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ORIGINAL ARTICLE
Year : 2016  |  Volume : 8  |  Issue : 1  |  Page : 5-9

Teaching professionalism to ophthalmology residents: A pilot study


Department of Ophthalmology, ANIIMS, Port Blair, India

Date of Web Publication17-Jun-2016

Correspondence Address:
Kavita Bhatnagar
Department of Ophthalmology, ANIIMS, Port Blair
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1858-540X.184239

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  Abstract 


Background: Professionalism is an important competence to be taught and assessed for ophthalmology residents; however, presently, there is no structured curriculum available for the same in India. Objectives: This educational research project was undertaken to develop, implement, and evaluate a formal training in professionalism for ophthalmology residents using reflections and role-plays on simulated patients before using it on real patients. Materials and Methods: This interventional study with pre- and post-intervention assessment was conducted from November 01, 2014, to March 31, 2015, with study sample of 12 residents in Ophthalmology Department of a Medical College in Western India. A resident professionalism log-book was prepared to document the course objectives, course outline, student groups, evidence-based rationale, and specific professionalism behaviors to be learned. Training modules were prepared and validated. Interactive lectures by subject experts, reading assignments, and seminars were used to teach basics of professionalism. Specific professionalism behaviors such as empathy, altruism, and informed consent were practiced using demonstration videos, role-plays, and reflections on their learning. Results: There was statistically significant improvement in resident's perceived importance of professionalism (P < 0.005). Mini-clinical evaluation exercise encounters observed were 71 with mean scores of 5.48, 5.45, and 4.81 on a 9-point scale for empathy, altruism, and informed consent, respectively. 100% faculty and residents were satisfied with this training program. Resident portfolios showed improvement in their humanistic/professionalism qualities. Conclusion: There is a need to have a structured training module for professionalism. Combination of reading assignments, interactive lectures, seminars, demonstration videos, role-plays, and reflections are effective methods to teach professionalism. Seeing the impact of this project, we have decided to continue it in future and also disseminate it to other departments.

Keywords: Ophthalmology, postgraduates, professionalism


How to cite this article:
Bhatnagar K. Teaching professionalism to ophthalmology residents: A pilot study. Sudanese J Ophthalmol 2016;8:5-9

How to cite this URL:
Bhatnagar K. Teaching professionalism to ophthalmology residents: A pilot study. Sudanese J Ophthalmol [serial online] 2016 [cited 2023 Jan 31];8:5-9. Available from: https://www.sjopthal.net/text.asp?2016/8/1/5/184239




  Introduction Top


Presently, there is no structured curriculum for teaching professionalism to ophthalmology residents. Medical educators are increasingly recognizing the importance of education about professionalism and are calling for improvement in this area.[1] There is evidence that deficits in professionalism training and education have negative consequences for both patients and physicians. For example, poor professionalism can affect patients' satisfaction and psychosocial adjustment.[2] Educational innovations to improve patient care must teach not only knowledge but also skills; they should foster an attitude of caring and compassion. Students engaged in such efforts must be willing to reflect on their own professionalism/humanistic qualities and their own emotional reactions to such encounters. A safe environment for exploring emotionally charged issues is important to the success of such educational endeavors.[3] In view of this, Accreditation Council for Graduate Medical Education and Medical Council of India have mandated six core competencies for residency programs and professionalism is one of them.[4],[5]

The present batches of residents never had a formal training in professionalism; therefore, a course needs to be designed for them.

This educational research project was undertaken to develop, implement, and evaluate a formal training module in professionalism for ophthalmology residents.


  Materials and Methods Top


This interventional study with pre- and post-intervention assessment was conducted from November 01, 2014, to March 31, 2015, with a study sample of 12 residents in Ophthalmology Department of a Medical College in Western India. Ethical committee clearance and informed consent from the residents were obtained.

Participating faculty members (voluntary) were trained in teaching and modeling of professionalism.

