Extract
The residency training process is presently undergoing substantial changes; the number and pace of these changes are occurring to a greater degree than anything seen in the past couple of generations. The introduction of the Accreditation Council for Graduate Medical Education (ACGME) core competencies and the institution of the eighty-hour workweek—to name just two examples—have changed residency training to such an extent that those who were trained thirty—or even ten—years ago are astonished at the difference. What should we currently expect from this changing educational process?
The residency training process is presently undergoing substantial changes; the number and pace of these changes are occurring to a greater degree than anything seen in the past couple of generations. The introduction of the Accreditation Council for Graduate Medical Education (ACGME) core competencies and the institution of the eighty-hour workweek—to name just two examples—have changed residency training to such an extent that those who were trained thirty—or even ten—years ago are astonished at the difference. What should we currently expect from this changing educational process?
There are a number of "customers" of the residency training process, including society, patients, residents, faculty, and deans. Two of these groups with sizeable investments in residency training are directly affected by the current changes in the educational process: the residents, who invest five years of effort while receiving a low salary, and society, which underwrites much of the cost of medical education and expects to be well served by the graduates of that education. This contract between society and academic medicine has long existed. Implicit in this contract is that academic medical centers will train new physicians who will bring the best and most advanced techniques in medical care to members of society, while society provides funding to academic centers in exchange for creation of new knowledge and new physicians who will improve health care in our nation. This contract will be under increased stress in coming years as the federal government seeks to reduce expenditures.
In today's management models, those who invest in a process are called "customers"; thus, both society (a collection of individual patients) and orthopaedic residents are customers of the training process1. Although the ACGME participates in the resident training process by providing regulations and guidelines for training and by accrediting training programs, the organization is not a customer of the training itself. The ACGME outcomes project was initiated to address perceived societal needs2. Also, the institution, although clearly interested in the product of the training process, is not a customer.
The purpose of the symposium presented at the 2006 Annual Meeting of the American Orthopaedic Association (AOA) was, therefore, to examine how orthopaedic educators are presently doing in their efforts to meet the expectations of residents and society.
The basic expectations of residents are clear. Residents expect to be well trained, to pass board-certifying examinations, and to be able to conduct their subsequent practices competently and successfully. In regard to the present status of residency training, residents have clearly defined what they want, expressed in the report of the 2005 AOA Resident Leadership Forum3.
In that report, the residents noted the primacy of three of the six core competencies: patient care, medical knowledge, and professionalism. Their summary recommendations include the following:"The creation and definition of a core set of orthopedics knowledge, within the framework of the six general competencies.""Ensure that the assessment tool of the orthopedic credentialing body truly reflects and [is] linked to whatever is defined as core orthopedic knowledge.""There should be a way to reward faculty to make education a priority… . In many programs, there is no real incentive for attending physicians to stop and teach."
"The creation and definition of a core set of orthopedics knowledge, within the framework of the six general competencies."
"Ensure that the assessment tool of the orthopedic credentialing body truly reflects and [is] linked to whatever is defined as core orthopedic knowledge."
"There should be a way to reward faculty to make education a priority… . In many programs, there is no real incentive for attending physicians to stop and teach."
Thus, the emphasis of the symposium in regard to resident expectations was concentrated on the ACGME competencies identified by the Resident Leadership Forum as having primacy— patient care, medical knowledge, and professionalism.
An informal poll conducted by one of us (J.G.) concluded that not much was expected from the residency training process. The American public has become very skeptical and increasingly pessimistic about the delivery of health care. According to the 2006 Employee Benefit Research Institute Health Confidence Survey, 31% of the 1000 respondents rated the system as poor and 28% rated it as fair4. These rates of dissatisfaction have doubled since 1988. The Commonwealth Fund reported that 55% of Americans polled in 2004 were dissatisfied with the overall quality of health care5. One major documented shortcoming is in respect to physicians' communication skills. An American Academy of Orthopaedic Surgeons (AAOS) public survey in the late 1990s noted that orthopaedists were regarded as less caring than other medical professionals and spent less time with patients, or in fewer words, were "high-tech and low touch."6 These surveys stimulated the formation of the AAOS Communication Skills Mentoring Workshops.
