Association of Pediatric Program Directors. The Little Organization that Could and The Seventh Competency

Transcription

1 Association of Pediatric Program Directors A P P D The Little Organization that Could and The Seventh Competency Presidential Address March 29 th, 2012 Ann E. Burke, MD

2 There Really isn t a Recognized Seventh Competency The Pediatrics Milestone s Working Group likes to call it the Seventh Competency ACGME: There cannot be seven competencies

3 Challenges 1. Lack of clarity and focus on professional values 2. Failure to assess, acknowledge and advance professional behaviors 3. Inadequate expectations for progressively higher levels of professional commitment 4. Erosion of professional values because of pace and commercial nature of health care Cooke M, Irby DM, O Brien BC Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco, CA. Jossey-Bass; 2010.

4 Residency Training Climate Forces Impacting Training: Resident activities are increasingly nonclinical 36% clinical care 15% organized teaching activities 35% tasks that are not educational Boex JR et al. Acad Med 2003; 78: Pediatric Residents spend only 14% of their time directly with patients and families Gabow PA, Leahy PJ. Acad Med 2006; 81(8):

5 Residency Training Climate Forces Impacting Training: Insufficient funds: GME dollars and stipends are out-dated Expanding information technology: Information overload with unintended consequences on learning and tasks Bush RW, Philibert I. Making Sense: Duty Hours, Work Flow, and Waste in Graduate Medical Education. JGME :322.

6 The Fishbowl When I go into the fishbowl to talk with the residents, I usually find them with their backs to me placing orders and notes into EPIC or frantically typing discharge summaries. They do not spend enough time getting to know their patients. *An Attending Pediatrician

7 The Uphill Battle ACGME with unprecedented rate of change over the last 3 years Duty Hours Generational Issues Technology Issues More Change

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9 Professional Formation Squeamish about addressing the aspirational dimension of medicine Inculcating a desire to be: Compassionate Altruistic Humane Cooke M, Irby DM, O Brien BC Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco, CA. Jossey-Bass; 2010.

10 Professional Formation Compassion Altruism Humanism

11 Professional Formation? Ongoing, self reflective process Habits of thinking, feeling and acting Demonstrate: Compassionate, communicative and socially responsible physicianhood Wear D, Castellani B. The development of professionalism: curriculum matters. Acad Med , 6: 602

12 Professional Formation? The physician we envision has, first and foremost, a deep sense of commitment and responsibility to patients, colleagues, institutions, society, and self and an unfailing aspiration to perform better and achieve more. Cooke M, Irby DM, O Brien BC Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco, CA. Jossey-Bass; 2010.

13 Albert Schweitzer

14 Milestones Project Feedback: APPD Annual Spring Meeting 2009 What do you want to see made more explicit in the about ACGME competencies that would assist your learners?

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16 Milestones Feedback from APPD Humanism and humanistic qualities Emotional intelligence Empathy Maturity Ownership of patients/accountability Self Care Compassion Trustworthiness

17 Milestones Feedback from APPD Humanism and humanistic qualities Emotional intelligence Empathy Maturity Ownership of patients/accountability Self Care Compassion Trustworthiness NO NEW COMPETENCIES!!!

18 Professional Formation Humanism Compassion Altruism

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21 Professional Formation HUMANISM

22 Humanism? A way of being Humanism provides the passion that animates authentic professionalism Cohen JJ. Linking professionalism to humanism: What it means, why it matters. Acad Med. 2007;82:

23 Humanism? The accordance of deep respect to humans individually and to humanity collectively, and concern for their general welfare and flourishing Goldberg JL. Humanism of professionalism? The White coat ceremony and medical education. Acad Med. 2008;83:

24 Humanism?

25 Humanism? The camera is an instrument that teaches people how to see without a camera. Dorothea Lange

26 Altruism? The cornerstone of the Hippocratic Oath, yet it remains intangible and opaque Motivation for helping behaviors Other-directed Involves a range of prosocial behaviors EMPATHY Burks DJ, Kobius AM. The legacy of altruism in health care: the promotion of empathy, prosociality and humanism. Med Ed 2012;46:

