated patient care needs, and careful consideration of high-risk conditions first and foremost; requires little prompting for follow-up	Has a broad scope of knowledge and skill and assumes full responsibility for all aspects of patient care, anticipating problems and demonstrating vigilance in all aspects of management; pursues answers to questions, and communications include open, transparent expression of uncertainty and limits of knowledge	Same as Level 4, but any uncertainty brings about rigorous search for answers and conscientious and ongoing review of information to address the evolution of change; may seek the help of a master in addition to primary source literature
Ambiguity	The capacity to accept that ambiguity is part of clinical medicine and to recognize the need for and to utilize appropriate resources in dealing with uncertainty
	Feels overwhelmed and inadequate when faced with uncertainty or ambiguity; communications with patients/families and development of therapeutic plan are rigid and authoritarian, with assumption that the patient can manage information and participate in decision-making; patient/family numeracy presumed; seeks only self or self-available resources to manage response to this uncertainty, resulting in a response characterized by their (individual) preexisting state of risk aversion or risk taking; does not regard patient need for hope; feels compelled to make sure that patients understand full potential for negative outcome (defensive/protective of physician)	Recognizes uncertainty and feels tension/pressure from not knowing or knowing with limited control of outcomes; explains situation to the patient in framework most familiar to the physician, rather than framing it with terms, graphics, or analogies familiar to the patient; seeks rules and statistics and feels compelled to transfer all information to the patient immediately, regardless of patient readiness, patient goals, and patient ability to manage information		Anticipates and focuses on uncertainty, looking for resolution by seeking additional information; aims to inform the patient of the more optimal outcome(s), framed by physician goals; does not manage overall balance of patient/family uncertainty with quality of life, need for hope, and ability to adhere to therapeutic plan; focuses on own risk management position for a given problem and does not suggest that more or less risk taking (different from physician’s position) could be chosen; still seeks patient/parent recitation of uncertainty/morbidity as proof that patient/family understands the uncertainty; has an unresolved balance of expectations with physician expectations taking precedence	Anticipates that uncertainty at the time of diagnostic deliberation will be likely; uses such uncertainty or larger ambiguity as a prompt/motivation to seek information or understanding of unknown (to self or world); balances delivery of diagnosis with hope, information, and exploration of individual patient goals; works through concepts of risk versus hope using conceptual framework that includes cost (e.g., suffering, lifestyle changes, financial) versus benefit, framed by patient health care goals; expresses openness to patient position and patient uncertainty about his or her position and response	Is aware of and keeps own risk aversion or risk-taking position in check; seeks to understand patient/family goals for health and their capacity to achieve those goals, given the uncertain treatment options; engages in discussion with high sensitivity towards numeracy, emphasizing patient/family control of choices with initial plan development and ongoing information sharing through changes as knowledge and patient health status evolve; remains flexible and committed to engagement with the patient/family throughout the patient’s illness, serving as a resource to gather information so that degree of uncertainty is minimized; openly and comfortably discusses strategies and outcomes anticipated with the patient/family, emphasizing that all plans are subject to the imperfect knowledge and state of uncertainty; balances constant revisiting of knowledge, uncertainty, and developed plans acceptance of what is unknown; transparent communication of limits of treatment plan outcomes