Desires Expressed by Patients
They wish to be heard.— To be dealt with as individuals with a unique set of values, fears, expectations, desires, and beliefs regarding health and its overall meaning to life— To be seen as a whole person, not just a body (machine) in need of repair— To see practitioners who have some degree of cultural competency when needed— To have their autonomy respected, even when their decision goes against the physician's suggested course of treatmentThey wish to be fully informed.— To be told what is and is not known regarding the condition at hand— To be told clearly when procedures are performed by trainees and to have those trainees properly supervised— To be able to trust that the physician is acting in the patient's best interest and not that of the institution, the third-party payer, or the physician himself or herselfThey wish to receive guidance from an expert whom they feel they can trust rather than be involved in a consumeristic relationship, which wrongly assumes equality of knowledge and situation.
They wish to be heard.
— To be dealt with as individuals with a unique set of values, fears, expectations, desires, and beliefs regarding health and its overall meaning to life
— To be seen as a whole person, not just a body (machine) in need of repair
— To see practitioners who have some degree of cultural competency when needed
— To have their autonomy respected, even when their decision goes against the physician's suggested course of treatment
They wish to be fully informed.
— To be told what is and is not known regarding the condition at hand
— To be told clearly when procedures are performed by trainees and to have those trainees properly supervised
— To be able to trust that the physician is acting in the patient's best interest and not that of the institution, the third-party payer, or the physician himself or herself
They wish to receive guidance from an expert whom they feel they can trust rather than be involved in a consumeristic relationship, which wrongly assumes equality of knowledge and situation.
First and foremost, patients wish to be heard. While this sounds simple, and is something that is no doubt already occurring, the way the word is currently used by the American public means far more than just an act of the senses. Not only do patients want to be listened to—truly listened to—they want to be understood, have whatever it is they are suffering from acknowledged, and be respected for who they are as unique human beings. As Tongue stated, "It takes most patients two minutes to state their story … yet the average medical doctor interrupts the patient within 18 to 23 seconds."7 Such understanding and respect on the physician's part necessarily includes compassion for the weakened state that many patients are in because of their medical complaint, as well as special care to avoid unintentionally taking advantage of that state, and pushing his or her own opinion or institutional goals rather than finding out what will truly serve the patient. This caution and care, in turn, requires that the physician gain some idea of the patient's strongly held health-related values, and how he or she might rank them if they came into conflict (such as need for anesthesia for pain relief against the need for active mental status). The now defunct President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research concluded after a discussion of the fundamental importance of quality health care to each and every individual that: "For these reasons a society's commitment to health care reflects some of its most basic attitudes about what it is to be a member of the human community."8
The other overriding concern of the individual patient is related, yet distinct. Rather than focusing on the recognition of values, this desideratum concerns the patient's sense of personhood. More specifically, the patient does not want to be treated simply as a complicated machine to be adjusted or fixed. What patients are demanding (or craving, at any rate) is that their minds, or even their souls, be considered as well as their bodies. The tendency to focus only on the physical is referred to in the literature as a form of "biological reductionism"9 or "reductionism of medical knowledge."10 Focusing only on the body and its malfunctions makes the patient analogous to an automobile—in other words, a nonperson. Kleinman observed that "in the broader biopsychosocial model … disease is construed as the embodiment of the symbolic network linking body, self, and society."9 If the medical picture of a patient continues to narrow, or becomes reduced to simply a set of cleverly connected body parts, we run the risk of ending up with a thoroughly dehumanized health-care system.
As implied by the phrase "high-tech and low touch," the physical aspects of health care and of surgery in particular seem to be in good shape. Technical skills, technological equipment, and knowledge of the way in which the body works are not the primary causes of concern today. Rather, it is the psychological arena that appears to be breaking down. As difficult as it may be to incorporate the subjective experience of the patient, to ignore the mental or spiritual side is to dehumanize the process of healing. Kleinman described illness as the experience of the individual suffering, while "the practitioner reconfigures the patient's and family's illness problems as narrow technical issues, disease problems."9 Ludmerer mentioned the historical distinction between an "‘internalist’ approach … particularly the increasing molecular level analysis," on the one hand, and an "externalist" approach, on the other, which takes into account "the social, economic, and political context of medicine."10 Both authors lamented the absence of attention and training for the evaluation of the psychological aspects of physician-patient relationships, the so-called "art of medicine." Ludmerer, in fact, stated explicitly that part of his goal was to "incorporate both (internalist and externalist) perspectives." Presenting one's unclothed, diseased body to another person, often a stranger, simply is not, and should not be, the moral equivalent of other free-market transactions.
