Helping Learners to Develop Professional Identity

Well thank you so much Mariah and welcome everyone uh on behalf of Dr dallas and myself I really want to express our appreciation for your attendance today and for the opportunity to uh share some thoughts with you about the topic of uh learners and development of professional identity um we would invite you to participate we have about 40 slides which we'll zip through probably in 40 minutes or so if we stick on the one minute per slide target we've set for ourselves we do want to invite your participation through questions or comments if you want to make a comment you can either type it in the chat or if you feel so inclined while please unmute yourself and just uh ask your question at any time we want this to be as as interactive as is possible in using a Zoom format so with that we'll hop right in here paul and I are going to tag team it so we'll be passing it back and forth and would invite your participation as you feel so inclined so here's our objectives for today we want to talk a little bit about the concept of what is now known as professional identity formation and explain a little bit about why this is highly relevant to both the education process for physicians as well as ongoing practice we want to talk a bit about the stages and influence and how this is developed the professional identity of a given learner how it is developed over time look at some factors both internal and external that might shape one's professional identity and finally attempt to apply this concept to some real life scenarios or clinical dilemmas so that's where we hope to go today uh this is an uh ambitious object objective set of objectives but we'll do our best to hit the target on each one of them and we have nothing to disclose this is this is a favorite way I like to disclose the fact that um we don't have any conflicts of interest related to this presentation and in fact I often say being a medical educator I wish I could could eventually have one of those but funding is scarce for this sort of thing so that being the case we have no relevant conflicts of interest to declare today all um so you know there's there's the issue of professionalism and the issue of professional identity formation uh professional you know what is what is a what is a doctor what is a professional how do you develop being a professional first of all and then how do you have it um well Henry David Thorough if you guys ever remember reading him when he lived at Walden for a couple years and wrote a book called Walden um reminds us that um in his preface he says I shouldn't use the word I so much and talk about me so much if there was anyone else I knew better well we use a lot of examples and there'll be a lot of eyes here when I and so forth um because we've you know uh we've seen medicine we've seen medical school we've seen students and residents and faculty and I wanted to share two instances with you that you know hearkens on professionalism one uh you you cannot um ever underestimate a mother's wisdom and I can remember when I was in residency a long time ago um I was um at home and I was doing some yard work and I was dressed in raggedy clothes and uh And I had a a hat on and slathered in in sunscreen and the hat was dirty from you know years of not being clean and so I had to go to Lowe's to buy something and she stops me she says "Where are you going looking like that you can't go out there you're a doctor somebody will see you." So there's an expectation uh that you look like a doctor right we'll talk a little more about that later she's very much very very wise and professionalist and just the other day a a good friend of mine um shared with me that a patient of his uh after he had examined him talked to him examined him and so forth sat down in his office finally this is a person who had been a a patient in Korea for a long time a person a real doctor he says so there are explicit and implicit um uh expectations of what a what a doctor looks like this is one of my favorite paintings here the the doctor from 1871 here's a professional looking doctor i guess we can all agree to that and unfortunately he's sitting at the bedside late at night um you know beside a child whose uh little hands and body were weakened by disease the mother if you can see it it shows up on your screen is in the back with her head you know her head weighed down with angst and and grief and then the then the father um in the background standing stoically this if I sit long enough with this picture it makes me a little bit tearful uh but we we have expectations of professionalism and how and how you identify that and how you become that is is a big question uh for us here uh today david um so a lot of has been written since the since the uh 70s 80 mostly 80s and 90s uh and we'll borrow um you know quite heavily from the scholar scholarly work of uh Cruz and Cruz from McGill uh this husband and wife team were um prominent figures in medical education particularly for uh professionalism um and they did they published their seminar work in 20 2018 next so uh defining our terms um professionalism versus uh professional identity uh formation which you know we may not have heard that uh term uh before next uh professionalism is a set of values right it's uh it's how we behave it's our relationships it's what makes us trustworthy uh to the public uh as doctors this is what the Royal College of Physicians uh published in in 2005 and it it's the framework it's a larger context for discussing how we identify ourselves as professionals how we um define or form a professional identity um so prof in in um there by the 70s 80s and and 90s we saw a lot of discussion about this you know back in in those day in in the 90s especially you saw the American College of Physicians and other organizations uh put out uh scholarly work and and white papers and and books even old books on the fundamentals of professionalism and actually in in uh 2002 the American Board of Internal Medicine the and the American College of Physicians the ACP the AM and the ACP um discussed three fundamental principles professionalism patient welfare welfare autonomy and social justice and want to remember these words because we'll come back to talk a little bit about them with through examples actually so patient welfare we need to be competent okay we can't uh practice medicine without being competent it's part of being a professional we need to be honest no one's going to say no be dishonest um I'm I'm I'm chuckling because we we'll talk about a case where that was that was the case um uh maintain confidentiality um patient autonomy we'll come back and discuss that a little bit uh social justice um what what are our professional responsibilities to society um how do how do we maintain trust uh you know how do we keep up with the new scientific knowledge so moving on as I mentioned a little little history 80s and 90s because the thought was we weren't being professional enough there were some threats uh the charter we we just uh mentioned and led to an examination of u how we transmit these values uh from one generation to another when I first started working here um back in the early 90s well 91 January the 2nd 91 to be