Professionalism and Medical Education's Hidden Curriculum (February 25, 2009)

like to welcome you to today's medical center our and Marsha Ted Childress from the center for biomedical ethics and Humanities and we're pleased to bring you these weekly programs I'm also especially pleased to announce today that beginning with last week's program the medical center now Medical Center our now is viewable on YouTube we have a dedicated channel UVA MCH which allows us to broadcast an hour-long film of the program and you can search for it you just go to the YouTube homepage also in your handout is the web address for that unfortunately our previous programs are not up there just last week starting with last week but you'll be able to see it there from now on and we thank the people in the Health Sciences Library who have made this technical leap forward possible for us we're very grateful our program today is entitled professionalism and medical education sidon curriculum growing numbers of medical educators now acknowledge that a considerable amount of medical student learning takes place beyond the bounds of the formal curriculum and that such learning is a kind of indoctrination in the unwritten rules of medicine and its practice increasingly medical schools are taking steps to modulate the effects of this shadow or in curriculum on students knowledge skills and attitudes the current emphasis in medical education on professionalism represents in part educators efforts to manage the inconsistencies and some of the outright conflicts that witness between the values ideals and expectations articulated in professional codes and the actual behavior of individual physicians including some of the students teachers and supervisors we're delighted to welcome today educator Frederick Cafferty a medical sociologist and professor of behavioral sciences at the University of Minnesota Medical School in dilute in this Medical Center our professor Haverty will pepper tea will inquire into this aspect of professionalism education there are lots of questions we can ask and in this short our begin to answer what is involved in the formation of a medical students professional self what is the medical schools responsibility for its own hidden curriculum as well as for the professionalism of its graduates how does the medicals will create and then assess the effectiveness of learning environments that foster a habit of professionalism to use David leeches phrase and the knowledge the moral undertaking that is the practice of medicine we'll have time to at the end of this hour for your questions and comments as well we're pleased to have as our co-sponsor for today's program the Academy of distinguished educators of the school of medicine and we're also holding this program in conjunction with the medical school's annual medical education research poster session you'll see posters about position education from faculty residents and medical students these posters are lining the corridor outside of the Health Sciences Library and this afternoon at five o'clock there's a reception and all of the the poster authors will be there for you to eat and talk with them as well we encourage you to come there this afternoon and now I'd like to welcome Fred Haverty and we'll see what yep I have to confess before I start that i did not know about the youtube connection and so i'm launching into these remarks with a great deal of anxiety my son my youngest son is on youtube I I was built to find some hockey footage of them they but the idea now that people go and find me is it's very disconcerting so maybe i should say something like hello David you should have for handouts or at least four views to kind lines if you will want a professionalism timeline and into a a kind line more the hidden curriculum curriculum literature and then also a copy because we're going to be referring to it quite frequently the new LC and the accreditation standard ms 31 dash a which brings the concept of professionalism and the concept of a hidden curriculum together I'll explain that more detail in just a bit and then there's a quote from an academic Madison article dealing with professionalism and I just wanted to make sure particularly with the timelines because I wasn't sure how well that they would show up that that you had copies of them that you could infer and so as I said use the point of to go to go through some of the materials so these are the four key topics that were going to be covering today issues of professionalism and doing a very pleased with you sort of the history if you will of modern-day medicines professionals of movement which has its origins back in the mid-1980s and then we'll do a very very quick review of some aspects of the hidden curriculum and then move quickly into talking a bit about learning environments but talking about learning environments within the context of the ELC music new accreditation standard ms 31 dash a and then finally some material that I really haven't presented before so I'm even more anxious than usual a cake on how we might think about approaching and assessing issues of professionalism and in curriculum from a learning environment perspective let me and that's the network analysis part let me before I start pointing out things on timeline again I encourage you if it's difficult to see to to refer to the handout which would be a lot clearer why certain things are up there that are on the timeline I'm a medical sociologist by training and someone who came into medicine and sociology only after I would graduate school white originally going to graduate school to be a criminologist very early on in in my training so so sorry that's what I was introduced to the two books by Elliot frights of profession of medicine and professional comments at seven nineteen seventy these were two hugely influential books that were published looking from a sociological perspective medicine status as a profession and and although fraction was not first sociologists to focus on issues of professional matter the gold mine really since the beginning of sociology horizon an academic discipline his analysis of sessions and his focus on medicine was groundbreaking and it created quite a stir with in sociology and what a soup was for sociologists the great debate within academic sociology about the nature of Medicine status as a profession and this great debate ranged all the way through the 1970s and into the 1980s with various people arguing various perspectives on where the medicine is becoming deep professionalized weather proletarian eyes what medicine corporatized and frightening turn argued that while some things are changing for physicians Memphis status as an organizational empathy was still more still maintaining its professional status and its social political prominence an overturning rights that have become point in the am buried with professionalism as one of three principal ways of organizing work the other two being the market which would be controllable overworked by Chris or bureaucracy is controlled by the