Finally, a brief note on the sort of relationship patients desire to have with their health-care providers. This is, of course, highly individualistic and thus difficult to generalize about, but it is worth noting that one can respect the patient's right to make his or her own medical decisions and yet still provide guidance and expert advice when needed. The so-called consumer model of health care would hold that medical care is simply another free-market transaction. Not only does this imply equality of power, position, and knowledge between doctor and patient, all of which can be deeply problematic, but it reduces the physician's role to simply handing out information and statistics on risks, and making offers of services available. While there may be some patients who would prefer this model, many, especially those who feel weakened and vulnerable because of illness, want more. They have sought out an expert for a reason, and while they still wish to be heard and to have their preferences respected, they do not want to simply be handed a set of facts. To approach the patient-physician relationship this way is to reduce what has historically been taken to be a unique and caring relationship to the equivalent of a transaction at Wal-Mart.
Patient Expectations—The Institution
The practice of health care, and the training of its practitioners, has retained numerous connections and commitments to social goals. More specifically, there is a history of a social contract of sorts between the medical community and society, which entails certain obligations on both sides of the contract. As Ludmerer describes it:During the revolution [the marriage of medical schools and universities in the early twentieth century] an implicit social contract was established. Society would provide the necessary financial, political, and moral support of medical education and research. In exchange, medical faculties would remember that they existed to serve, and the measure of their success would be the quality of their academic work and their success at ensuring that medical practice in America was conducted according to high, professionally determined standards10.
During the revolution [the marriage of medical schools and universities in the early twentieth century] an implicit social contract was established. Society would provide the necessary financial, political, and moral support of medical education and research. In exchange, medical faculties would remember that they existed to serve, and the measure of their success would be the quality of their academic work and their success at ensuring that medical practice in America was conducted according to high, professionally determined standards10.
For most patients, however, the role of the institution is more difficult to define. This is not surprising, as there have been radical—usually unintentional—changes in the health-care system in the past forty years. These include the advent of Medicare and Medicaid and a subsequent increase in clinical work, the creation of the managed-care system, the growing emphasis on profits and management within teaching hospitals and universities, an increasing scarcity of funds, and "dumping" of indigent patients at teaching hospitals9. Ludmerer, who has written with great clarity on the subject, summed up the situation as follows:In the new (and still evolving) system, there was marked skepticism toward the professional authority of physicians, unprecedented external oversight and review of medical decision-making, intense price based competition among doctors and hospitals, and unparalleled opportunities for large, profit seeking corporations in health care. Control shifted from the "providers" … to the "payers."10
In the new (and still evolving) system, there was marked skepticism toward the professional authority of physicians, unprecedented external oversight and review of medical decision-making, intense price based competition among doctors and hospitals, and unparalleled opportunities for large, profit seeking corporations in health care. Control shifted from the "providers" … to the "payers."10
As a result of this power shift, physicians, faculty members, residents, and nursing staff are all under tremendous pressure to produce along the lines of the business plan put forth by those who are allegedly keeping the whole endeavor afloat. The influence of physicians in determining hospital policy is obviously considerably diminished compared with previous generations, but patients can and do have difficulty separating the hospital experience from the experience with their physician, usually assuming the physician has primacy in hospital policy and operations.
The effect of the considerable number of uninsured and underinsured individuals in the United States is enormous, with physicians and hospitals maneuvering for an improved payer mix. The negative effect on teaching institutions, which traditionally bear a greater burden of caring for the uninsured, is substantial as many teaching hospitals operate under continuing financial strain11.