exact um it struck me that I had to write things down for my residents uh on the warts this do this for pre-rounding do this for uh uh for attending rounds do this for whatever work rounds and because I thought why doesn't everybody know this how did this how did it get to me but it didn't get to them um so these values that uh that may or may not have been I don't want to use the word cast aside but may have been uh somewhat um colored differently uh are embodied in in their word professionalism um we haven't taught it explicitly uh it's been transmitted by role models like I said I I found that I had to actually teach it explicitly i'm in the process of just this morning writing down how our residents should respond to their patients uh for labs because I realized they weren't responding in the way that I I always thought it was the correct way to to do it um and the thought was that role models alone were no longer effective maybe it's because we don't see role models anymore they come they come in for a second then we uh we we watch them on uh you know on YouTube or or something like that um I I I heard of a medical school recently who uses YouTube uh to teach physical diagnosis it killed me i love physical diagnosis i had to take the knife out of my back um you know that we were now teaching physical diagnosis in medical schools uh through um uh YouTube um we can talk about that more later because that's something I I would love to get off my chest next so I think this is me the next couple so the result of of this history so far seemed to be that um uh late 90s early 2000s that we kind of reached a consensus that we could no longer depend solely on role modeling or uh more passive forms of teaching that in fact we needed to be more explicit about teaching the concept of professionalism to our learners our medical students our residents fellows uh even early faculty sometimes so one of the results was this of this was the development of curricula throughout the continuum of medical education that included both content knowledge and uh methods of instruction as well as assessment and so when you put together a curriculum obviously you have to have a cognitive base for that which meant that uh different specialties and different organizations defined professionalism what it meant to their particular discipline their specialty and also talked a bit about how medicine should relate to society which goes back to what Dr dallas just mentioned uh the so-called social contract between medicine and how how medicine relates to the public and and how medicine addresses the public's expectations of medicine and all of this was brand new this was not something that had been really talked about all that much but it really became a an item during this period of time and I think that the assumption underlying a lot of that was that if we led our learners to have a greater understanding of professionalism that this would result in them behaving more in a more professional manner and of course the jury still out on that in some cases I think and often often it's true and maybe sometimes it's not so true simply understanding something does not necessarily uh lead to a change in behavior but nevertheless this emphasis on teaching and promoting and assessing professional behaviors really move the emphasis to to doing professionalism how do you do that and how does that work itself out in terms of what a physician does every day during practice and then finally in this regard all of the major accrediting bodies that you see listed there for the medical school education residency education on into the American board of medical specialties and even in other countries the accrediting standards began to uh reflect this requirement that u various programs had to develop their definitions of professionalism and then demonstrate how they were teaching their learners and assessing them on their professionalism which espec especially the assessment part is is not easy to do back to you Paul we we talked about how this you know um added emphasis or increased emphasis in the in the past uh 20 to 30 years but it goes back more longer than that okay um you you know about the alpha omega alpha honor society it's an honor society for the uh for medical students it was actually started in 1902 by this fellow uh William Webster Rupless a number of other medical students in Chicago and the reason they felt that they had to start this because they looked at their classmates and they they said this he said this honesty was conspicuously absent and behavior in the halls and classrooms was rough and borish uh that's an amazing condemnation of the status of medical students of the state rather of medical students and medical education and I want to concentrate on that word honesty because remember the charter talked about honesty uh well that was very key um and they also def wanted to uh make sure that people were professional that they were leaders that they were scholars that they were involved in research and community service you know we we think community service is a recent thing you know We we want to do community service because you know uh for the for the good of the community but also because Dr music wants us to do it for advancement uh so but it's old right it's old and and people uh people saw that there was a need for for for uh personal and professional honor and and dignity and integrity what what alpha omega alpha actually means is right there in the Greek axion and for those of you who read Greek I apologize for not including the correct uh uh breathing uh and accentu signs there because I couldn't get my computer to write them but it actually means worthy and and it's translated be worthy to serve the suffering uh in the alpha omega alpha website but it actually means worthy not be worthy you are worthy uh be are you are worthy to actually better the situation of to to advance the situation to to improve the situation alundas awas uh and arundas is different it means pain as an algae right neuralgia arthria and it's different than odinia like a gyophasia whatever odenia is specifically painus has a spiritual component to it it's a spiritual component so imagine if you put that all together what they were looking for in a in a in a physician um you know it's much more than what we we anticipate the physicians today um as professionals nice and it goes even further than back than that right the hypocratic oath there were there were doctors all over the place there were barbers right people who cut and you didn't want people to cut they would shouldn't have been doctors they were something else um so this idea of professionalism actually goes back 2,500 years what it is to be a professional what it is to be part of this profession what what it is that your identity should be like in this uh profession and it started off with an oath right i swear I swear by the Apollo God and Hyia and all the uh the uh appropriate health related gods of the of the time um and I want to call your attention these are the the standards for it you can read through those and and and return to them if you like but professional conduct the third the fourth one down expectations for professional behavior for honesty integrity