Professionalism: Beyond a Hidden Curriculum

Thank you for joining us for our Health Professions educator series session today um you know I've been in um medical education for more years than I'd like to admit um no math FAS uh but I've been participating across the Continuum in various um various roles but even today our office uh ex expands throughout the Continuum and we have you know uh little our fingers and toes in each area and every meeting that I go to administratively I I have to say that something um about professionalism a professional identity formation or or something along these lines pops up for one reason or another so this is definitely uh a presentation that we could give now we could give once a month different aspects of it but it's extremely applicable across the Continuum in all different spaces so um today we have we are very fortunate to have Dr re Rebecca Paulie here with us um to present on professionalism Beyond a hidden curriculum Dr Paulie is vice dean of the medical school she's also Vice chair and professor of internal medicine for the Virginia Tech Killian school of medicine and kilan clinic so she is well equipped to present on this session um because she's way more involved D administratively than I am um and Hears A lot of this and has gotten into the literature and can inform us in a myriad of way so go ahead and take it away Dr Paulie thank you very much Sherry um and thank you for the invitation also um I'm going to have Sarah Advance the slides so I appreciate her help with that um as you know this is a an absolutely huge topic and relevant for all of us in so many ways so want to um Begin by just trying to to carve out a piece of it with some very practical tips uh got room for dialogue during our conversations so um be ready for that so the learning objectives are to recognize specific competencies of professionalism can be taught describe how knowledge attitudes and skills of professionalism can be assessed and then realize professional identity as lifelong adaptive Learners scientists Physicians citiz citizens impatient centered Physicians is a developmental process next slide when I say professionalism you say compassion ethics patient listen honesty this is warn word doodle that I found um related to professionalism and I want to know what words come to your mind when you hear professionalism so if you'll type those in the chat or raise your hand we'll get some ideas of how professionalism what that brings to mind for you showing up on time competence trust and authenticity respect for others mutual respect flexibility engaged learner lifelong learner emotional intelligence trustworthy diversity and inclusion truthfulness respect for colleagues Integrity great um some very specific some related to values some related to behavior um so we'll discuss and tease these out as we go along next slide so a little bit of historical context um almost 2,000 years ago the first oath of medical ethics was recorded the code of HR Robi and then in the fifth century BC we have hypocrates uh more recently in the 1950s Merton described the task of medical education is to shape the Novis into the effective practitioner of medicine to give him the best available Knowledge and Skills to provide him with a professional identity so that he comes to think act and feel like a physician next slide when we look in the 1990s the behavioral model of professionalism was quite prevalent and that focused on performance actions Behavior being demonstrated in uh 2009 a professional presence described by haery what one is rather than what one does so beginning to Define this identity that was further expanded by Richard and Sylvia Cruz in 2014 describing values developmental process and being socialized the validation of the importance of assessing professionalism uh has um been evidenced by its inclusion by the lcme as well as the acgme next slide what is the hidden curriculum we we hear that term not infrequently so I've created these practical definitions seeing in the real world I e clinical rotations how people behave and what is valued as compared to what is taught in the classroom or even in the oy Suites a secret code of professionalism and for developing a professional identity knowing the real Playbook it's how to be accepted into the professional fraternity now as I said these are practical definitions are you aware of more formal ones or would you describe the hidden curriculum in different terms so if you'll either raise your hand or type that in the chat um we'd like to to see what you think of when you hear the term hidden curriculum the mapping and structure beyond that of just the content intangibles agenda cynical side of medicine recognizing the hierarchy unspoken expectations more akin to an apprenticeship see one do one teach one values learned outside the classroom okay so I was wondering um if if this is a term that would be familiar to you um and we'll explore that a little bit more uh next slide so this is a i a good case example of the Hidden curriculum uh and this is taken from medical professionalism best practice I can't believe this place after this morning's surgical Grand rounds about work life balance and well-being I figured I would ask my new attendant about days off I need to attend a wedding this rotation I showed my schedule with weekends that I need to be off to the attending he immediately asked me if I realized how demanding surgery is as a specialty he even encouraged me to rethink my specialty choice now I'm worried about my grade and getting a letter of recommendation what's up with the disconnect with what is said and what is done so the curriculum was saying well-being work like fat balance is important but then the actions that this medical student observed that hidden curriculum of sort of real life um really did not um focus on well-being and jumped a few extra steps to tell the the student that maybe a different specialty is one that he or she should be um considering next slide when we think about competencies that are relevant to professionalism these are a few that should be considered uh adherence to ethical principles effective interactions with patients and people important to them effective