In summary, societal expectations regarding academic institutions are ill defined. As a result, there is no pressing societal or political agenda at present to systematically address this issue, as "causes and effects of the poor financial status of teaching hospitals remains a separate issue to be resolved."11
Are we meeting expectations in the competencies of medical knowledge and patient care? The short answer is an emphatic yes. The evidence for this statement was presented to us by the American Board of Medical Specialties (ABMS) last year12. By cross-referencing the ABMS database of board-certified physicians with the Federation of State Medical Boards (FSMB) database of physicians, they documented that 90% of all United States licensed physicians were board certified. The FSMB database of physicians with a final adverse action taken against their medical license documented that 90% of these final actions involved the 10% of the physicians who were not board certified. More than any other information available, these numbers indicate that we are proceeding in an appropriate manner; that is, orthopaedic training leading to board certification.
Our residency programs are required to teach the six competencies (including patient care and medical knowledge) in their curriculum in the ACGME Program Requirements for Orthopaedic Surgery. Many programs currently use the competencies to evaluate resident performance.
The ACGME "Facilitator's Manual: Practical Implementation of the Competencies" specifically addresses medical knowledge and patient care13. Medical knowledge competency designates that residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) sciences and how to apply this knowledge to patient care. Medical knowledge content refers to what residents need to learn. This is addressed by a specialty-specific curriculum that addresses key skill sets and the specific requirements of the Residency Review Committee. The patient care competency states that residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. The content for patient care is specialty-specific skills that address key skill sets, specialty-specific procedural knowledge, and knowledge about information technology.
The requirements for medical knowledge and patient care are addressed in the residency evaluation tools of most programs. Examples of evaluations of competency in medical knowledge include the following statements: (1) The resident has knowledge that is current and appropriate for his or her level of training; (2) The resident cites current literature appropriately and applies it to all patients; and (3) The resident demonstrates an investigative and analytical thought process in his or her approach to clinical situations. Examples of evaluations of competency in patient care include the following statements: (1) The resident develops plans for patient management in a reasoned and logical manner on the basis of the applicable clinical data; (2) The resident understands the indications for operative procedures and the possible complications to be encountered; (3) The resident has excellent technical skills in operative procedures; and (4) The resident monitors patients' progress appropriately after surgery. Presently, not all programs include evaluations by the nursing staff and almost none include patient evaluations.
The ACGME currently measures the potential of a program to educate residents using the following criteria14: (1) Does the program comply with the requirements? (2) Does the program have established objectives and an organized curriculum? (3) Does the program evaluate its residents and itself?
The ACGME Outcome Project (effective July 2006) is reflected in changes in the Program and Institutional Requirements that require programs to (1) identify learning objectives related to the ACGME's general competencies; (2) use increasingly more useful, reliable, and valid methods of assessing the residents' attainment of these competency-based objectives; and (3) use outcome data to facilitate continuous improvement of both resident and residency program performance. "Beginning July, 2006, the accreditation focus will be on evidence that programs are making data-driven improvements, using not only resident performance data, but also external measures."15
The competency of professionalism is directly related to competence in medical knowledge and patient care. The work of Papadakis et al. has been most informative. They examined medical student files of sixty-eight physicians who had graduated from the University of California, San Francisco (UCSF), and had been disciplined by the Medical Board of California and compared them with 196 matched UCSF graduates who had not received Medical Board of California disciplinary action16,17. They learned that those disciplined were three times more likely to have displayed unprofessional behavior in medical school. They identified three domains of unprofessional behavior that were strongly associated with later disciplinary outcome: (1) poor reliability and responsibility, (2) lack of self-improvement and adaptability, and (3) poor initiative and motivation. A larger study of three medical schools and forty state licensing boards confirmed their findings.
Teherani et al. emphasized that a graduate medical education structure must include (1) admission documentation, (2) learner evaluation, (3) program evaluation, and (4) institutional commitment18. They stressed the concept that professionalism is the most important of the competencies, as proficiency in other competencies is directly linked to professionalism.