respect for colleagues and the medical profession respect in such a a profound way that you respect the person who taught you this profession and are dedicated to passing along those skills to their sons and this is what they say at that time is with sons um with younger generations of doctors and fostering that community and that continuity of medical practice and duty to teach i I discovered this profoundly when I first came to Ronok and I was trying to get our residents to go to certain locations and I had a attending tell me I'm not interested in in teaching at all and I thought how can you not it struck me as as odd how can you not be interested in in you know passing along the knowledge that someone else uh gave to you the sense of responsibility for the next generation great so I think I have the next few and so all this leads us then to to look a bit at the literature and say well what what do our current colleagues what do our our more recent colleagues have to say about this notion of professional identity in medicine our comments have focused mostly on the concept of professionalism more broadly but now we want to make a little bit of a a pivot to this more specific and and recent interest about um professional identity formation exactly what does that mean well here's a couple of definitions from the more recent literature both in about 10 years ago dr uh Heidi Wald at Arkansas I believe uh talks about this being the development of professional values moral principles actions and aspirations and ongoing self-reflection on the identity of the individual and then also in that same year cross Al said the extent professional identity really means the extent to which an individual feels like a member of the profession of which they intend to become a part so do they feel like a physician that's actually quite important and we'll come back to that a little bit more recently um the authors that that we've uh depended on quite a bit Cruz and Cruz along with some colleagues uh said that professional identity is really a representation of self achieved in stages over time during which the characteristics values and norms of the medical profession are internalized resulting in a person thinking acting and feeling like a physician i think this is for my money the best definition that I've run across in the literature i think it covers everything because it talks about uh the person's uh being achieving this identity over time during stages and gradually internalizing the values and norms of the medical profession so we often ask our students you know do you feel like a physician i know I've done some coaching with students recently and it's part of a new program here and uh we talked about this a little bit at what point in time do you feel like a physician i'm working with first year students and they almost always tell me no not yet but it's coming you know they're starting to to assimilate some of the values and the characteristics of a physician already the medical school has actually paid quite a bit of attention to this in the last couple years as part of our recent efforts to revise the curriculum and I want to call out particularly Dr jed Gonzalo our senior associate dean for medical education who has worked on this along with Dr lesie Lante and some other colleagues um and this is currently on our web page there's a link there you can go visit and learn a lot more about this if you'd like we've always talked about uh some of these things but I like the way that this new identity has been put together you see at the middle in the middle part there you see we hope to graduate people who are patient centered physicians and what does it take to get there we hope that they will be lifelong master adaptive learners as well as system citizens and scientist physicians so this is our school's most recent attempt to spell out what we think it means when we're trying to have our students adopt this um professional identity and I won't bother to go over this in great detail but if you go to that web page or other web pages um you'll find that we have paid a lot of attention to the general area of professionalism with one of our competency domains as well as a number of objectives there accountability and self-awareness and seeking help and all of these things are grounded firmly in the literature that we've very lightly reviewed just in the last few minutes talking about professionalism and how that has to work its way into a person's professional identity also the accrediting body for the residency and fellowship uh training world the ACGME has also put together what they call their six general compet competencies if you're a physician uh with us today I'm sure you've heard this before and one of those six general competencies is spelled out there again talking about professionalism and how part of one's identity as a physician means that you will demonstrate some of these types of characteristics shown here so again our friends Cruz and Cruz put together this nice graphic which I think combines a lot of these things into one uh picture if you will and they talk a lot about the physician as both the healer as well as the professional so you see the aspects of both of those things here and then when you put them together you have these things that overlap between the two i just like the way that they u put this out in a very nice graphic that's pretty easy to follow so professional identity formation is really a lifelong process um it's something that takes time and it requires us to think about it over a long period of time I think with our learners and on into residency training and practice so I guess the person could say you know looking at this scale if over here to the left you're a lay person and all the way over to the right you're a physician a fullyfledged practicing physician it's it's uh interesting to ask our learners where are you on this on this journey of 1 to 10 where are you on this scale and we ask a couple of rhetorical questions here that we'd probably like to hear from you on if we have time are we equipped to teach these topics and how do we create significant learning experiences where we can teach these topics and involve our students in some uh direct learning experiences that touch on this idea of developing their professional identity which uh leads us to you know this question you know it's clear from the cruises and uh from Ruth and from uh hypocrates that we need a professional identity we have to have a professional identity in this profession as professionals um but how can we address the need for learners uh to develop that professionally they they they're clearly not professionals you know on that scale uh they're they're a lay person they're one and then at some point they become a physician gradually and then they're they're it so when when the it's like uh there's an old story of of someone asking about when when he he was going to change something happened in his life and a wise hermit said come up with come up with me to the rooftop at 12:00 at night and he sat there and didn't say anything the wise person didn't say anything uh to the learner and next thing you know it was about 8 9 in the morning it was light he says when did we sit up here