The teacher has first of all to reveal, to take away the veil covering many students’ intellectual life, and help them to see that their own experiences, their own insights and convictions, their own intuitions and formulations are worth serious attention. It is so easy to impress students with books that they have not read, with terms that they have not heard, with situations with which they are unfamiliar. It is much more difficult to be a receiver who can help the students distinguish carefully between the wheat and weeds in their own lives and to show the beauty of the gifts they are carrying with them. —Henri Nouwen
What is professionalism? How can we uphold and promote it? How can it be taught, or at least learned? These are complicated questions. The Accreditation Council for Graduate Medical Education (ACGME) states that physicians in residency and fellowship programs should demonstrate “a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diverse patient populations .” But what professional responsibilities are physicians expected to carry out, what ethical principles should they adhere to, what exactly does it mean to be sensitive, and in what respects are patient populations diverse?
If educational discussions around professionalism are to make a difference, they need to be both practical and specific. We should avoid spending the bulk of our time attempting to define professionalism and instead devote a substantial portion of attention to real-life situations where physicians face important choices in this domain. Such case discussions are often both more engaging and more illuminating than discussions of abstract principles, in part because they invite participants to search within themselves and work together in defining their own professional expectations and ideals. Telling and memorization work less well than asking and discussing.
To begin with, we need to discard some superficial notions about professionalism. It does not pertain primarily to dress or grooming. It is not about chewing gum or wearing an identification badge within 12 inches of eye level. Professionalism is not a costume. Moreover, professionalism does not consist primarily of a list of “Thou shalt not’s.” We do not admire physicians’ professionalism because they do not lie, cheat, and steal, or even because they refrain from dealing with patients and colleagues in a disrespectful manner. There is no list of unprofessional behaviors that we can distribute to learners and rest assured that they will always conduct themselves professionally.
Instead of merely enumerating types of unprofessional conduct, we need to work to define the qualities that characterize consummate professionals. Our goal is not merely to raise the floor, so that no one falls below minimal standards of professionalism. It is also to raise the ceiling, so that everyone can perform at their highest level. To do this, we need to focus less on behavior and more on identity and aspirations. What really matters most in this sphere is not the institutional policies, procedures, and rules we follow, but who we are and what we stand for, the attitudes we exhibit every day. Real professionalism is not impressed on us from outside, but something that springs from within.
Toward this end, we present here seven case descriptions provided by diagnostic radiology residents and introduced at the 2012 AUR annual meeting, each followed by a brief discussion of the salient issues elucidated in discussions involving residents, faculty members, and program directors. Knowing that such cases are real-life accounts provided by peers helps to elicit a high level of resident engagement and enthusiasm for such discussions, which can become quite animated. This is especially important, because presentations on professionalism can sometimes seem as dry as dust. One thing about teaching professionalism is certain: boring learners is a recipe for failure.
Avoiding conflict
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A postoperative abdominal ultrasound examination demonstrates a critical vascular stenosis. When the finding is communicated to the surgeon, he states that, based on his intraoperative visualization, this is impossible. He further indicates that no such diagnosis should be shared with the patient. To placate the surgeon, the radiologist changes the report to read that the examination shows “normal postoperative findings.”
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Truth telling
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A computed tomography (CT) scan of the abdomen and pelvis was performed overnight, but not interpreted until the next morning. An acute finding was identified and communicated to the patient’s physician by phone. The resident dictated the report and sent it to the attending radiologist. To the resident’s surprise, however, the attending physician changed the time of notification in the report, making it seem as though the physician had been notified during the night.
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Misleading a patient
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A patient who recently underwent esophageal surgery is scheduled for a percutaneous gastrostomy tube placement. During the procedure, the tube is inadvertently passed through both the anterior and posterior gastric walls. In discussing the adverse outcome with the patient, the radiologist explains, “Unfortunately, a known complication of this procedure has occurred, and the next step is to refer you to surgery to complete the procedure.”
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Overwork
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In one program, radiology residents on night float duty cover multiple hospitals with large case volumes, often reaching 100 or more CT examinations. In some cases, these residents have only a year of residency under their belts. The residents decide to meet with the program director and chair to share their concerns about patient welfare. They are told that radiology is a highly competitive field, and that if they cannot do the work, new residents will be found to take their places.
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Data omission
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When radiologic colleagues and referring physicians offer new information about patients, a radiologist refuses to incorporate such data into her reports. She states that his job is strictly to interpret images, and incorporating additional data is unnecessary.
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Day’s end
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A senior radiologist makes it a point not to answer the phone after 3:30 pm. Moreover, he makes it clear to everyone else in the reading room that they are to follow the same policy. The rationale, he states, is that by this point the group is generally behind on the work list and it is important to avoid taking on any additional commitments so that everyone can leave the reading room by quitting time.
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Interaction discouraged
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Over the course of the work day, referring physicians visit the reading room to request consultation about their patients and their imaging studies. The attending radiologist is known to dislike such interactions, and does whatever she can to ignore visitors and make them feel unwelcome. She implicitly encourages residents to do the same. “Why can’t they just view our reports through the electronic medical record and leave us alone?” she asks. If the report has not yet been dictated, she tells referring physicians to check the computer again soon.
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Acknowledgments
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References
1. Nouwen H.: Creative ministry.1971.DoubledayNew York
2. ACGME. Competencies: Professionalism. Available at: http://www.acgme.org/acgmeweb/Portals/0/PDFs/commonguide/IVA5e_EducationalProgram_ACGMECompetencies_Professionalism_Explanation.pdf .