Designing a Curriculum for Professionalism and Ethics Within Radiology

Although professionalism and ethics represent required competencies, they are more challenging than other competencies to design a curriculum for and teach. Reasons include variability in agreed definitions of professionalism within medicine and radiology. This competency is also framed differently whether as roles, duties, actions, skills, behavior, beliefs, and attitudes.

Standardizing a curriculum in professionalism is difficult because each learner’s (medical student/resident) professional experiences and interactions will be unique. Professionalism is intertwined throughout all (sub) specialties and areas and its teaching cannot occur in isolation as a standalone curriculum. In the past, professionalism was not emphasized enough or at all, with global (or no) assessments, with the potential effect of trainees not valuing it.

Although we can teach it formally in the classroom and informally in small groups, much of professionalism is witnessed and learned as “hidden curricula”. The formal, informal, and hidden curricula often contradict each other creating confusion, disillusion, and cynicism in trainees.

The corporatization of medicine pressurizes us to increase efficiency (throughput) with less focus on aspects of professionalism that add value, creating a disjoint between what we do in practice and preach to trainees. Progressively, expectations for our curriculum include providing evidence for the impacts of our efforts on patient outcomes.

Generational differences in the perception of professionalism and the increasingly diverse and multicultural society in which we live affects our interpretation of professionalism, which can add to confusion and misunderstanding.

The objectives of this article are to outline challenges facing curriculum design in professionalism and to make suggestions to help educators avoid or overcome them.

Background

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Framing and Standardizing a Curriculum in Professionalism

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TABLE 1

Professional Roles of the Radiologist that Can Be Taught to Residents.

Health Care Step Professional Role(s) Patient seen in clinic or on the ward—Examination request sent Referring clinician provides relevant history, including surgery, medical conditions, and contraindications and allergies Examination request received Radiologist needs to ensure imaging appropriateness, that is, that patient gets the imaging that will be best for their health outcome, and discusses this with the clinician if needed Examination is scheduled Radiology should ensure that examinations are done in a timely fashion, triaging exams according to medical need Examination is protocoled Correct exam—modality, body part, side, kVp, mAs, contrast administration, and reconstructions Patient arrives to radiology Ensure no contraindications to the examination Examination is performed Optimize radiation and other side effects, prevent falls, for procedures (obtaining informed consent, sterile technique, and safe practices when imaging and intervening) Examination is interpreted and reported Radiologist reviews relevant history, generates an appropriate differential diagnosis, uses standardized reporting templates and terminology, and answers clinical question asked Results are finalized and communicated in relevant cases Communicate results of examinations, including urgent unexpected, or incidental findings in a manner that is compliant with agreed policies

kVp, kilovoltage potential; mAs, miliamperes (current).

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TABLE 2

Within the Framework of the New Accreditation System, Developmental Steps or Milestones (of Relevance to Professionalism), in which Residents are Assessed for as they Progress in Competence are Illustrated Below with Examples. Some of These Subcompetencies Overlap with and Lie Within the Other Traditional Core Competencies.

Relevant Competency Subcompetency Example Professionalism/ethics Confidentiality Keeping confidence of imaging findings on a famous person from the press or other colleagues Interpersonal and communications skills, professionalism/ethics Communication of unexpected, significant, or urgent findings Calling the referring physician in the emergency room, and ensuring they understand the significance of urgent imaging findings, disclosing complications and adverse effects from imaging Practice based learning and improvement, medical knowledge, Patient care, professionalism/ethics Patient safety Proactively taking steps to ensure that all patients are safe before, during and after interventional procedures Practice based learning and improvement, professionalism/ethics Lifelong learning Staying up to date with the latest evidence based radiology in order to deliver the best patient care Systems based practice, professionalism/ethics Quality improvement Carrying out regular audits or reviews of one’s practice, to look for systematic error and taking steps to mitigate or reduce it Systems based practice, professionalism/ethics Teamwork How to work as effective teams doing interventional procedures or treating severe contrast reactions Patient care, medical knowledge, professionalism/ethics Being a consultant Evaluating referrals and potential referrals, using experience and knowledge of imaging to optimize imaging for patients, ensuring appropriateness of imaging