uh in the dark uh now now we're here in the light he says when did it actually become day you know so there's that gradual time when it became day one was clearly dark one was clearly light when it became day was a a significant question so it's a goal right that we have to to teach uh professional identity formation there's a shift from faculty teaching uh in which uh the learner learns passively perhaps uh to learners being actively engaged uh in developing their own professional identity with support from peers and faculty that's what Cruz and crew said um you know we have to dissect every every word that's very important because we're asking learners or people who are developing uh to develop in their own way well how do they know how to develop it's kind of an interesting uh an interesting question but it is a goal that we have to to have for ourselves next week so what are what are influences on on professional identity personal experiences uh probably from you know potty training all the way to medical school and residency i think it all it all fits in there about how we become uh professionals um Dave and I were talking about this the other day um if you ask physicians when uh in their 50s if they feel burned out 50% of them feel they've burned out if you ask third-year medical residents are they they feel burned out 50% of them feel they're burned out and I'm you know being a little loose with the numbers um interns how many of them feel burned out 50% well okay you can understand the the person who's been practicing for 20 years how they might feel burnt out and maybe you can understand why the why the intern feels burnt out because they're working very hard he has students third-year students 50% of them feel like they're burned out and then same thing with first year students that have practiced no medicine and I told David I said "David I think we're just picking the wrong people you know to be doctors we're picking people who are likely to be burned out you know it's a personality that we're shooting for and maybe it comes with a certain type of a desire to be successful um so a formal curriculum certainly can uh influence our professional identity we need to be careful of the hidden curriculum and the role model um because you may be role modeling correctly you may be role modeling incorrectly uh and that plays a big uh a big part of how u professional identity is influenced uh what about your uh what about your your mentors um students and residents were asked about what they wanted in a mentor in one in one study um and if you ask uh interns what they wanted in a mentor what they want attending they want an attending who can teach them how to do things if you ask the uh the residents they want an attending who has the encyclopedic knowledge i want to go to Dr so and so and he's going to tell me everything I need to know about X but if you ask students what they want in an attending it's a person who teaches them how to be a doctor um so this mentorship concept is very very important uh what about peer relationships right one may one may ask the question if it's the the blind leading the blind uh in peer relationships in this in as far as professional identity but in one study you know 65% of what a a resident learns it's because they learn from another resident not from an attending and let need to let that sink in for a for a second what about organizational culture you you we we change our culture because of whatever we're told to change our our culture for um but they're little micro cultures and then there's a big macro culture we want to impart to our our learners as professionals um some learners uh have a great deal of self-doubt i don't know if I can be that and that influence I can be that doctor um had one one resident tell me one time um uh I it was in the clinic about 30 years ago 30 years ago now and and the resident says I mean a student says uh uh I love my internal medicine rotation um but I don't think I want to learn medicine that well so I'm going to become I'm going to go into family medicine let that sink in for a little bit i want to be a good doctor but I don't want to be as good a doctor as it takes to be like this i want to be less than that uh and then also whatever happens in moral distress or ethical um uh dile dilemmas that may happen during your during your career next um so we t remember community uh we talked about that already with with root and with um and with hypocrates as well um so what are the expectations that our community has we we belong to various communities physicians do professionals do uh medicine in its in its broadest sense our subsp specialties are the health system that we work in uh the internal medicine department versus the surgery department are we educators primarily or researchers primarily uh and the residents and fellows and the students are they they need to join this and which you've heard the word internalizing and once again we quote put it in quotation because you you internalize these concepts uh and what the values are and what the uh norms are for this particular community um but they need to be made clear um and and explicit so we all understand that that's exactly what we're we're looking for there next so when does it happen um Dr musk said it was a was a continuum and it certainly is it's hard to tell you can tell day you can tell night but when does it come in between uh happen that way we don't know um but sometime probably in premedical school to medical school is probably a critical uh time when uh when you're premed and you're in at the greatest university in the in the United States which by the way is the University of Virginia for those of you who are questioning i might have a second opinion on that one there you go i'm I was hoping somebody would give me some push back i think it's some Virginia Tech alumnist oh I forgot we were Virginia Tech okay sorry um and into and into medical school then you know how you transition from medical school to residency because there's that thing now I'm a doctor i got to act I got to act like like one um so you know this change this identity formation happening in stages i was reminded of a of a medical student had many years ago who was quite an arrogant uh young man i I love this guy um first and in first and second year you couldn't teach him uh much by fourth year he he spoke at the at the convocation at graduation and spoke you know so eloquently memorialized a a colleague of his and and I sat there and I was I was aed by by his eloquence and his clear thought and I thought to myself he's become a doctor he's become a doctor you know third year um maybe took took a little bit of the uh the edge off his arrogance um and he become a good a good doctor um so we develop it during residency and fellowship then we go into practice and we learn a little bit more sir William Oler said it takes 10 years after graduating medical school for a person to start to become a good physician 10 years i used to quote that to folks when I was younger uh I said I'm I haven't become a good physician yet because I haven't been out of residency um 10 years yet so it's lifelong for for certain uh it's self-directed uh but other other things direct us as well and we