"Core orthopaedic knowledge" was evaluated by completing a search of the web sites of the AOA, AAOS, and all societies listed as members of the AAOS Board of Specialty Societies. The Pediatric Orthopaedic Society of North America (POSNA) web site includes the Structure of Curriculum for Pediatric Orthopaedic Residency Training19. The original work for this curriculum was completed by Richard Gross beginning in 1990. A search of all twenty-two orthopaedic specialty societies revealed two other residency curricula: those of the American Orthopaedic Foot and Ankle Society20 and the Orthopaedic Trauma Association21. No other residency core curricula were found.
The 2006 Annual Meeting of the AAOS had one podium presentation22 and two poster presentations23,24 addressing the orthopaedic surgery core curriculum. Wadey et al. conducted a national survey to determine the importance of 281 curriculum items. In their three presentations, they focused on hand and wrist reconstruction, trauma, and the spine22-24. Their results indicated that 84% of the questions on hand and wrist reconstruction, 98% of those on trauma, and 58% of those on the spine were probably important to know by the end of residency. These findings indicate that coming to a consensus about a core orthopaedic curriculum is possible.
Following completion of residency training, the surgeons are evaluated with regard to their competency in medical knowledge, patient care, and professionalism through the American Board of Orthopaedic Surgery (ABOS) peer-review process for admission to the Part-II certification examination and the current recertification examinations. This peer-review process is unique to orthopaedic surgery. The ABOS indemnifies the evaluators for their participation in peer review. The results of the peer-review process are reviewed by the Credentials Committee of the ABOS before the applicant is admitted to the examination. The competencies are reviewed with a number of specific questions in the following areas: medical knowledge, practice-based learning and improvement, communication and interpersonal skills, and systems-based practice. Patient care is evaluated with three questions covering the management of complex problems, surgical skills, and overall clinical skills. Professionalism is evaluated with specific questions addressing respect, compassion, responsibility and integrity, and ethical values. Each evaluator has four possible responses: unsatisfactory, marginal, satisfactory, and excellent. Review of the 2006 ABOS Part-II examination peer-review responses of 8000 peer reviewers resulted in 108,853 responses for 700 applicants25. This resulted in 105 unsatisfactory and 663 marginal responses. These adverse responses were most common with regard to competency in patient care (0.89%), specifically related to the management of complex problems, and competency in professionalism (0.88%), specifically related to responsibility. The adverse responses for the other competencies were 0.80% for communications and interpersonal skills, 0.56% for practice-based learning and improvement, 0.43% for systems-based practice, and 0.30% for medical knowledge. Peer review for admission (application in 2005) to the 2006 recertification examinations was done by 15,000 peer reviewers with 195,375 responses26. This resulted in 251 unsatisfactory and 1214 marginal responses. These adverse responses were most common with regard to competency in professionalism (1.07%), specifically related to responsibility, and in communications and interpersonal skills (1.06%). The adverse responses for the other competencies were 0.97% for patient care (with regard to surgical skills), 0.59% for practice-based learning and improvement, 0.56% for systems-based practice, and 0.34% for medical knowledge.
Overall, patient care, professionalism, and communication and interpersonal skills are the three competencies with the most adverse peer-review responses.
As a summation of the outcomes of orthopaedic residency training, several conclusions can be made: (1) Certification is meaningful, most public expectations are being met, and medical school performance is predictive of professional behavior in practice. (2) Medical knowledge and patient care evaluation tools are relevant. (3) Orthopaedic core knowledge should be defined, and orthopaedic peer review is very good.
When the core competencies are closely scrutinized, it becomes obvious that they are not completely separate but have considerable overlap. The essential theme in the overlap is medical ethics and professionalism.
What is professionalism? How is it defined? Webster's Dictionary provides the following definition: "Professionalism is the conduct, aims, or qualities that characterize or mark a profession or a professional person."27 A Google search brought up more than fifty pages of references to the term "professionalism." The pages covered diverse occupations ranging from medicine and law to architecture and the military. Several descriptions were quite germane to the topic of professionalism. An article in the Army News was entitled, "Professionalism: More Than Just Knowing Your Job." 28 There are other definitions that further define this standard; these include striving to grow professionally through continuous study and participation, continuously seeking the broadening of professional horizons, knowing when to bring in outside expertise, following highly ethical practices, following ethical procedures, maintaining a high degree of ethical conduct, and placing high emphasis on personal integrity.