27 The Doctor by Sir Samuel Luke Fildes, R. A. ( ). 1891

28 Altruism and Empathy Predominantly cognitive attribute that involves understanding of patient s experiences, concerns, perspectives combined with a capacity to communicate this understanding and an intention to help Empathy erodes during medical school Hojat M. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med 2009; 84:1182 Decreases in empathy during residency Neumann M et al. Empathy decline and its reason: a systematic review of studies with medical students and residents. Acad Med 2011;86:996

29 Compassion? Compassion: empathetic consciousness of others distress together with a deep desire to alleviate it.

30 Compassion? The good physician treats the disease; the great physician treats the patient who has the disease.

31 The Seventh Competency Personal and Professional Development Makes more explicit the nuance of some of these qualities Will assist learners and raters in consistency with what characteristics and actions to look for and assess. Outlined by the Milestones Working Group Pediatrics Milestone Project.

32 Personal & Professional Development 1. Develop the ability to use self-awareness of knowledge, skills and emotional limitations to engage in appropriate help seeking behaviors 2. Use healthy coping mechanisms to respond to stress 3. Manage conflict between personal and professional responsibilities 4. Practice flexibility and maturity in adjusting to change with the capacity to alter behavior

33 5. Demonstrate trustworthiness that makes colleagues feel secure when one is responsible for the care of patients. 6. Provide leadership that enhances team functioning with the ultimate intent of improving care of patients 7. Demonstrate self-confidence that puts families and members of the health care team at ease 8. Recognize that ambiguity is part of clinical medicine and respond by utilizing appropriate resources in dealing with uncertainty THE SEVENTH COMPETENCY

34 Personal & Professional Development 2. Use healthy coping mechanisms to respond to stress Three dimensions of burnout (Maslach) Early, intermediate and advanced professional identity

35 Burned Out Residents? 220 Residents from three large pediatric residencies Maslach Burnout Inventory Measures: Emotional exhaustion Depersonalization Personal Achievement Decreased from 75% to 57% with duty hour change Landrigan CP, et al. Effects of the ACGME duty hour limits on sleep, work, hours and safety. Pediatrics 2008; 122;250.

36 Depressed Residents? 220 Residents Harvard Department of Psychiatry National Depression Screening Day Scale 19.6% of residents screened positive for Depression No significant change with work hour changes Landrigan CP, et al. Effects of the ACGME duty hour limits on sleep, work, hours and safety. Pediatrics 2008; 122;250.

37 Mindful Practice Being attentive Implies presence rather than detachment Allows one to see a situation from several angles at the same time Epstein RM. JAMA. 1999;282:833

38 Personal & Professional Development 4. Practice flexibility and maturity in adjusting to change with the capacity to alter behavior

39 Flexibility and Maturity? Emotional intelligence The ability to perceive emotions in oneself and others Facilitating thought Understanding emotions Managing emotions

40 Personal & Professional Development The Trustworthiness Construct: a. Ability or level of KSA b. Discernment c. Conscientiousness d. Truthfulness Kennedy TJT, Regher G, Baker GR, Lingard L. Acad Med 2008;83:S89-92 Kennedy TJT et al. Jour Gen Int Med 2007;22:

41 Recently Highlighted Steve Ludwig s: Striving for Polygamy Three marriages Family, Self and Work Balance and appreciation Ludwig S. The Joseph St. Geme Jr. Lecture. Acad Peds 2011;11:5-8

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43 Recently Highlighted Janet Serwint s Presidential Address: Humanism Our own Humanism Reviewed Strategies for Self- Care Serwint JR. Humanism through the Lens of the Academic Pediatric Association. Acad Peds 2012;12:1-8

44 Recommendations 1. Promote formal ethics instruction, storytelling and symbols 2. Address the underlying messages in the hidden curriculum 3. Offer feedback, opportunities for reflection, and assessment of professionalism with longitudinal mentoring 4. Faculty who simultaneously support learners and hold them to high standards Cooke M, Irby DM, O Brien BC Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco, CA. Jossey- Bass; 2010.

45 Getting over the Mountain Raise the bar of Professional Formation Practice Humanism, Empathy and Compassion Celebrate and use the Seventh Competency Embrace and enjoy what we do each day Take good care of ourselves and others

46 APPD Board 2011

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50 We think we Can, We know we can!