Radiologists in teaching hospitals and in practices with residents rotating through are involved in the education of their residents. The Accreditation Council for Graduate Medical Education requires evidence that trainees are taught and demonstrate competency not only in medical knowledge and in patient care—the historic focus of radiology education—but also in the so-called non-interpretative core competencies, which include professionalism and interpersonal skills. In addition to accreditation agencies, the prominent assessment practices represented by the American Board of Radiology core and certifying examinations for trainees, as well as Maintenance of Certification for practitioners, are planning to feature more non-interpretative competency assessment, including professionalism to a greater extent. Because professionalism was incorporated as a required competency in medical education as a whole, more clarity about the justification and expected content for teaching about competence in professionalism, as well as greater understanding and evidence about appropriate and effective teaching and assessment methods, have emerged. This article summarizes justifications and expectations for teaching and assessing professionalism in radiology residents and best practices on how to teach and evaluate professionalism that can be used by busy radiology faculty in their everyday practice supervising radiology residents.
Introduction
We are now in the age of managed health care and Accountable Care Organizations, which encourages specialties such as radiology to demonstrate the added value of the services we provide. In the context of changed expectations for health care, changes mandated for health profession education included competencies beyond the traditional focus on trainees’ acquisition of medical knowledge . The Accreditation Council for Graduate Medical Education (ACGME) specifically targets professionalism as a competency that training programs are required to teach and assess. Radiology’s established tradition of education—defining and fostering competency in medical knowledge and patient care (the traditional interpretative skills emphasized in radiology education)—facilitates our ability to define the content and scope of our curricula, as well as share best practices in assessing progress on predictable milestones and competency attainment of our trainees. In contrast, formulating teaching and assessment in the essential “non-interpretative skill” of professionalism has posed challenges to medical education. We learned that challenges medical education encountered in teaching professionalism included diffuse and disparate definitions of professionalism; variability in trainees’ experience and opportunity to reflect on professionalism; discrepancies between professionalism in explicitly planned curriculum and informal experience; and findings that faculty are less likely to explicitly articulate and share their standards for professionalism, let alone observe and provide constructive feedback to trainees on their progress in achieving competence in professionalism.
Moreover, generational differences emerge between young trainees, new faculty, and senior practicing radiologists, which along with technology are casting a different light on professional values and beliefs. As trainees mature and gain knowledge and autonomy, their learning and feedback preferences will also change and evolve; educators need to keep these factors in mind. Our collective experiments and experience have also enabled us to share lessons learned for strategic and effective education.
In the first article of this series, the authors outlined how the construct of medical professionalism has evolved, including pivotal historical events precipitating expectations for the practice and teaching of professionalism . In that paper, the authors share their insights on the teaching and assessment of professionalism in radiology trainees, supported by a literature review on more successful strategies. Multiple examples of opportunities and ways for readers to teach and assess professionalism to trainees in their radiology practices are provided.
Why Should We Teach Professionalism? Sharing the Message with Our Faculty and Trainees
There is an explosion in the volume of literature and media coverage on medical professionalism owing to a perceived decline in professional values and behaviors among physicians . The teaching of professionalism also represents a regulatory and certification requirement, as well as the ethical thing to do.
The teaching of professionalism has assumed a more central place within graduate (medical school) and post-graduate (residency programs) medical education in recent years. There are many reasons underlying the teaching of medical professionalism, which include the medical professions’ commitment to address prior transgressions and to prevent their occurrence in the future. In addition, the teaching of professionalism allows us to be transparent and to assure the public, patients, and allied professions that we value professionalism highly and take it seriously. Radiologists should emphasize, model, and teach professionalism to our colleagues and trainees, whenever opportunity permits.