interactions with people working within the Health Care system or team commitment to autonomous maintenance and continuous Improvement of competence for self systems and others re reliability and accountability so as I said these are some to be considered uh next slide when we look at VTC so's professional identities and there's there's this inter interplay between professionalism and professional identity formation that we will get a sense of uh during this conversation so looking at the professional identities and I want to credit Dr Gonzalo for this development um and I think the wording here is just right on target that a lifelong Master adaptive learner scientist physician system Citizen and a patient centered physician are the goal professional ident ities that we want to help nurture and develop in our Learners as well as to uh demonstrate these ourselves next slide so breaking these out a little bit more of what we desire as outcomes in professional identity formation a physician who possesses skills and qualities related to learning adaptability ability to thrive in changing environments in ongoing personal and professional development physician leader who uses a systems thinking mindset and his or her professional role to develop use the Knowledge and Skills necessary to contribute to the holistic needs of patients populations of patients and Health Systems to achieve the best outcomes a physician who has the ability to integrate clinical medicine and scientific inquiry and research Bridging the Gap between bench sciences and direct patient care next slide CL what are the attributes of professionalism that we identify in our student handbook commitment to engage learning compassion conscientiousness respect self-awareness self-care sense of Duty social responsibility teamwork and trustworthiness so you can see many of these um descriptors are similar to how uh you described professionalism uh in our early uh chat conversation next slide so when we think about the competencies of professionalism how do we try to teach these attributes well knowing the concept of the hid hidden curriculum we must make the words and values real and demonstrate those in our actions we must roll model these behaviors and then correct our actions when we deviate off course when we realize well maybe that didn't really come across as quite as attentive or as compassionate as I meant to be on the hospital rounds today so identify that realize it self-correct um and continue to role model patient examples can be very helpful in trying to teach the attributes so professionalism and we'll see a little bit later um narrative writing case Reflections is one of the common methods used peer input can be very valuable and then as I said narrative Reflections um really on what could be what did happen and what could be better many of these um in looking through the literature the narratives relate to difficult or complex patients uh interactions and also to to team interactions that that may be complex next slide so some of the key points on professionalism uh development that um are in this book understanding medical professionalism which is um you know it's almost 10 years old now um or is 10 years old but it's still um I think very a very solid foundation for this topic so demonstrating professionalism depends on multiple competencies including knowledge attitudes and skills necessary to navigate complex situations the ability to reflect analyze options and act professionally in challenging situations can be developed throughout a career from medical student to resident to practicing physician professional resilience the ability to handle complex situations can be enhanced by address adding issues in both the work and personal environments teams can develop a culture to support and Foster the ability of the team members to manage professionalism challenges next slide so when we look at um what is the likelihood of professional Behavior being exhibited uh in contrast to unprofessional behavior I thought this was an effective um schematic so if we look at self- inent or one's purpose and goals plus selfefficacy that confidence that one is able to perform this purpose and goals plus the influence of positive role models so those are all um strong positive attributes and then we have to mix into this equation burnout or personal dist stress negative role models and stressful situations and you see that's come up several times in the slide complex or stressful situations I think it's it's easy to be professional when everything is going well um when we put in the stress of efficiency multiple do demands juggling multiple balls um being pulled those stressful situations contribute to mistakes happening so when we have the uh denominator rising in quantity then that can um affect the outcomes of the equation next um right so a comment about the hidden curriculum uh infusing bias um absolutely and that um depending on the environment the culture of the institution that could um increase the the denominator of that equation so what about societal context how does this play a role well social media um prevalent as it is uh the post reflect the individual's opinion it may also reflect that person opinion represents either intentionally or unintentionally the opinion of the institution or in fact the profession and I think Learners and more than just Learners um may not consider the consequences of this there are generational uh influences part of that due to experiences Norms in worldview um I recently saw this um it was a a clip actually on social media that contrasted the different Generations I didn't include the clip because of some inappropriate language but I think I can make the point here for us so the the clip shows uh a supervisor who's receiving calls from um someone who uh is not going to be coming to work that day and the Boomer answers the phone with a very formal title um I I don't understand that doesn't sound like you're that sick exactly what are what's going on with you the Gen X says I'm so understaffed but we'll make it work the millennial says I'm sorry to hear that oh are you actually going to the concert that's happening oh well I understand if you are I'll cover you but