Faculty Bibliography

BACKGROUND: Evidence supporting professionalism as a critical measure of competence in medical education is limited. In this case-control study, we investigated the association of disciplinary action against practicing physicians with prior unprofessional behavior in medical school. We also examined the specific types of behavior that are most predictive of disciplinary action against practicing physicians with unprofessional behavior in medical school. METHODS: The study included 235 graduates of three medical schools who were disciplined by one of 40 state medical boards between 1990 and 2003 (case physicians). The 469 control physicians were matched with the case physicians according to medical school and graduation year. Predictor variables from medical school included the presence or absence of narratives describing unprofessional behavior, grades, standardized-test scores, and demographic characteristics. Narratives were assigned an overall rating for unprofessional behavior. Those that met the threshold for unprofessional behavior were further classified among eight types of behavior and assigned a severity rating (moderate to severe). RESULTS: Disciplinary action by a medical board was strongly associated with prior unprofessional behavior in medical school (odds ratio, 3.0; 95 percent confidence interval, 1.9 to 4.8), for a population attributable risk of disciplinary action of 26 percent. The types of unprofessional behavior most strongly linked with disciplinary action were severe irresponsibility (odds ratio, 8.5; 95 percent confidence interval, 1.8 to 40.1) and severely diminished capacity for self-improvement (odds ratio, 3.1; 95 percent confidence interval, 1.2 to 8.2). Disciplinary action by a medical board was also associated with low scores on the Medical College Admission Test and poor grades in the first two years of medical school (1 percent and 7 percent population attributable risk, respectively), but the association with these variables was less strong than that with unprofessional behavior. CONCLUSIONS: In this case-control study, disciplinary action among practicing physicians by medical boards was strongly associated with unprofessional behavior in medical school. Students with the strongest association were those who were described as irresponsible or as having diminished ability to improve their behavior. Professionalism should have a central role in medical academics and throughout one's medical career.

BACKGROUND: Although peer assessment holds promise for assessing professionalism, reluctance and refusal to participate have been noted among learners and practicing physicians. Understanding the perspectives of potential participants may therefore be important in designing and implementing effective peer assessment. OBJECTIVE: To identify factors that, according to students themselves, will encourage or discourage participation in peer assessment. DESIGN: A qualitative study using grounded theory to interpret views shared during 16 focus groups that were conducted by leaders using a semi-structured guide. PARTICIPANTS: Sixty-one students in Years 1, 3, and 4 in 2 mid-western public medical schools. RESULTS: Three themes students say would promote or discourage peer assessment emerged: personal struggles with peer assessment, characteristics of the assessment system itself, and the environment in which the system operates. Students struggle with reporting an unprofessional peer lest they bring harm to the peer, themselves, or their clinic team or work group. Who receives the assessment and gives the peer feedback and whether it is formative or summative and anonymous, signed, or confidential are important system characteristics. Students' views of characteristics promoting peer assessment were not unanimous. Receptivity to peer reports and close positive relationships among students and between students and faculty mark an environment conducive to peer assessment, students say. CONCLUSIONS: The study lays a foundation for creating acceptable peer assessment systems among students by soliciting their views. Merely introducing an assessment tool will not result in students' willingness to assess each other.

Increasing physician and patient mobility has led to a move toward internationalization of standards for physician competence. The Institute for International Medical Education proposed a set of outcome-based standards for student performance, which were then measured using three assessment tools in eight leading schools in China: a 150-item multiple-choice examination, a 15-station OSCE and a 16-item faculty observation form. The purpose of this study was to empanel a group of experts to determine whether international student-level performance standards could be set. The IIME convened an international panel of experts in student education with specialty and geographic diversity. The group was split into two, with each sub-group establishing standards independently. After a discussion of the borderline student, the sub-groups established minimally acceptable cut-off scores for performance on the multiple-choice examination (Angoff and Hofstee methods), the OSCE station and global rating performance (modified Angoff method and holistic criterion reference), and faculty observation domains (holistic criterion reference). Panelists within each group set very similar standards for performance. In addition, the two independent parallel panels generated nearly identical performance standards. Cut-off scores changed little before and after being shown pilot data but standard deviations diminished. International experts agreed on a minimum set of competences for medical student performance. In addition, they were able to set consistent performance standards with multiple examination types. This provides an initial basis against which to compare physician performance internationally.