learn to uh to adapt next um what are some of the strategies that we can use to foster uh professional identity uh formation well um we'll hear uh it should be an educational objective if we find that it's missing then we should put it in our our curricula we see that we we talk about it and we have that at BTC um and perhaps we we need to make sure it's intertwined in in teaching on professional not not only the the global professionalism but the the subset of that which is uh professional identity formation um faculty need to learn this uh better faculty you know when we were pushing out the the portable ultrasound curriculum it was clear everybody wanted to learn this but we need to teach our faculty first before we taught anybody else and this community that we practice in needs to be supportive of this through various events and rituals and we'll talk about one of them uh here in a little bit next so what what are the challenges in teaching professionalism and teaching professional um um identity formation um so uh Maxine Pavadakis in in the New England Journal of Medicine in 2005 did this wonderful study they looked at un unprofessional behavior in students and then asked the question what happens to them later and in her study she showed there were that unprofessional behavior in medical students they were three times more likely to do so in practice as well and if they were defined as having a lack of responsibility either for their learning for their classwork for showing up on time or whatever the odds ratio was 8.5 well imagine that i mean that's that that puts a mark on them so maybe they did develop some of the things before maybe as like a like a tiger we know a tiger doesn't change their stripes it's they're deep uh there may be some challenges there because how do we change change something that may not be changed in some people or be maybe difficult to change some people um and what uh uh uh she was discovered also was that when they were told when the students were defined as being apathetic so there was apathy and poor initiative and it also correlated in a big way with multip disciplin multiple disciplinaries actions uh later we have a program called residents at risk in the internal medicine residency program and these are residents who um score below a certain u number on their inservice training exam and we know that it correlates with their ability to pass the boards uh one two three years uh down the road um and I can recall a resident that we had who was smart smart enough um but he had some of these concerns poor initiatives mapping and lack of responsibility and he was assigned to me in the residents at risk um and it was clear that he wasn't interested in getting any better uh and I remember saying at one of our meetings um he's going to be a problem uh he may not be a problem for us because we'll get him through this we will make sure that he passes his boards uh and and the prediction came to uh to be the following year he was kicked out of his fellowship program uh for the same behavior that he had while he was here and and that happens for residents but also happens for faculty if you look at the CME uh literature faculty that have been defined as difficult when you when you um put them through uh multi- faceted CME uh a multifaceted CME program to see if they uh improve uh few of them improve so the question is when it's ingrained uh is it too late for change is it too late for change i don't know the answer to that question but I but I pose it because we've seen examples of it so moving on you know is too late for change how do you are people going to change are people going to become professional are they going to develop an identity there's an article I used to share this is 1991 now i used to share back in the days when we used to pass out articles to to house officers i used to pass this one out on my ward months do house officers learn from their mistakes well there was a survey of 254 house officers only 114 completed well about half um and you know an anonymous survey about mistakes they made and these mistakes were significant they mistakes in in diagnosis or prescribing or evaluating or communicating or procedures and a serious outcomes in 90% these weren't subtle mistakes deaths in 31% of cases and they asked what was the difference those residents who accepted responsibility that's a professional uh you know uh element right um for mistakes and discuss their mistakes they were less likely uh to make any mistakes again and they more likely to report constructive changes but those residents that did not make constructive changes did did not do so because they attributed their mistake to job overload to I didn't get enough sleep um work too hard it's someone else's responsibility and if they if they felt like there was a judgmental atmosphere they were less likely to report changes one might one might wonder whether the judgmental atmosphere stemmed from them inward to outward or whether it stem from outward to to to them inward inward so uh we see why you can develop or how you can develop by actually taking some responsibility and maybe being able to uh to change and that's what we hope for next um so another study in 1994 I I quote this all the time to the to the residents and the students you know why do doctors get sued why do patients sue their doctors this is by Lancet in 1994 um and they say that they sue the doctors because they want to make sure there is a standard of care can't help my dad now but I want to make sure you guys uh follow standard of care honesty remember we talked about honesty in that in that charter yeah physicians still get sued for lack of honesty they want patients want explanations and communication um compensation was not was on the list of course but it wasn't as high on the list and not so much it need to be punitive uh compensation but it need to be uh cover costs um accountability there was one case which I was involved as a malpractice um witness a defense for the defense uh where the physician the surgeon who was responsible for the mistake during surgery um sat down talked with pay patients patients family patient passed away um and um took responsibility and held himself accountable uh and they didn't they didn't sue him they sued the hospital they sued the nurses uh they they you know they they sued the the janitor I don't know they sued everybody uh but they didn't sue the doctor who took accountability and what were some of the keys in another study uh for why patients sue their doctors he never talked to me one person said "He never examined me have we ever seen that before didn't put my hands didn't put his hands on me didn't present himself as a doctor." There's all kinds of professionalism stuck in that statement and one person said "I didn't like him from the first time i wanted to sue him from the first time I saw him i was waiting for an excuse which came five years later." So not only do they define what that doctor looks like as a professional but they also have in mind what they're going to do to them if they fall from that professional you know uh pinnacle next so what what is what is you know we finally a doctor uh you know uh I I put in there uh health doctors professional doctors and