be sure to set your social media on private and then the jenz says not the vibe I was hoping to hear I'll send food so I think when we think about these generational differences uh it really points us to how professionalism has to be communicated across among how we need to incorporate the expectations of the Learners in these different generations with our expectations so it just comes to to point out how important communication is within this concept of professionalism next slide so what are some professionalism breaches in this article um which was actually in the most recent um issue of academic medicine there was a national survey of internal medicine clerkship directors and the four main categories of unprofessional behavior identified by faculty of medical students on this clerkship included involvement which was usually related to timeliness and engagement Integrity whether the student followed rules um participated as a team member communication both verbal and non-verbal and introspection with self-reflection response to feedback and I thought it was interesting in this particular article and the respondents of uh faculty only 50% of Faculty said that they had had or felt comfortable with providing feedback so only 50% had had formal training and what professionalism is and then how one evaluates professionalism so they're critiquing professionalism without um formal instruction on on what that includes um 99% of the um responses by faculty were based on what they observe behavior of the students so I I think there's room for us to think about facult equ development around what is professionalism how we communicate that to our wider teaching faculty uh next slide what are some of the professionalism locals that we have currently in courses content activities so I I selected a few here in our orientations professionalism is discussed we have a code of conduct we have class guiding principles which are created by each medical school class we have the Virginia Tech principles of community we have role modeling in our uh lace experience their recognitions of professionalism such as membership in the gold humanism Honor Society whether professional professionalism is included in letters of recommendation or the mspe or might it be mentioned when one receives honors for clerkships we also have some regular ation um Student Government the leak mppc honor code and safe watch next slide where do we have room to expand in our curriculum and activities well we have a new course being developed the profession of medicine and identities there is the potential for peer assessment with feedback we might consider expanding formal recognitions the consideration of a peer professionalism award and then more visibility of our student organizations who have professionalism Andor humanism as core values um so I'm I'm gonna pause here for a second I didn't put a chat bubble on this one but I'm just curious um what you think uh about these as potential places uh to expand our involvement and receive feedback hey um Rebecca this is Lesley don't know just thought I'd jump in and and um I I'm not sure whether you mentioned it or not but the assessment that we've been doing in um in phase one right now with the harmonized Milestones where we actually are asking for feedback from Educators across all different domains on a lot of these professionalism competencies so I think giving bringing this more into a formal curriculum into a formal setting we're we're asking faculty to evaluate provide evidence for and then uh a path for engagement with the learner along these axes I think is I would add to um that'll add to this list although that will be part of pomy that actually spans more than just that that professions of medicine and identities course because it is something that we're we're doing in all of of our curricular venues absolutely and um I'm going to show that in an upcoming slide but um thank thank you for the um appetizer Rebecca can I can I comment uh so so it it's really interesting to me the wide varieties of definitions that people had at the beginning of your lecture for pro professionalism for me some of those were much more defining the profession rather than professionalism when you had the slide about categories of unprofessional behavior that much got much more to what I think of as professionalism in terms of values not attributes or professional goals a lot of that first part of the lecture was about that I mention this now because it would certainly impact this course development um you had the SL you know so often it's about what not to do rather than what to do and when we see people running into trouble it's when they deviate from the expectations that really Center about around the ethical humanistic values so I I'm just worried about a course like this getting too diffuse and not focusing on what people generally think think of as professionalism so th those are just some thoughts so we um I'm going to show uh one of the articles that really focused on the idea that professionalism is a Continuum much like we um expect our students to learn over time about clinical Sciences or basic Sciences we expect them to learn over time about professionalism so there's not an absolute in many cases an absolute on off professional unprofessional so I think um some of your points you you'll see with that that it is really this Continuum and so the positive aspect is around development of those skills rather than a deficit identification yeah it'll be real interesting I mean I'm I'm thinking of egregious examples but measuring this it'll be very interesting to see whether those more egregious behaviors are affected At All by what you're talking about which is important I'm not saying it's unimportant I just don't think of that in my mind as you know the sort of my core definition but enough said Thank you any other comments before we com yeah I have a comment Rebecca related to the the student who wanted to go to a wedding and pick off from the surgical rotation I mean normally I would side with the student however in that case I feel like the student went to the faculty member and sort of dropped the problem in the faculty member's lab and the approach that you