A resident professionalism log-book was prepared to document the course objectives, course outline, student groups, evidence-based rationale, and specific professionalism behaviors to be learned. Training modules were prepared and validated. Interactive lectures by subject experts, reading assignments, and seminars were used to teach basics of professionalism. Specific professionalism behaviors such as empathy, altruism, and informed consent were practiced using demonstration videos, role–plays, and reflections on their learning. The role of simulated patients, observers, and doctors was played by postgraduate students themselves. Role-play checklists prepared by 3 experts were used to assess residents on items mentioned in [Table 1]. Retrospective pre-evaluation was used for resident self-assessment of importance and skills of professional behaviors mentioned in [Table 2]. Mini-clinical evaluation exercise (Mini-CEX) rating scale developed by Norcini et al.[6] is used by the authors to assess clinical skills of residents in ophthalmology on a regular basis since January 2013. This scale was used to see improvement as a result of this intervention on resident's professionalism/humanistic qualities during the study period as well as for giving feedback to the students.
Table 1: Observations of role-play check-list

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Table 2: Retrospective pre-evaluation importance

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Residents were trained to write reflections on their learning. They were asked to write their reflections on learning at the end of intervention.


  Results Top


A total of four senior faculties and 12 postgraduate students in the Department of Ophthalmology were enrolled for the study. Of 12 students, 6 have just entered 2nd year of residency and 6 have just entered 3rd year of residency.

As shown in [Table 2], participants were asked to rate the perceived importance of various subcompetencies of professionalism which were included in the introductory workshop and seminar as: 5 = Very important, 1 = Not important, before and after attending the workshop, seminars, and role-plays. There was considerable improvement in the scores from the pre- to post-workshop values. The improvement was statistically highly significant for all the subcompetencies as can be seen in Tables 2 and 3 (P < 0.05).{Table 2}

As can be seen in [Table 1], only 50% residents greet the patient, only 40% reassure patient if he/she is anxious, only 40% includes spouse or relative in the discussion, and only 60% explains need for procedure, complications, benefits, and prognosis postintervention.

A total number of resident-patient encounters observed ranged from 22 to 25 over a period of 4 months. Mean score was highest for empathy (5.48) followed by altruism (5.45) and lowest scores for informed consent (4.81) on a nine-point Likert scale [Table 3].
Table 3: Mean scores in subcompetencies of professionalism using mini-clinical evaluation exercise (9-point scale)

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  Discussion Top


There is a growing concern among medical educators about quality of medical graduates and postgraduates in our country.[7] “Professionalism is the basis of medicine's contract with society.”[8]

We believe that the competence of professionalism is a dynamic one that occurs during each and every patient encounter. Physicians as well as residents and fellows probably drift in and out of full compliance with all of the elements of professional competency. This drift may occur due to external factors that impact professional performance (e.g., time of day, clinic census or time pressures, hunger, anger, illness, psychosocial stressors, or other environmental factors). In addition, there clearly is a hidden curriculum from which good and bad professional behaviors are role modeled for our learners.[9]

There are increasing threats to professionalism in the modern medical era, including generational-based attitude differences among physicians and physicians-in-training, increasing patient loads with declining reimbursements, the malpractice and litigation crisis, evolving and expensive biotechnology and information technology, the corporate transformation and commercialization of the health care marketplace, potentially conflicting financial relationships with industry, and the politics and economics of managed care.[10]

This educational research project was undertaken to develop, implement, and evaluate a formal training in professionalism for ophthalmology residents realizing the fact that professionalism can be taught and assessed also and it should not be learned by chance alone. The major reason to incorporate these skills into training program is to improve doctor-patient relationship and overall patient care.[9]

This pilot study was clear in its purpose. The objectives were defined and blueprinting was done. It was meticulously planned after carefully reviewing the literature and with consensus of all the stakeholders and paying due attention to the response process.

Mini-CEX has been widely used for assessment in a single work-based encounter in clinical competence including professionalism at top of Millers pyramid the “Does” level.[11] In this study, 100% residents said that this training overall and role-plays and mini-CEX exercise to assess them was useful for them. The mean score for extent of its usefulness was 5.47 (78.14%) on a scale of 1-7.