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What Should We Teach? Clarity About the Construct
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Table 1
A Suggested Formal Curriculum to Teach Professionalism to Radiology Residents, Categorized Into Competencies with Examples of How They Relate to Radiology Practice and Patient Care
Criterion Examples Professional competence Staying up to date on professional certification; Having radiology practice (including technical equipment) conform with the American College of Radiology Practice Parameters and Technical Standards; Using the American College of Radiology Appropriateness Criteria; Selecting appropriate imaging tests for different patient scenarios; Advising consulting clinicians regarding suitable tests for their patients; Staying up to date with the latest science and evidence to enhance scholarship and advance the field. Professional duties or responsibilities Review of radiology images; Monitoring performance of imaging when needed; Supervising medical students; Assisting technologists and nurses; Supervising administration of contrast material; Obtaining informed consent for procedures; Participating in interventional procedures; Dictation of radiology reports; Communication of unexpected, significant, or urgent findings to referring practitioners; Signing off reports promptly; Treating contrast reactions; Managing adverse events. Scientific knowledge Staying up to date with the latest science and evidence to enhance scholarship and advance the field; Knows how to appraise published studies; Is able to apply findings from literature to current patients. Accountability Accepts responsibility for mistakes they made. Just distribution of finite resources Understand principles of comparative effectiveness of imaging tests. Patient confidentiality Be familiar with the Health Insurance Portability and Accountability Act (HIPAA); Maintaining appropriate confidentiality of patients’ medical imaging findings. Adherence to ethical principles Adhering to high ethical and moral standards; Practices medical ethics principles, including respect for autonomy, non-maleficence, beneficence, and justice. Improving quality of care Minimizing radiation dose to patients, appropriate precautions after administering radioactive substances for diagnosis and therapy. Improving access to care Principles of evidence-based medicine and radiology; Not discriminating against patients based on sex, age, ethnic group, religious affiliation, social standing, lifestyle choices, etc. Reliability Timeliness of signing off reports; Dependence of patients and system on us Effective/appropriate interactions with patients and those important to them Communicating clearly and understandably with patients, families, and caregivers; Honesty; Knowing the necessary and appropriate elements of voluntary informed consent for diagnostic and therapeutic imaging procedures; Clearly documenting findings in reports; Knowing how and when to communicate findings that are unexpected, urgent, or incidental. Effective interactions with people working within the health-care system Communicating clearly and understandably with colleagues, referring clinicians, technologists, nurses, and clerks. Commitment to autonomous maintenance and continuous improvement of competence for self Puts systems in place to ensure he or she complies with regulations for licensure and practice; Striving for excellence; Keeps up to date with radiological information; Adequately prepares for core and certification examinations and for radiology practice; Learning from personal oversights and errors and using them to improve performance in the future; Constant self-regulation to enhance performance; Self-organization to improve efficiency and effectiveness; Reflection on one’s actions and decisions to ensure the best outcomes in the future. Commitment to autonomous maintenance and continuous improvement of competence for systems and others Continuously trying to improve performance clinically; Stays up to date with the latest evidence as it matures; Putting systems in place to increase competence and efficiency when working in teams or multidisciplinary groups; Learning from personal oversights and errors and using them to improve performance in the future; Reflection on one’s actions and decisions to ensure the best outcomes in the future. Maintain trust by managing conflicts of interest Declaring outside interests and potential conflicts of interest to the relevant authorities at his or her institution and university; Being aware of and familiar with local conflict of interest policies; Managing and applying a conflict of interest plan when necessary or appropriate. Mindfulness Being aware of their thoughts and feelings in their current situation; Calmly acknowledging and accepting their current thoughts and feelings; Looking after their work, life, family, and recreational balance.