know would normally be taught would be you know it's okay if the wedding is a very important person and you really do need to take off you know we we respect your judgment as you know as the student however you know the correct approach probably would be to go to the faculty member and say you know I found this other student who's going to cover my rotation that day and I'm going to swap with with that student you know does that work for you so come to the faculty member with a solution rather than dropping the conflict in The Faculty member's lap and asking the faculty member to handle it that that's just my feedback and I think those are things that can be taught to students so that they don't fall into that trap and get insulted because probably that faculty member didn't mean to insult the student probably that faculty member was simply you know you know expecting the student to come with a solution well I think a lot of that is timing and communication and I I think the student probably thought oh gosh they just talked about well-being and um work life balance and integration and this is the perfect opportunity but you know this is an attending who's just joining the service trying to start rounds and that timing but I definitely agree that when problems are identified um and someone can bring a solution with it is much more productive um for everyone okay we'll move on um thank you Dr Paulie there are a couple of comments right in the chat okay if you wanted to so one was just uh it sounds like the hidden curriculum may also this is from a little bit ago me mean that the infusion of bias um that is implicit bias by Educators providers into our words actions impacting our professionalism is this accurate um I I would say yes um and I I think that also gets a little bit to not necessarily being aware of um what can be interpreted that that may seem um acceptable and normative to us but across Generations um May um cause someone to to hear it as if fingernails were on a a chalkboard so I think that part of just trying to to take um the temperature of how was that received how how how were my my words perceived by others and my actions is very important and then there was one more comment um from your last slide love the idea of peer-to-peer feedback I think the selection process for the gold humanism Society is peer-based for M students as well correct I I believe um that is is correct um it's generally the I believe the students who are already um so the upper level students um looking at the selection process I'm not sure how much is um based on the students who are in the same class um thank you so um what and how might we assess professionalism so this gets a little bit to some of the points that were raised so the deficit framework perpetuates a rigid dichotomous characterization of behavior is either unprofessional or professional rather than the spectrum of behaviors in clinical science basic science research and health systems and interprofessional practice we expect and accept accept knowledge and skill acquisition as continuous and cumulative why not so for professionalism why is it more of a switch on or off and isn't it our charge to help in that developmental process for Learners to understand what is accessible what what is acceptable how about timing how about communication skills that might include um problem solving next slide so when we look at um the harmonized milestones and this was provided to me um by Brock with um certainly the the leadership of uh Dr Gonzalo so Dr meron and Dr Gonzalo and the the Medical Education team looking at the harmonized Milestones um in acgme selecting out these areas to not only identify um deficits but to think about development how how can we put emphasis on these topics and help students all along rather than just identifying and punishing them when behaviors that are deemed unprofessional occur so accountability and conscientiousness you can see what falls under that interprofessional and team communication and commitment to personal growth and reflective practice so um this has been a pilot for the first year students was recently Incorporated with second year students and I I think the scale um is helpful that it um identifies novice so saying you know we we realize you're at the very beginning um practicing and then meeting those Milestones next slide so mention briefly professor professional identity um sort of intertwin with professionalism so when we look at um professional identity as it as how it's defined um this was one definition I found the integration of knowledge skills values and behaviors of a profession with one's pre-existing identity and values so as I said we all bring our world view um their generational differences in that and experience but now we're going to incorporate and integrate the knowledge skills values and behaviors to create our professional identity next slide professionalism and professional identity formation um in this article um about two years ago three theor theoretical perspectives on professional identity were discussed one is the individualist one is more centered on social and context and then the third is an integration of the individualist and the social contextual next slide so when we look at the professional identity the individualist uh much of that is focused on developing one's values goals and the teaching technique that used is writing uh and reflective uh narratives they often focus on events that were challenging to what we perceive as our identity and then understanding teasing out our reaction to those events so it may be complex or ambiguous circumstances in the clinical realm uh rights of Passage activities or hard conversations that um people tend to want to reflect on and have um narratives conversation next when we look at more the societal context that's um focused on one's professional identity formation through a social group or interactions with others so this might include how we interact on an interprofessional team um in the teaching of this students were partnered with patients to influence the patient centered and patient valued approach so to actually have small groups with patient to understand what it is that patients value and