Professionalism has been variously defined by different authors. A more representative list of selected attributes that might compose professionalism are altruism, accountability, excellence, duty, honor and integrity, respect for persons, confidentiality, informed consent, and empathy.[9] We did a retrospective pre- and post-evaluation to assess residents' perceived importance on these sub-competences before and after attending the course. There was a statistically significant improvement in perceived importance of all the subcompetencies after attending this course (P< 0.05) [Table 1].

Majority of students opined that faculty feedback was more useful than multiple encounters being observed with mean scores of 5.9 (84.2%) and 5.6 (80%), respectively. Patients feedback on attending resident's communication behaviors was very satisfying with more than 90% of them said that they treated patient and his/her family with respect and dignity, encouraged patient to ask questions, listened to them without interrupting, and discussed management options with them. 100% faculty felt that there was an improvement in resident's humanistic qualities/professionalism since the time we introduced mini-CEX to teach and assess both clinical skills as well as professionalism and humanistic qualities to postgraduates in our department.[12]

Empathic behaviors have been defined as the ability to take another person's point of view and to project a sense of understanding with the other person's experience. Empathy entails responding to patients' emotional state, helping them deal with their emotional responses, and demonstrating a true sense of caring. Current research highlights the need to recognize the importance of attending to the patients' emotion-laden comments and to improve empathic skills.[13]

Patient satisfaction and treatment compliance were shown by Kim et al.[14] to relate directly to a physician's empathic behavior. Among 550 Korean patients surveyed, perception of physicians' “affective empathy” and “sense of partnership” had the strongest impact on patient satisfaction and compliance. By contrast, “cognitive empathy” and “information sharing” had little effect on patient satisfaction and a negative effect on compliance. Kim et al. concluded that improving empathic communication skills might be the most effective approach to improving patient satisfaction and treatment compliance. Similar results were found among Danish patients in a study conducted by Zachariae et al.[15] In our study, residents mean score on mini-CEX rating scale for empathy was 5.47/9 which is average and needs to improve. Retrospective pre- and post-evaluation shows residents perceived importance as 2.5 and 4.5 prior and after attending this course, respectively. There was statistically significant improvement in the scores (P - 0.004).

The ability to accurately read a patient's cues is an essential part of empathic behavior. Studies illustrate the need for increased focus on patient cues. The study conducted by Easter and Beach examined the patient interactions of surgical residents and attending physicians by analyzing audiotaped consultation sessions. The results showed that of the 160 identified “opportunities” for empathic responses, 70% were missed.[16]

Maintaining a professionalism portfolio and learning through writing reflections of their experiences on a daily basis were new experience for them and they enjoyed this experience although initially, they found it difficult to write reflections on their learning experiences. Students wrote that doctors do not always remember that people in trouble want to be reassured and we want to give that reassurance. However, the “everything will be alright” approach is not a help as everything may not be alright. The kind of reassurance that people in difficulty need are not meaningless comfort that the problem will take care of itself, but rather our statement of faith that they will be strong enough to work it out even if it is not alright. Let them know that you are available and would work with them in finding something that can help.[17],[18]

Once we are responding rather than reacting, there can be times when offering assurances or giving advice can be helpful. Those times come after you have listened and others know they have been heard, and after you have shown them respect and recognized how they are feeling. With the experience of this project, this assessment method may be included in university curriculum and disseminated to other specialties as well.


  Conclusion Top


While overall there has been an emphasis on the need for teaching professionalism to undergraduate and postgraduate medical students, there is also a need to have a structured training module to teach and assess professionalism. After seeing the impact of this project, we have decided to continue it in future and also disseminate it to other departments.

Limitations

  1. Limited exposure in 3 months' time.
  2. Scoring variability among raters.
  3. Small sample size as we did not include residents from other units in the same department as the faculty was not trained.


The road ahead

  1. Motivating and involving other faculties of my department and other departments.
  2. Making it a part of institutional curriculum.