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Teaching Professionalism to Radiology Residents
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Assessing and Evaluating Professionalism in Radiology Residents
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Table 2
An Example of a Global Rating Tool Used to Assess Radiology Residents in the Competency of Professionalism
Professionalism Unsatisfactory Circumscribed Deficits Effective/Competent Above Average Outstanding Arrives on time and prepared Demonstrates professional and sensitive interaction with patients Dresses appropriately at all times Signs reports promptly Ethical behavior (with respect to workplace performance) Able to perform effectively when under stress
Table 3
Assessing Radiology Residents in Professional Values and Ethics, According to the Milestones (Adapted From Reference )
Professional Values and Ethics Has Not Achieved Level 1 Level 1 Level 2 Level 3 Level 4 Level 5 Demonstrates the following professional behaviors:
Is an effective health-care team member
Demonstrates professional behaviors listed in the second column Is an effective health-care team leader, promoting primacy of patient welfare, patient autonomy, and social justice
Demonstrates professional behaviors listed in the second column Serves as a role model for professional behavior
Demonstrates professional behaviors listed in the second column Participates in local and national organizations to advance professionalism in radiology
Mentors others regarding professionalism and ethics
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Table 4
An Example of a Multi-assessment Instrument for Radiology Residents in the Competency of Professionalism
Yes/No Questions for patients
The resident: identified himself or herself and his or her role clearly addressed me in an appropriate manner demonstrated good listening skills communicated information in a way that was easy to understand addressed questions and concerns raised to my satisfaction appeared knowledgeable about the diagnostic test or procedure Questions for colleagues, fellows, faculty, nurses, technologists, and clerks
The resident: demonstrated appropriate boundaries with patients discusses patient imaging in a respectful manner maintains confidentiality of patient information responds promptly when paged or called assumes responsibility for his or her own mistakes advocates for the needs of patients in the face of system barriers communicates with attendings and consultants in a timely manner composes, dictates, and drafts understandable and useful radiology reports collects essential information from previous caretakers following hand off uses clear verbal communication with colleagues takes on extra work to help the team shows initiative for own learning works beyond usual duties to provide care for patients listens and responds to others respectfully solicits input from nurses and other health-care workers acknowledges limits of own knowledge or ability balances honesty and tact in conveying information maintains composure during difficult interactions
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Table 5
Example Components for Objective Structured Clinical Examinations in Professionalism for Radiology Residents
Scenario or Case Study Source Informing Competency Expectations It is 4:55 PM, Friday, you are asked to protocol a CTPE CT and indirect CTV on a 26-year-old woman who had a CTPE and CTV study 3 days ago (which was negative for PE and DVT, but showed pneumonia). You suspect that if you try to cancel this examination, the ER physicians will go to your on-call resident colleague or a senior faculty, who will tell the resident to do it anyway. What do you do? Imaging appropriateness, patient safety, radiation protection The patient for the breast biopsy comes down from the ward and has already taken her pre-procedure valium. You are the resident on the service and it is your job to consent her. She seems a bit drowsy and groggy. She is happy to sign it and asks you to “Please get it all over and done with.” What do you do? Elements of voluntary informed consent You see a spiculated nodule on a chest radiograph or mammogram, and looking at the old studies, it was there a year ago but it was not mentioned in the report. How do you report the study? What do you do? ACR Communication Guideline A patient with liver metastases on US (who seems well informed about her disease in general) asks you (the resident) what are the findings, when you return to the room. The attending radiologist has “popped off to their office for a minute or two.” What do you do? Do you tell her? Resident responsibilities, responsibility of supervising faculty, communication You are the resident in MRI and the clerk hands you the phone, saying it is the patient herself asking about her MRI result on her study done 4 days ago. What do you tell her? What do you say? Communication, HIPAA At the conclusion of a procedure, the interventional radiologist asks the technologist to list a catheter for billing purposes that was not actually used. This will bolster up the reimbursement to the hospital. What do you do? Appropriate documentation, Appropriate billing, honesty, fraud prevention You are a resident on the interventional service and the patient refuses to have his or her angiogram done by you. You have already rotated twice through angiography and have done more than 60 diagnostic angiograms (including 15 therapeutic interventions). What do you do? Patient rights, voluntary informed consent The technologist informs you that they accidentally gave intravenous contrast for the chest CT study but noticed afterward that the study was supposed to be a low-dose, non-contrast nodule CT protocol. The prescribing radiologist’s handwriting was not legible. What do you do? Communication, openness, disclosure, transparency, honesty
ACR, American College of Radiology; CT, computed tomography; CTPE, computed tomography pulmonary angiography; CTV, computed tomography venography; DVT, deep venous thrombosis; ER, emergency room; HIPAA, Health Insurance Portability and Accountability Act; MRI, magnetic resonance imaging; PE, pulmonary embolism; US, ultrasound.