then incorporate that into one's professional identity communities a practice which will have their own professional and moral values and code of ethics influence this societal context next slide and then the one I think that's probably the most practical to most of us is this um taking both the individualist perspective and the societal context so this is an active process which uh incorporates as I said those two areas to make this third one and it does require or include reflective and narrative writing but what's interesting is now it's across a longitudinal experience so it's not just sort of a a a one time it's how do you process this built on um all of the interactions that are occurring within your learning environment next slide so um do you think professionalism and professional identity formation do you think that early Behavior makes a difference in um either one's um professionalism um breaches as a practicing physician or during the clinical years so if it's identified early could is there something to say that that's going to um play out in one's performance later what do you think is there evidence for this Rebecca I think it's interesting and I remember a study from a long time ago where um where they talked about I can't remember if it was during Medical School application I think it was more so during residency application and it tied um lapses and professionalism during that time so if there was a delay in um or you had to um sort of the coordinators had to nag the incoming residents um to get their uh social security number um in on time or their their their board scores or whatever it was they had they weren't getting things out in on time and they showed a correlation between those lapses and professionalism in actual um practice later on in life um I can't remember uh who that study was done by but I just it stood out in my mind that there was a a continued tie across the Continuum um for those behaviors right um I you know I had um I had heard this and then I had heard um maybe some comments that said it wasn't quite as as clear as was thought early on so I would I pulled a few articles specifically around this predicting behavior and so we'll we'll go over those next uh next slide um there's a a recent study in medical teacher by uh some folks at wake far far as that looked at preclinical indicators so behavior in years one and two does that predict professionalism breaches in the clerkship years and what they looked at um was negative peer assessments during the preclinical year so this was a retrospective study and in their longitudinal classes they ask peers to evaluate each other and I'll show this in the next slide but based on terminology adjective descriptors of their peers uh they found that that was a predictor so if your peer identified you with more negative than positive attributes that was definitely a predictor of professionalism issues in the clinical years the other was multiple unexcused absences so the next slide will show us um the breakdown of the descriptors so um on the left side of the slide are the positive descriptors and then on the right the negative and the instruction to the students of to give this to their peers um they had to be together in Long longitudinal setting they were um encouraged to be honest and that this would not um that it would be anonymous and it would not impact their peers grades they were instructed to select a minimum of three words but there was no maximum of words so if uh and they have a formula which I I won't go into the the full formula but if a certain number if if one had a predominance of negative assessments then that was a predictor for these preclinical students to have professionalism issues during the clerkship next slide and then another study looking at um professionalism and behavior was done by at UCSF a study that looked at over 6,000 of their graduates from 1943 to 1989 and then looking at State Medical Board issues that um were taken in a 10-year period um from 19 90 to 2000 and um they were able to identify 70 professionalism cases uh in this group so you can see it's it's a less than 1% of um graduates had these professionalism issues but the question was is there anything that was predictive among their students that um could have potentially could be identified earlier uh and looking at all of the board actions 95% of those were professionalism rather than cognitive kinds of issues and in this study students with unprofessional comments and evaluations during their time in medical school were two times as likely to be disciplined than those without such comments grades and standardized test scores did not predict disciplinary action next slide so um I wonder leave a little bit of time for us um I'm glad we've been talking going along but if there were some other specific questions that and comments that you had so the the way I pulled this together as far as conclusions are defining teaching and assessing professionalism has an extensive history we need to be aware of the Hidden curriculum and to intentionally roll model Excellence we can't say that we're teaching professionalism we expect you to to do this and then turn around and not exhibit those attributes teaching professionalism should incorporate content for the acquisition of knowledge and the development through practice and observation of skills and attitudes professionalism is Continuum not an on or off dichotomy and it should include development and set expectations rather than identify or punish a deficit uh next so we're to that point of um questions or comments and I I know a few have gone by in the chat that um I didn't quite catch Sher if you want to highlight any of those and and we um totally open to any other comments uh thoughts that you have let's see one comment it seems logical since our early behavior and experiences are significant in the development of our beliefs and implicit biases which seem to impact our professionalism yes that was a comment on your earlier comments um let's see next one is the Milestones you showed do not contain anything about ethical Behavior I realize that this is hard to measure but I don't think one can talk about professionalism without considering ethical