Acknowledgments

The author acknowledges contribution of GSMC-KEM MCI Nodal Centre Faculties, Faculties and Postgraduates of Department of Ophthalmology, Dr. DY Patil Medical College, Pune. The author also acknowledges the support of Dr. S. L. Jadhav, Professor, Department of Community Medicine, Dr. DY Patil Medical College, Pune, for data analysis and statistical analysis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mueller PS. Incorporating professionalism into medical education: The Mayo Clinic experience. Keio J Med 2009;58:133-43.  Back to cited text no. 1
    
2.
Roberts LW, Warner TD, Hammond KA, Geppert CM, Heinrich T. Becoming a good doctor: Perceived need for ethics training focused on practical and professional development topics. Acad Psychiatry 2005;29:301-9.  Back to cited text no. 2
    
3.
Blank L, Kimball H, McDonald W, Merino J; ABIM Foundation; ACP Foundation; European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter 15 months later. Ann Intern Med 2003;138:839-41.  Back to cited text no. 3
    
4.
The Accreditation Council for Graduate Medical Education Core Competencies. Available from: https://www.acgme.org [Last accessed on 2014 Sep 10].  Back to cited text no. 4
    
5.
Medical Council of India, Regulations on Graduate Medical Education; 2012. Available from: http://www.mci.org [Last accessed on 2014 Sep 12].  Back to cited text no. 5
    
6.
Norcini JJ, Blank LL, Duffy FD, Fortana G. The mini-CEX: A method for assessing clinical skills. Ann Inter Med 2003;138: 476-81.  Back to cited text no. 6
    
7.
Bhatnagar KR, Saoji VA, Banerjee AA. Objective structured clinical examination for undergraduates: Is it a feasible approach to standardized assessment in India? Indian J Ophthalmol 2011;59:211-4.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.
Sox HC. Medical professionalism in the new millennium: A physician charter. J Am Coll Surg 2003;196:115-8.  Back to cited text no. 8
    
9.
Lee AG, Beaver HA, Boldt HC, Olson R, Oetting TA, Abramoff M, et al. Teaching and assessing professionalism in ophthalmology residency training programs. Surv Ophthalmol 2007;52:300-14.  Back to cited text no. 9
    
10.
O'Donnell JF. A most important competency: Professionalism. What is it? J Cancer Educ 2004;19:202-3.  Back to cited text no. 10
    
11.
Oreopoulos DG. Is medical professionalism still relevant? Perit Dial Int 2003;23:523-7.  Back to cited text no. 11
[PUBMED]    
12.
Bhatnagar K, Radhakrishnan OK, Lune A, Sandhya K. Formative assessment using direct observation of single-patient encounters in ophthalmology residency. Sudanese J Ophthalmol 2014;6:49-53.  Back to cited text no. 12
  Medknow Journal  
13.
Shapiro HM, McCrea Curnen MG, Peschel E, St James D. Empathy and the Practice of Medicine: Beyond Pills and the Scalpel. New Haven: Yale University Press; 1996.  Back to cited text no. 13
    
14.
Kim SS, Kaplowitz S, Johnston MV. The effects of physician empathy on patient satisfaction and compliance. Eval Health Prof 2004;27:237-51.  Back to cited text no. 14
    
15.
Zachariae R, Pedersen CG, Jensen AB, Ehrnrooth E, Rossen PB, von der Maase H. Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease. Br J Cancer 2003;88:658-65.  Back to cited text no. 15
    
16.
Easter DW, Beach W. Competent patient care is dependent upon attending to empathic opportunities presented during interview sessions. Curr Surg 2004;61:313-8.  Back to cited text no. 16
    
17.
Baernstein A, Fryer-Edwards K. Promoting reflection on professionalism: A comparison trial of educational interventions for medical students. Acad Med 2003;78:742-7.  Back to cited text no. 17
    
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Gordon J. Assessing students' personal and professional development using portfolios and interviews. Med Educ 2003;37:335-40.  Back to cited text no. 18
    



 
 
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