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TABLE 3

The Competency of Obtaining Informed Consent, Shown at the Five Milestone Levels and the Dreyfuss Learning Stages

Milestone Level Example Description Dreyfuss Level Needs to be shown by faculty present, is focused on performing the steps involved in the task and needs assistance. Novice Level 1 Faculty is present. Respect patients’ autonomy. Is truthful. Recognizes limitations and seeks help when appropriate. Maintains appropriate boundaries. Maintains confidentiality. Needs supervision with faculty present, starts to recognize patterns but still needs to reason analytically and needs some assistance. Competent Level 2 Works as an effective member of team performing informed consents for various procedures with faculty present. Level 3 Takes initiative to talk to and consent patients. Faculty availably nearby. Trainee is comfortable carrying out the tasks and appreciates different contexts and rarely needs assistance, but knows when to ask for help. Proficient Level 4 Faculty is available if needed. Serves as a role model to other trainees. Level 5 Faculty is available if needed. Teaching and supervising others in obtaining informed consent. Performs task effortlessly, knows how to adapt to get relevant information, while thinking ahead and about important patient issues downstream from current task, and fully aware of constraints and limitations. Expert Performs the task intuitively, teaching others, and carrying out the task efficiently. Master

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TABLE 4

Examples of professionalism and ethics curriculum content, and the framework(s) they fall under

Virtue Competency Identity Altruism Appropriateness of Imaging Personal Identity Development (e.g. Erikson’s Theory of Identity Development), Self-efficacy, Locus of Control Theory, Developing situational awareness Humanism (includes compassion, respect, and effective communication with patients) Prioritizing Imaging Requests (during the routine workday, and on call /at the weekend), Prioritizing Workload or “time management” Professional Identity Development [Holden and Wald references] Honesty Patient Safety (screening patients at time of imaging request) Understanding connection between cultivating self-compassion and that for others Reliability Patient Safety (prescribing or protocoling the correct study for a specific patient at the current time) Social Learning Theory Confidentiality Informed Consent for diagnostic and interventional studies (including pregnant patients and lactating mothers) Health Belief Models, Responding to loss and grief Managing conflicts of interest Counseling patients and clinicians regarding radiation risks and exposure The Sick Role Respect for autonomy (respecting the patients’ choice not to have contrast or a certain type of test) Patient Safety (performing or supervising studies) Recognizing cognitive traps and biases that can lead to medical errors Beneficence and non-maleficence (choosing or recommending the diagnostic imaging that will help and not harm the patient) Study Quality (optimizing imaging planes, phases, and coverage/volume for diagnostic imaging) Patient Centered Care Justice (distributive) - fair distribution of scarce resources (deciding which patients get the urgent CT studies first) Patient Safety (recognizing and treating contrast reactions) Intra and intercultural aspects that impact patient care decisions and preferences Justice (rights based) - respect for people’s rights, including refusal of contrast or diagnostic imaging tests Communication (including unexpected, significant, or urgent findings) Patient preferences (screening and diagnostic testing) Justice (legal) - respect for morally acceptable laws Teamwork elements, including working as inter-professional teams The Radiologist as a Consultant (a physician who is an expert in imaging), Addressing the cognitive and emotional challenges of uncertainty in imaging decision making

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The Hidden Curriculum

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Commoditization and Corporate Medicine and Radiology

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Societal Changes

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Generational Differences in the Perception of Professionalism

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Conclusion

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Designing a Curriculum for Professionalism and Ethics Within Radiology

Background

Framing and Standardizing a Curriculum in Professionalism

The Hidden Curriculum

Commoditization and Corporate Medicine and Radiology

Societal Changes

Generational Differences in the Perception of Professionalism

Conclusion

References

Further Reading

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