aspects of the profession as for instance exemplified by the hypocritic oath the Milestones only get to the mechanics of communicating and other activities um say for the basic things such as attendance it may be possible to teach these ethical behaviors but hard or impossible to measure them the slide would with eductive choices concerning early behaviors and UCSF study end point of board disciplinary actions gets more to that point so that was more a comment I don't know if there's any um response necessary there then we have another one a question let me just pause on that just for a second um so um the Milestone is a um pilot of selected Milestones from um the acgme format I don't my um I would like for Dr Gonzalez there there he is I was looking at my little um Hollywood Squares board here um if you'd like to comment on that I I think it's a it's a beginning for us um Jad yeah I think you hit it I think thanks Dr scolnick for bringing that up this is a pilot of items to operationalize this I just want to give a nod to all the medical Educators who are on the call but out outside to actually pull this off was a probably one of the biggest initiatives that we done we've done in the past year and it was not easy to do all the way from the educators to the staff so thank you to everybody for doing that but professional behavior and ethical principles is professionalism one in the acj harmonized milestones we didn't start on the ethical one we did a pilot of a subset of items to see how it would go knowing that in the next year or two years do we expand let's let's learn the process primarily but the substance of your comment Paul I think at least I would agree I don't say everybody but I would agree with that as well probably harder to assess and then um the next comment I see is what are your thoughts on how to best reduce Observer Bias when evaluating students and practitioners and I think this um points to the importance of peer input um and there I was reading one study that talked a lot about near peer um and the students tended to respect um trust the the words of their near peers so those third or fourth years who are now going back to the first or second year saying um this is um How We Believe professional Behavior should look these are some of the skills this is the knowledge you should have so I think um including peers having near peers will get uh across some of that bias potentially if it's generational bias I think we just have we need to continually try to be um developing ourselves and and be aware of um what our biases are in in how to to um take those into account in evaluating others one thing I will say on the clerkship article the um even at if the professional Behavior were described by the faculty member they were reluctant to report it they were reluctant to have it go into the grade and there was very little communication across clerkships so if um one if a student were identified with a professional issue in one clerkship that clerkship director was unlikely and you know I think we all have opinions about this whether um because of wanting to give the student the best shot and not to have bias in Behavior but also Al to be aware of those with continued um professional um issues how how do we how do we address that so I think those were some interesting thoughts Rebecca I think that's a critical point because you know maybe maybe because of the positions I've hel held I see the bad outcomes if that kind of communication doesn't take place and sometimes we pass students on we pass trainees on we pass Junior faculty on when there when there are these warning signs and egregious behaviors so I I I I'm not quite sure how to um elicit that kind of communication but I think that's a really important Point lesle yeah was back to the sort of the concept of bias I think I'm Brock isn't on Brock Meson isn't on but what we often talk about these sorts of Assessments can be object subject effective and challenging to do and that's why making really clear what we've tried to do with the harmonized Milestone pilot is make really clear what sources of evidence we are using to assess each Milestone and then to do multiple of those assessments from a lot of different people so that you know you you do detect to what Paul was saying sort of these patterns these Aggregates of of behaviors that then allow you to to make sure that yeah there may be any any single data point may have some bias spaked in and that's just something we need to to work on and and address but when you in aggregate see sort of these patterns of behavior that's when it it becomes really clear that that we need to to be having discussions and then also sort of the faculty development to again to Paul's point where faculty are really reluctant to give this kind of feedback um and that's where I think a community coming together as faculty and recognizing this is something we want for all of our Learners and we all need to be giving what can be really challenging assessments to to them and we're all in it together and we've all got each other's backs as as we give this feedback um knowing that it's supposed to be constructive and moving us forward rather than um you're sort of standing you're the only one giving the student this Fe that can be a really hard position to be in I think another piece um that we might not have emphasized too much so far is that engagement of Learners in creating the expectation so that it's not just being driven at them that this is what you have to do and that's one reason I put the little piece about student organizations to have a a broader stronger voice potentially so that these expectations are also what they expect of themselves um and their peers yeah I really like the way we at our school um we involve our Learners in all aspects of developing a variety of things so have those different voices from different perspectives um to help us to form um the way we move forward our policies um also uh I I think to to Leslie's point we often um when trying to provide feedback or or assessments I think we sometimes give a little bit too much of the benefit of the doubt and say oh they must have been just having a bad day or I'm not going to report that but