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Addressing Lapses in Professionalism in Radiology Residents
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Conclusion
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Table 6
Useful Resources Identifying Professionalism Principles Applicable to Radiology (and also to Research Projects)
Resource Source Teaching Medical Professionalism (Book). Cruess RL, Cruess SR, and Steinert Y. Excellent introduction to and background for the topic. * http://www.cambridge.org/us/academic/subjects/medicine/medical-law-ethics-and-forensic-medicine/teaching-medical-professionalism Measuring Medical Professionalism (Book). Stern DT. Excellent introduction to and background for the topic. * https://global.oup.com/academic/product/measuring-medical-professionalism-9780195172263?cc=us&lang=en& Understanding Medical Professionalism (Book). Practical tips on teaching this competency in the field. * http://www.abimfoundation.org/Resource-Center/Understanding-Medical-Professionalism.aspx The American Medical Association (AMA) Code of Ethics http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page (Free) The American Board of Radiology Foundation online modules on Ethics and Professionalism http://www.acr.org/Education/e-Learning/Online-Modules-on-Ethics-and-Professionalism (Have to be an ACR member) Institute of Medicine (IOM) reports (1999) “To Err is Human,” (2001) “Crossing the Quality Chasm,” (2003) “Transforming Health Care Quality,” and (2015) “Improving Diagnosis in Health Care” http://nationalacademies.org/hmd/reports/1999/to-err-is-human-building-a-safer-health-system.aspx
http://nationalacademies.org/hmd/reports/2001/crossing-the-quality-chasm-a-new-health-system-for-the-21st-century.aspx
http://nationalacademies.org/hmd/reports/2003/priority-areas-for-national-action-transforming-health-care-quality.aspx
http://nationalacademies.org/hmd/reports/2015/improving-diagnosis-in-healthcare.aspx The Physicians Charter http://www.abimfoundation.org/Professionalism/Physician-Charter.aspx (Free) The American College of Radiology Practice Parameters and Technical Standards http://www.acr.org/Quality-Safety/Standards-Guidelines/Overview (Free) The American College of Radiology Appropriateness Criteria (ACRAC) http://www.acr.org/Quality-Safety/Appropriateness-Criteria (Free to access, but advanced searches require ACR membership to login) The Royal College of Radiologists “iRefer: Making the best use of clinical radiology” (formerly “Making the Best Use of Clinical Radiology Services”) Free to National Health Service Employees in the UK and members of the Royal College of Radiologists. There is a fee for others who wish to purchase copies (Not available online at present, but can be purchased by phoning the Royal College of Radiologists)
https://www.rcr.ac.uk/publication/irefer-making-best-use-clinical-radiology RADPEER http://www.acr.org/Quality-Safety/RADPEER (To join requires a fee) Informed Consent Terry B. Informed Consent in Clinical Medicine. Chest 2007;131:563-8. The American College of Radiology Practice Parameter for Communication of Diagnostic Imaging Findings http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Comm_Diag_Imaging.pdf (Free) Teaching and Assessing Professionalism: A Program Directors Guide https://www.abp.org/sites/abp/files/pdf/professionalism.pdf (Free) The Professionalism Mini-Evaluation Exercise (P-MEX) Cruess R, McIlroy JH, Cruess S, Ginsburg S, Steinert Y.
The Professionalism Mini-evaluation Exercise: a preliminary investigation. Acad Med. 2006 Oct;81(10 Suppl):S74-8. Climate of Professionalism Survey Quaintance JL, Arnold L, Thompson GS. Development of an instrument to measure the climate of professionalism in a clinical teaching environment. Acad Med. 2008 Oct;83(10 Suppl):S5-8. The Agency for Healthcare Research and Quality. Team STEPPS (Training for teams to communicate to enhance patient safety) http://teamstepps.ahrq.gov/ (There is a fee to purchase training materials) Department of Health and Human Services Regulations Title 45 of Code of Federal Regulations http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html (Free) Food and Drug Administration Title 21 of Code of Federal Regulations http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm (Free) Health Insurance Portability and Accountability Act (HIPAA) http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/index.html (Free) International Committee of Medical Journal Editors (ICMJE) Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals (The Vancouver Group) http://www.icmje.org/icmje-recommendations.pdf (Free) The World Medical Association Declaration of Helsinki, updated 2013 http://www.wma.net/en/20activities/10ethics/10helsinki/ (Free) http://www.wma.net/en/20activities/10ethics/10helsinki/DoH-Oct2013-JAMA.pdf The Nuremburg Code https://history.nih.gov/research/downloads/nuremberg.pdf (Free) The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html (Free) Professionalism in Radiology: A Guide for Residents and Medical Students https://www.mededportal.org/publication/9105 (A small fee).
ACR, American College of Radiology.
Resources that serve as an introduction and overview are marked with an asterisk ( ).
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