Our colleagues in internal medicine have had an ongoing commitment to the study of professionalism. The American Board of Internal Medicine, the American College of Physicians, and the European Federation of Internal Medicine developed a physician charter that was published simultaneously in the Annals of Internal Medicine and The Lancet in 200229,30. The charter outlines three fundamental principles and a set of professional responsibilities that are the core of professionalism. The AAOS is one of ninety professional associations, societies, and certifying boards that have endorsed this charter. The preamble of the charter states that "professionalism is the basis of medicine's contract with society. It demands placing the interests of the patient above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health." We must show our residents that professionalism is more than just doing our jobs. The Department of Internal Medicine at Northwestern University set a goal to put the principles stated in the charter developed by the three organizations into practice by facilitating reflection, self-assessment, and active discussion regarding professionalism in everyday clinical work. Their chairman explicitly made professionalism one of the Department of Medicine's primary missions31,32.
The AAOS Orthopaedic Educators' Course was begun several decades ago. It was soon evident to the faculty that we were doing an adequate job in training the residents in both the cognitive and psychomotor domains. Participants had been asked to bring real case studies of problem residents. After in-depth discussion of these cases, it became clear that the "problem resident" exhibited substantial deficiencies in the affective domain—interpersonal skills, communication, and ethics. On the basis of these discussions, the faculty wrote an article entitled, "Professionalism in the Orthopaedic Resident: A Method for Evaluation and Development," which was published in Clinical Orthopaedics and Related Research in 198333. Four desirable values of professionalism were defined as placing the welfare of the patient first, commitment to orthopaedics and departmental policies, cooperation, and personal and intellectual integrity. We proposed the creation of a feedback system of resident evaluation that included several different sources such as office personnel, operating-room personnel, and nurses on either the orthopaedic floor or an orthopaedic clinic. We called this system the "Informed Grapevine," and this was the genesis of the 360-degree evaluation system. We emphasized that there had to be an early identification of the problem resident and early counseling regarding his or her deficiencies.
Simon, in his presidential address to the AOA in 2000, noted that almost all of the information from the Membership Committee of the AAOS and the Credentialing Committee of the ABOS on the incompetent or troubled physician points to problems identified in an individual's residency training program. He believed that these deficiencies were almost always known by the program director34. His comments reinforced the knowledge that had been gained from faculty members of the Orthopaedic Educators' Course. If this scenario is well known, why are we still having the problems?
There are several reasons. Initially, faculty members have difficulty identifying problematic ethical behavior in residents when there is not a commonly accepted set of minimal ethical expectations. Therefore, faculty members are often hesitant to point out that a behavior is unethical. If the faculty can be introspective and specific in defining some minimal elements of ethical behavior, then not only will the residents have a common standard by which to be judged but there will also be a defined standard by which we could start to evaluate the faculty in a systematic way. Secondly, the evaluation and identification of the problem resident must be done before the end of the third postgraduate year. If the identification goes beyond this year, there is reluctance on the part of program directors to terminate the resident. Therefore, the evaluations of the residents must be done early in their training and must be done frequently, and the program director must act to counsel, and terminate if necessary, the problem resident. The onus, therefore, is on each of us who are program directors or department chairmen to act accordingly.
On the other hand, there are some problem residents who know how to play the system. They know that their behavior is being constantly monitored, they know the rules of the game, and they can slip all of the way through the residency training program and even past the ABOS examination. When the monitoring system is finally off, their behavior patterns eventually change to the detriment of all.
Can Professionalism or Medical Ethics Be Taught?
The answer is a qualified yes. Medical schools have already developed courses early in the medical student curriculum that discuss many ethical situations. There have been numerous papers about teaching medical ethics to our residents. The Ethics Committee of the AAOS has developed an "Ethical Issues in Orthopaedic Surgery" discussion guide to accompany a group of video cases depicting ethical problems35. In order to be implemented successfully in a residency program, these studies must include substantial focused discussion and incorporate the background information in the literature with appropriate moderators leading the discussion. In addition, as ethical issues arise that relate to the orthopaedic community, open dialogue with the residents must be undertaken to provide them with the perspective on these issues. Is this enough? One of us (M.F.S.) believes that residents come into our training programs with many of their personal characteristics and behavior patterns already developed. It is probable that these patterns can be modified through the training program, and it is our responsibility as educators to develop the tools to modify these behaviors when necessary.