if you if you don't report isolated incidents is it's very difficult to see that full picture the the full constellation um so I think anytime you can uh give your part it pro um of the puzzle it really U pulls things together in a lot more cohesive manner other thoughts comments yeah I have a question I'm Doug alhouse can you hear me yes we can yeah have we benchmarking our medical school to other medical schools do we have a professionalism problem do we feel related to other medical schools what's the Thought on that um I you know I I'm not sure how we would um be able to quantitate that I mean we do have data on end of year surveys um about do do students feel that the environment facilitated their growth as an individual and our numbers are above the national average on those so if we look at that I you know I think we can feel good about things um I I do know that um we can always be better so I'm I'm not in in their um I think there to me one of the takeaways would be the the emphasis on on peer engagement growth development looping that back around as part of the feedback Circle rather than it being strictly from um attending faculty that they receive this I think it legitimizes it for it to come from peers so I don't think we have a particular problem I uh think we can always make our learning environment um more of a collaborative effort and engaged uh Learners I've got another question too if if we identify say a student that has professionalism problems do we ever do a look back at their application go back to the admissions committee look at their application and see what what were the red flags that might have been there and how can we maybe avoid this in the future I think it is a conversation with the admissions folks um and I don't you know when I've asked that question in the past there there wasn't an answer that was able to say clearly that um there are red flags and and here they are um because if you know that um special ingredient to know that would be something that every admissions committee would would want to know um so I don't think there's been a specific maybe you know a trend here or there but but not an absolute definite of this was a red flag and it was missed you know I've not been part of the MMI process but one could see in that context creating a scenario or questions to get a handle on it because Doug I have I've had that thought also when some of these problems arise that is there something at the admissions level we could do but that I don't know others who know more about M MMI might want to C comment on that Rebecca can I make a comment on that um at my prior institution we did something like this we we got together a task force and we put together a definition of professionalism then we operationalized it by turning it into a ratings format and we piloted it and eventually started using it across the board and we used the same ratings format for people who came to be interviewed for admission to medical school that we subsequently used in the curriculum and so we did a little study where we looked at two years worth of data and we started by looking at the ratings of professionalism among third-year clerkship students and we went back and found that 20% of those students had been red flagged for concerns about professionalism when they were in the admissions interview process I I think that was pretty surprising that that you could actually Identify some folks as part of the admissions process that might be at risk for some professionalism issues later so I don't know if something like that's doable here if our admissions team would find that to be something that they could do but I thought it was an interesting finding well the the more data that we can have the the better will our answer be in the end I think thank you other comments I think we're kind of closing in on the the end of the hour I I do want to comment Rebecca if I can on Doug's first question we did strategic planning I I see Don here Don was part of that those task forces as well we had five task forces I think we would have predicted four of them we had 175 people from the community identifying the strengths of the school and areas for improvement or growth assessments phase one phase three curriculum we expected those but the one that I didn't expect was professional identity and conscientious behaviors of our students that came from the community of 175 Community members in our community saying hey we need to be doing better at this so I although we don't I agree with Rebecca's response we don't have the quantitative numbers for different schools and I think this is a higher education challenge that there are some trends if we were to generalize but internally our community was identifying it as an area for growth to the point where it became a strategic planning task force and now it culminated in the pomy course so I'm just taking the big picture of you on what what all of you had been seeing in some of the harmonized Milestones of pomy course for example that are manifesting in changes to the curriculum this community survey specify any particular Pro problematic behaviors they noted I mean I wonder why they came conclusion what was the last part of that Doug I'm sorry I didn't understand the last part yeah I'm trying to think okay Le let's elaborate on that if they felt like they were professional identity problems community members professional people and outside of medicine let's say in the community what what were their particular concerns were they specific or yeah and I'm happy to talk offline if you'd like Doug when I say Community I mean all of us on this call our clerkship directors our faculty PhD mddo nurse social worker involved in the process about raising the bar of Excellence when it comes to professionalism everything Rebecca just talked about that there was a Delta that hey we need to be focusing more on that onor yeah go Doug yeah the only thing I wasn't sure what you meant by Community but I see you're talking about the vtcsom community okay I I understand okay sorry Doug okay all right I guess we're at the end of the hour thank you for your attention and your participation thank you everybody have a wonderful rest of the day.