this is what the in the Google right because you you always got to access Google and this is what you you get now I I'll call your attention to the top uh row second from the right there's some people there that you might might recognize who come up in that uh in that search but what's what what is the the what is the u the common thing you see most of them are wearing white coats most of them are wearing stethoscopes uh no one is wearing a headlamp anymore there used to be a synron of physicians wearing a headlight we have pen lights now obviously whatnot and it's got to be the right stethoscope by the way it can't be the little chintzy ones that you got you got to have a nice cardiology to look like a like a real doctor so this what people expect and maybe we don't we changed their expectations of what doctors should look like next slide so the white coat right what happened to the white coat marcus Welby wore a white coat but house didn't wear a white coat one could argue if those of you have seen who watch TV uh which one you would like as your as your doctor uh one is phenomenal uh position but has a bunch of rough edges including an addiction and that's the one on the right and then Marcus of course is a perfect doctor so it's symbol right it's a symbol of um of professionalism when you enter into the profession you know you get a white coat right medical schools have it I was just at the um graduation ceremony for the doctors of physical therapy and they were doing their white coat um ceremony as well lot you know these white coat ceremonies a lot of aspirational a lot of inspirational words you know a lot of Latin occasionally some Greek for the really arerodite um and they put on the white coats and it always struck that the people who are wearing the white coats uh have wrinkled white coats and they're wrinkled in a fashion that says they've never been out of the box before you know when David and I were talking about doing this talk he says "Yeah we we can challenge him." He says "But some people might be triggered." I hope I'm triggering some people but you can tell me you can tell me later so what is this message that we're sending people expect a white coat and we're saying wear a white coat but we don't wear white uh white coats is it is it something we want as a legacy or is it or is it lip service i know it's a little palemical there but I'm happy to provide you with that uh that in Thank you Paul appreciate your your your comments and thoughts as always so again we thank you we kind of wrap up this section by thinking a little bit again about what are the strategies we can use to foster our learners to think more about their professional identity we've mentioned some of these already but guided reflective practices reflection is really one of the key tools I think in this area um we ask our learners to reflect on what they've learned at various points in the process and particularly related to different issues related to um professionalism or ethical concerns or things like that mentorship and coaching programs we've talked about as well as peer support and role modeling we also need to do I think a better job of addressing leadership training and and developing future leaders for particular roles within uh medicine and the health system and then finally to address well-being proactively we hear a lot about well-being today and Paul talked about that earlier uh but I think it's important to be out in front on that because it is a very serious issue uh for our clinical faculty so having said all that how in the world can we measure this idea of professional identity formation well I have to tell you there's not much out there about that uh there's a little bit but we tried our best to find uh some particular ways that we could suggest for further uh ex exploration on your part and so I think the first thing to say is that it is difficult to assess professionalism or identity formation at the level of the individual you know we do a lot of these type of ratings in the group setting so our curriculum here at the med school uses problem based learning quite a bit and I think if we had a PBL preceptor uh here with us they could probably agree that it's uh fairly uh easy to address how a group is doing but it's a little more difficult to address how each of the seven or eight students in a PBLO group is doing particularly on the area of professionalism so we have a lot of different ratings that we try to use in this regard mostly in the clinical setting in internal medicine they've had something called the mini clinical evaluation exercise for quite some time we have end of rotation evaluations we have uh 360deree ratings where people on the healthcare team can rate each other on various aspects of performance and that could include professionalism and then many schools are going to a portfolio-based approach where they ask you to compile over time a significant number of reflections and ratings and other assessments of how you think you're doing and how others think you're doing with regard to your professionalism here's a couple examples from the literature u this was a study from 2021 so just about four years ago and it asked learners to kind of self-reflect at various points u how they feel about being a physician so you can see the first question i feel like I'm a member of the medical profession uh number four I'm pleased to belong to the medical profession number seven I feel characteristics with other members of the medical profession so the idea here is you give them this and ask them to fill it out at various points in time and then you track it over time to see if it changes uh somewhat similar to that uh was a different study about 10 years ago that was based primarily on reflective exercises so students were asked to write about their uh insights about professionalism and self professional identity formation this involved both medical students as well as dental students and here's some of the questions that they were asked um what you know it it asks about how has your professional selfidentity changed over the past year thinking about particular courses what has had the greatest impact on your professional identity um and so forth so you can see here there are some ideas out in the literature of how one might do this a lot of is based on self-report or evaluation by an expert in the uh clinical setting which again can present some challenges so we don't have the answers in this regard for sure we're just throwing these out there as potential areas for for further exploration so much work to do from a scientific perspective of questionnaires or what have you and evaluating yes what about you know measuring by example because uh you know while while you know one thing is an anecdote you know many things many anecdotes are necessarily mean data but we sometimes think it does so I wanted to share with you a couple of experiences experience I've had um here as well as as well as from other institutions but um you know we talked about the word autonomy right in the charter and I was practicing this early on in my my career and I went to a lady intensive care unit she's 89 years old and she needed um a corateed arterectomy for corateed artery stenosis and I