One of us (M.F.S.) also polled graduates of the Northwestern orthopadic surgery residency program regarding their feelings on professionalism and ethics, with an emphasis on when they felt they learned about these subjects. Many of them admitted to having discussions in medical school, but they pointed out that their most prominent examples came from their peers and attending physicians. Therefore, the need for strong, ethical role models continues to be at the core of teaching ethics and professionalism effectively. The way that the role models approach a difficult patient, end-of-life decisions, and complex relationships with industry has a substantially larger impact on these individuals than any type of case study, vignette, or discussion group that can be assembled for didactic learning.
The results of this poll underscored what has been termed the "hidden curriculum" of professionalism—the faculty and the faculty's professional behavior patterns36. We have been reluctant to deal with many issues relating to professionalism. These range from the faculty members who tailor their practices to eliminate uninsured patients and those on Medicare to the faculty members who are high earners and refuse to participate in educational conferences or meetings. There are other faculty with lucrative consulting arrangements with industry who do not believe that these monies should be shared with either the department or the university.
Such faculty behavior presents a distorted view of professionalism. There are instances when recent graduates of residency and fellowship programs have expected a remunerative corporate relationship as a condition for using a company's product although their body of work does not justify any such relationship. They have seen this type of relationship with faculty develop in their training program and think that this is their key to professional and academic success both in their peer group and their community. Problems with these relationships between academia and industry have resulted in an intense study of their consequences. A recent publication has delineated ethical and legal guidelines for orthopaedic surgeons37.
Societal Expectations
How might we put back into practice the historical commitment of medicine to the common good? It is obviously not the case that physicians or trainees are incapable of caring for or honestly serving their patients. It is the system in which they work that seems most culpable in discouraging the embodiment of such caring. The Association of American Medical Colleges (AAMC) Graduate Medical Education Task Force stated that "the status quo serves neither residents, institutions, nor the public as it should."38 Because of the heavy workloads, young doctors do not have time to interact with their patients and pursue professional and personal development. A study of the characteristics of high and low rates of malpractice claims has noted that surgeons with lower claim rates were more likely to manifest exemplary modes of professional peer relationships and responsible clinical behavior39. Other factors contributing to lower claim rates were completing a fellowship, being a graduate of an American or Canadian medical school, having board certification, or being in a group practice.
There can be no substitute for time—time to learn, to reflect, to observe, and to put oneself in the other person's (the patient's) shoes. No amount of required reading, virtual training, baptism by fire, or simple repetition on the hospital wards is going to transform inexperienced medical students into physicians of the type society desires. In order to be able to truly understand what it means to respect each and every patient as a human being with intrinsic worth, one has to take the time for himself or herself to define, in concrete terms and examples, what ideal patient care entails—namely, trust, empathy, compassion, and cultural competence. Jordan Cohen, past president of the AAMC, echoed this point beautifully when he said: "Wouldn't it be nice if medical schools and teaching hospitals operated more like law schools and moot courts—that is, in a safe, sequestered academic enclave, insulated from the vicissitudes of the real world and free to contemplate an idealized version of reality?"40 Of course, this will never be the case for teaching hospitals, but it does point to the need for time to think, even about the ideal that may never be reached. The AAOS Communication Skills Workshops are a direct result of this societal expectation; perhaps familiarity with the content of those workshops should be required to satisfy the ACGME objective of interpersonal and communication skills.
The residents' work hours are limited and are divided between their role as students and their role as a labor force. Institutional priorities often tilt the balance toward the side of the labor force. Thus, residents may be left unsupervised and may not have adequate time to discuss cases or other important issues with more seasoned mentors, and these valuable learning experiences may be lost. This underscores the need for faculty who function as role models in a more patient-centered approach.