BACKGROUND: No universally accepted method to measure professionalism exists. We developed an instrument to measure specific aspects of professionalism in surgical residents. METHODS: Professionalism was deconstructed into 15 domains. Behavioral descriptors were determined for extreme and selected intermediate anchors. It became evident that residents could "go too far" in some professional behaviors. Therefore, although a 7-point continuous ordinal scale forms the framework, a score of 7 does not necessarily indicate the ideal. This characteristic minimizes the problem of inflated ratings. RESULTS: The instrument was utilized by attending faculty to evaluate residents and also by residents as a self-evaluation. Calculated from ordinal values, mean (SD) of the ratings across domains for faculty evaluations of residents was 4.95 (0.38) while mean for self-evaluations was 4.95 (0.39). Reliability was high (coefficient alpha 0.85). CONCLUSIONS: This instrument provides a means to measure professional behaviors during surgical residency. Repeated use will be required to thoroughly establish validity and reliability.

OBJECTIVE: To assess the importance to patients of various aspects of bedside interactions with physician teams. DESIGN: Cross-sectional survey. SETTING: VA hospital. PATIENTS: Ninety-seven medical inpatients. INTERVENTION: Survey of 44 questions including short answer, multiple choice, and Likert-type questions. MEASUREMENTS AND MAIN RESULTS: Data analysis included descriptive statistics. The sample was predominantly male, with a mean age of 62. Overall satisfaction with the hospital experience and with the team of doctors were both high (95% and 96% reported being very or mostly satisfied, respectively). Patients reported learning about several issues during their interactions with the teams; the 3 most highly rated areas were new problems, tests that will be done, and treatments that will be done. Most patients (76%) felt that their teams cared about them very much. Patients were made comfortable when the team showed that they cared, listened, and appeared relaxed (reported by 63%, 57%, and 54%, respectively). Patients were made uncomfortable by the team using language they did not understand (22%) and when several people examined them at once (13%). Many (58%) patients felt personally involved in teaching. The majority of patients liked having medical students and residents involved in their care (69% and 64%, respectively). CONCLUSIONS: Patients have much to teach about what is important about interacting with physician teams. Although patients' reactions to team interactions are generally positive, patients are different with respect to what makes them comfortable and uncomfortable. Taking their preferences into account could improve the experience of being in a teaching hospital.

The General Agreement on Trade in Services (GATS) is the result of an ongoing process of opening national markets to foreign health services within an international framework of trade agreements that prohibit discriminatory treatment of foreign suppliers. Developing markets are growing, as is demand for health care services, and most of this demand is being met by the private market. The globalization of health services requires the resources of the academic and corporate sectors of the developed world for equitable and sustainable growth. Health services trade should be seen as a tool for achieving these goals, rather than as an end in itself.

OBJECTIVE: The purpose of this study was to establish outcome measures for professionalism in medical students and to identify predictors of these outcomes. DESIGN: Retrospective cohort study. SETTING: A US medical school. PARTICIPANTS: All students entering in 1995 and graduating within 5 years. MEASURES: Outcome measures included review board identification of professionalism problems and clerkship evaluations for items pertaining to professionalism. Pre-clinical predictor variables included material from the admissions application, completion of required course evaluations, students' self-reporting of immunisation compliance, students' performance on standardised patient (SP) exercises, and students' self-assessed performance on SP exercises. RESULTS: The outcome measures of clerkship professionalism scores were found to be highly reliable (alpha 0.88-0.96). No data from the admissions material was found to be predictive of professional behaviour in the clinical years. Using multivariate regression, failing to complete required course evaluations (B = 0.23) and failing to report immunisation compliance (B = 0.29) were significant predictors of unprofessional behaviour found by the review board in subsequent years. Immunisation non-compliance predicted low overall clerkship professional evaluation scores (B = - 0.34). Student self-assessment accuracy (SP score minus self-assessed score) (B = 0.03) and immunisation non-compliance (B = 0.54) predicted the internal medicine clerkship professionalism score. CONCLUSIONS: This study identifies a set of reliable, context-bound outcome measures in professionalism. Although we searched for predictors of behaviour in the admissions application and other domains commonly felt to be predictive of professionalism, we found significant predictors only in domains where students had had opportunities to demonstrate conscientious behaviour or humility in self-assessment.