laid out all the information for her and she was looking at me with her eyes glazed over and I don't want to hear any of that you're my doctor you make the decision so we to be careful with autonomy so it doesn't you know move into abandonment you know so you know it's all about the autonomy and teaching it uh and ongoing self-reflection is so important we talked about before nipsis is the Greek word uh for being aware and if you're not aware that one patient who I didn't one day I didn't tell her that she needed to lose weight and she started crying i said "Why are you crying?" She says "Don't give up on me just don't give up on me you you you the first time you didn't tell me that I needed to work on my weight." Um responsibility we s we saw that personal responsibility um you know one of one of my residents one time said when I asked her about why she hadn't responded to her labs to her patient she goes "Are you not seeing the results?" Thought wow well I I know I'm seeing the results question is are are you developing that identity as a professional to see those results and not only personal responsibilities but professional responsibilities um a case once that I that I defended uh with as the defense witness where patient wasn't little but I mentioned this to the student the resident head just discussed um the timely results lab results I share with the patient patient didn't think he got the results in timely fashion and sued the doctor so role model we talked about good role models this was a a um a and and Chad if he's still on here may remember uh this but we often times bemoan the fact that when our residents are looking for internal medicine programs they're also applying to other programs and they don't necessarily tell us about that um and u so one of the program directors I don't know what institution she stood up and says I tell them to do that so in essence I tell them to be dishonest uh to apply to several programs and not tell anybody that they are uh and you can imagine if you're you're that role model um uh what you're what you're passing this is the h the hidden agenda which is brings us to the next uh slide you know what what is that hidden uh agenda um that you that that a program may have or an institution may have um so uh you know um recall one time um when we talk about value and balance in our in our profession we were doing a a budget uh and I'm I'm was off on Mondays and so the budget meeting was on Monday and I remember being asked to come in on Monday my day off i thought well you know I'm going to practice balance here i'm not going to come in but where where is the hidden agenda there what about July residents uh a secretary shared this with me at another institution where three people had gotten together she was an earshot of them and they said "Remind me to stay out of the hospital in June in July." And and I thought "Wow amazing." because you're responsible for teaching these these uh students but you don't think you taught them well enough whether it's you know uh knowledge or professionalism that you want to actually be taking care of them and you they want they want you want them not to be taking care of you um or another person that was shared with me where uh a student was not behaving appropriately and and they didn't give her the the uh guidance but said we couldn't wait for her to actually leave the service uh and I think there there many other examples that we potentially could share but we're coming to the end of our time here and David maybe we can end up with the questions sure so I hope this uh has at least uh stimulated some further thought um reflecting on our our presentation we've we've tried to summarize where we think the literature is on this concept um it's so new that we couldn't come to a whole lot of firm conclusions particularly about how the best way is to teach this we made some suggestions and also in the area of assessment which I think we just barely started to scratch the surface uh so hopefully this has been somewhat uh thoughtprovoking for you and you can continue to explore this on your own in support of the CME credit we have a couple of questions here that we want to ask you um and you can answer these um either uh uh verbally or or probably not just in your own in your own head but the first one says true or false both are true or false questions professional identity formation while not a static concept is nonetheless fully formed by the time a physician finishes residency training true or false and then the second one says "Some retrospective studies show that unprofessional behavior by medical students can be predictive of future disciplinary actions involved with practicing physicians." That was something Dr dallas talked about so here's the answer the first one is false we we tried to stress that this is a concept that doesn't uh finish when one is not complete when one finishes the residency training but rather continues on into practice and then um the other statement is true that Dr dallas talked about the papadoca studies how um unprofessional behavior can indeed be predictive of future disciplinary actions we'll end with a little bit of a humor here i like these despair.com slides if you ever seen some of these and uh this is an example of of what I would say anti-professionalism or or not not really grasping the concept of professionalism somebody just painted around the the tree trunk there so at any rate that's all we have i'm sorry we we didn't leave as much time for questions but we we do have some time and morale i'll pitch it back over to you for for the last few minutes yeah fantastic thank you guys so much i think you gave everyone a lot to think about um a question in the chat why do students and residents want to be called by their first name and not Dr jones that's an interesting uh question i I when Dave and I were talking about this the other day I recall being in medical school we were all referred to as doctors uh the attendees were referred to us as doctors we weren't a doctor and then there was this move to being called student doctors they were called student doctors uh this is student Dr dallas this a student doctor whatever um and um why they why is it the students that are preferring to be called by their their first names or the residents or is it the the the programs that are doing that uh for for them i don't know the answer uh to that to that question okay let let me jump in here Dr allison say "I ask that question because I teach your uh first year medical residents one day in my free clinic." They always say "I'm Joe." And they and I say "Well what's your last name?" I say "In in my clinic you have to be go by Dr jones or whatever." Because the patient needs to know that who you are i mean we have so many volunteers we have so many students uh variety of people who see my patients i want them my patients to know uh who is the doctor but they I agree with you they they kind of push back on that i think where have they learned this um anyway I felt like a doctor the first day I got into medical school i was so excited and maybe we're picking the wrong students if they're not excited to do this if they're going to burn out really burn out that's craziness why would anybody