None of these changes will take place overnight. We are a deeply consumeristic and individualistic society and, while many pay lip service to a higher ideal, making changes that might lead to restructuring of the health-care system will be an uphill battle. Humanizing a bureaucratized system will be equally difficult. Institutional changes are harder to make than personal ones, and the bigger the institution, the harder it is to effect attitudinal changes, much less changes in action plans. Yet, we have no choice. Our health-care system, while highly functional for many, is also increasingly leading to greater and greater dissatisfaction for patients and caregivers alike. With so many patients now without insurance, or funded by government programs, change is not possible without political will and capital. Medical care and medical education are just one more expense for those compiling federal and state budgets and thus must compete with other entitlement programs, such as general education and military spending.
Resident Expectations
The issue of core knowledge has been addressed by the subspecialties of pediatrics, foot and ankle, and trauma. The residents' request for the definition of core knowledge to "ensure that the assessment tool of the orthopedic credentialing body truly reflects and [is] linked to whatever is defined as core orthopedic knowledge"3 is reasonable and should be addressed by academic orthopaedic organizations.
Faculty members have a great impact on the residency training process, both directly and through the "hidden curriculum." Teaching is presently valued less by the academic medical center than is research or the generation of revenues from practice income. This also is an issue begging for consideration from academic orthopaedic organizations.
We must show our residents that professionalism is more than just doing our jobs.
The outcomes of residency training are variable, depending on the lens used to view them. The residents' desired outcome is the successful completion of the board examinations and the acquisition of sufficient skills and knowledge to begin practice. It appears that these objectives are being met quite well at present. The 2005 AOA Residents Leadership Forum made some recommendations regarding the creation of a core set (content) of knowledge; it appears that they are achievable, although most subspecialties at present have not formulated a core curriculum. The residents also felt that faculty in many cases do not teach, and they noted that in many programs there is no incentive to teach. This is obviously antithetical for a teaching program and represents a serious problem.
As we developed this symposium, all of us came to a common conclusion—that professionalism is the basis for successful outcomes. Achieving or improving professionalism is not as easy as it may sound, as Greene, relying heavily on Ludmerer, noted that teaching hospitals are evolving toward a bottom-line mentality, with productivity rewarded much more tangibly than teaching. One of us (M.F.S.) is very clear that many current faculty "present a distorted view of professionalism." This view was confirmed by the audience participation and questions at the symposium that documented that the vast majority of those in attendance felt that at least some of their colleagues did not serve as good role models for professionalism.
The questions from the audience at the symposium clearly indicated that we have a long way to go before we meet the expectations for residency training held by society, residents, and our profession. In line with the position that we are meeting the competency of medical knowledge, 58% of the 116 respondents in attendance agreed that we have sufficient definition of the basic and clinically supportive sciences to adequately assess medical knowledge competency, although obviously a substantial minority did not agree. While we recommend that unprofessional residents be recognized and eliminated by the third postgraduate year, only one-third of those in attendance felt comfortable in their ability to achieve this objective. The most startling answers were in response to the statement: "My colleagues in our program's orthopaedic surgery faculty all serve as excellent role models for the competencies of professionalism and medical care"; an astonishing 84% disagreed, and 87% felt their department did not have an effective mechanism for dealing with faculty lacking in the competencies of professionalism and/or medical care.
In conclusion, this symposium noted that the changes in medical care over the past generation have had a profound effect on medical education in that the control of health care, previously directed by the physician, is now in the hands of the payers. The bottom-line mentality necessarily adopted by teaching hospitals has placed more emphasis on faculty practice reimbursements, often to the detriment of teaching programs. What patients desire most is essentially professional behavior by their physicians.
Finally, this symposium defined professionalism as the sine qua non, without which good residency outcomes will not be achieved. The audience's questions documented that we as orthopaedic educators fall short in monitoring the professionalism of ourselves, our colleagues, and our residents. As Schafer stated in his challenge to us, we need to "walk the walk before we talk the talk." That is a big challenge, but one that we cannot afford to fail.
Note: The authors thank the members of Jennifer Greene's medical ethics class at St. Edward's University in the summer of 2006, including Phil DeRiggi, Cheryl Lozano-Whitten, Laura Matkin, Lina Najm, and Nancy Rose, for their valuable input on a number of these issues.
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