burn out they just need more sleep maybe but I think if they burn out in the first in medical school maybe we picked the wrong people that's Sorry I just had to say that because you said Yeah this is one of those Yeah this is one of those topics that I think requires Dr harrington's uh input as a psych as a psychiatrist because it has a lot to do with uh with you know your psyche and people with the wrong psyche dr henderson did you have something to add oh must have been an accidental unmute i was going to say in in the clinic where I go I occasionally encounter a medical student and and they they are still introduced at least sometimes as student Dr jones or student Dr thomas or whatever it might be so that phrase is still around and I always appreciate that i I can't I'm getting to the age now where I can't always tell the residents from the medical students so good for somebody to tell me i think it is important for all of the residents to uh be referred to that way actually um one thing that um Dr dallas kind of alluded to that I find more uh you know in the the 15 years roughly since I graduated is that the residents aren't always given the opportunity to quote unquote get their doctor on they're actually asked to sort of defer to higher levels um you know you got to ask the fellow oh no the fellow's got to ask the attendant and you know pretty soon what happens if you train in that kind of environment is that you don't internalize that professional identity that I am the doctor um so everybody gets called student doctor uh in third year because I want them to get used to it and I can understand why they might say you know you can call me John there's another good reason um which is that if everybody is referred to by their surname there can be no question that I called Sally Sally um because she's a woman and I called Dr jones who happens to be a man uh Dr jones so it it really avoids some of the pitfalls that I might run into um as a as a physician with learners um and so I think that's just an important concept everybody should be referred to by their surname uh it helps them to get their doctor on helps them to I think take in that professionalism there's one other piece that they also I just think Dr dallas have been taught a little bit more that having worked in urban populations before I came here um versus more rural populations I think that patient said you do what you want doc I trust you that kind of uh paternalistic trust I often don't see in other populations so I think that if we have to be cognizant of kind of a a middle road um it's you know because if you don't give people the options in front of them they'll say that you were a paternalistic jerk uh somebody will uh you're never going to find that that that person that sort of deferred to authority and said "Do whatever you think is right Dallas." um is is mad at you for saying "Okay well if I was treating you like my mom this is what I'm doing." That's a Yeah I had a a colleague uh who was doing a um physical history and physical for a retired four-star general and he was a little bit um scared of the retired fourstar general who was also physician and didn't do the rectal exam so uh Greg goes back to the on call room he gets a call from the program director who had gotten a call from the fourstar general and said "Your resident did a poor evaluation he neglected to do the rectal exam." Uh he wasn't professional enough and I thought it was amazing because he did he he recognized the fact that there is things that physicians need to do and yes I I agree with you we we don't we don't necessarily we're not necessarily practicing the same medicine with every patient as far as how we come across a good position as a co as a coach if your player is playing well you you may just give them tips if your player is not playing well you you you maybe because they don't have the ability and so you need to know you need to know that so you need to know who your patient is so you can provide them with the care that they actually need at that time and not to cut you guys off but we are over the hour so if folks need to leave um thank you so much for joining us um and we appreciate your time but there is another question in the chat if Dr musk and Dr dallas have a minute to to respond to the last one fantastic um from Dr atkins how do the values demonstrated by our health care organizations surrounding medicine as a business or product productivity- based employment models sculpt the professional identity of physicians and learners david Well I I u boy that is that is quite a question and it probably deserves a seminar of its own frell just to be honest with you I think it has a profound impact personally now I can't say that from experience because I'm not a clinician so I don't work in that in that context and Paul you certainly can comment on that but I think it has a uh over time I think we've seen a shift maybe a subtle shift from medicine as a profession to more of medicine as a business so I I'll give you one out of many concrete examples i was sharing this with Paul last week when we were talking about this the use of the term provider is a very businessoriented term i do not like that term i have tried my best to eliminate it from my vocabulary because I know many many clinician friends who do not like that term they are not a provider of a service they are a professional rendering a service and there's a huge difference between the two so I I think it's had a profound impact and I don't think it's necessarily always been bad but I think some of it has been somewhat negative paul what do you think well I I I agree with you um I I think the majority has been negative the the other day you had a resident who um um lady came in with duria okay and so the urine was negative so it meant that she had to do a pelvic exam uh and that's what has to happen okay that's that's uh you know we got to look for things that you can only find there and of course very conscientious resident and she was like so busy she was like I don't have time to do a pelvic exam in this in this patient i remember feeling that as a resident too you know where I had to get finished uh I had to uh see all these you know 17 patients in this walk-in clinic or whatever um and so this productivity and this through throughput uh pushed her into almost not making the right decision turns out uh she ended up having a sexually transmitted disease which would not have been figured out unless she had that path smear um so yeah I think I think it has been negative and and you know and also I've seen this concept well insurance ain't going to cover that um so and so ain't going to care if I if I put in this special uh time so So why do it i'm not saying that's correct i'm just saying I've I've heard that i've seen that in national discussions have discussed that with you know American College of Physicians and other places so awesome thank you all again for for giving extra time to us today we really appreciate it um the CME link was shared in the chat so please use that to get CM credit or just to give us feedback on the session and Dr musk and Dr dallas thank you so much um for leading us in this discussion today we really appreciate your time pleasure have a