organization and professions that could full overworked by highly specialized and skilled workers and France and came to view professions of professionalism as a counter to the excesses of the market bureaucracy I didn't know it then but very little of this debate that was going on with in sociology made it all into medicine it was it was as if this this the spear was going on upon over this particular area of academia and over here in medicine there things were going to be quiet there was a publication in nineteen eighty or the Wellman who was then the editor New England medicine wrote what is a a stunningly classic article on medical industrial complex but what's really interesting to me about that article is that if you trace out its citation counts and when it began to take off Romans article really fell in death years in medicine for quite a while because the debate if you will with in academic medicine about professionalism really wasn't going to take off for another five six years and so in some respects relevant was a precursor tool to all of this they took away my first job and then my second job the third job which landed me in Minnesota and it was about that time that that I began to run into editorials commentaries articles wellman Jewish lundberg variety of people commenting on what was characterized as the inherent clash between commercialism and professionalism and this was really the initiation of medicines professionals and debate of a debate within medicine about its professional staffs and for me it was simply this sounds birth familia but my background have been sociology and now I was beginning to transition over into medicine and an academic medicine an organizational medicine i should say had reason to be concerned prior to the 1980s their brightest ok right now via prior to the 1980s medicine at least as a as an industrial sector really was composed of two industries is a small pharmaceutical small medical equipment and in 1982 this and ended a decade-long bear market runaway inflation was was a term was used frequently and we transitioned into what was going to become the nation's 2nd longest bull market billions of dollars flow into the marketplace this was a period of time that was known as the dot-com era but millions of those dollars flow to the health care where investors were in search of new opportunities and people who are promising both solutions to health problems and return to investors were beginning to come up with ideas about how to revolutionize medicine and big money was made I don't know how many of you always not work at these days and some things that's probably not wise to it's discouraging but some of you may know of a company called HCA back in 1987 this was a sleepy to hospital company in El Paso Texas it subsequently merged with Columbia Columbia HCA and in a ten-year period of time when public expanded and had become by 1997 the nation's largest hospital company and its ninth most valuable company meaning number of shocks dr. Bashir's times the stock price and this is my memory growth naca was not alone in its rags-to-riches story so organized medicine was right the increasing former presence in medicine was transforming what too large what had been to that point largely a cottage industry and what emerged out of those concerns again driven by a lot of articles in the medical literature was this new modern-day professional as a movement that's now 25 years old and still evolving and the movements going through a couple of different ways or iterations the first wave had to do with definitions of meanings so there was a lot of articles about how professionalism taking to find and we need to somehow come up with better ways of defining things so we could talk about with that and articles like the cruise cruise improves down there's another article up there by her swing focused on issues of definition a second wave quickly followed something to quickly focusing on measurement Oh fine we know better now what talking about now we need to be able to measure assess it and the stern look up there is an example of of the good piece of literature on mission organizations and work by organizations both preceded and quickly follow this the abim Foundation has played a major role in the organized medicines professionalism movement they were the ones back in 1989 that switched over from what had been there project humanism to project professionalism in 2002 Davi em foundation with partners help to formulate the position Charter and just a couple of months ago the abim foundation had a conference multi-stakeholder conference on 21st century professionalism to me very interesting its focus was on how different types of payment systems might promote or him the profession with another types of organizational structures my blog every professional how different things of policies may promote or hinder professionalism the the medical journals played a very important part in this this whole movement a key journal in all of this was the academic medicine which is the journal of the double a of C and Anna main driver in that it was under its then editor adine Kelly and they were just a ton of literature came out under her editorship on the issues of professionalism the next week was codification that was led by the acgme when it established at six core competencies one of which was professionalism on the Graduate Medical Education follow in 2008 you had the LC in the July of tube down coming up with its new accreditation standard ms dirty more dash a.m. we'll we'll come back to that but down over here that is the accreditation standard you can see from the text that this is where the LCM II sought to merge issues of professionalism with with issues of the HIPAA curriculum bowel nail lap down or in just a second if you want to read more about the the waves and I apologize for for being self-serving but there are two publications that will sort of detail that that history for you first and perspectives of biology of medicine and the second chapter and quote that will be out the spring okay that brings us up to date on professionalism and the professional as a movement and what I wanted them switch over to before coming back is the second time line which is more less a timeline of or just a way of organizing some information on the hidden curriculum the concept itself comes out of education and an education theory but at first appeared in the literature in 1993 there's a very interesting story at least it's an interesting story to me about that that first article and how it actually came to be an article with a great deal of credit going to Dean but if we have time that will tell you a little story about it during the question period but since that first publication have been literally a couple of hundred articles that have in one way or another attempted to to pull that concept that tired to issues of both medical education in general but then also professionalism specifically there have been a variety of provinces the ABI ever 2005 as reference up there for that have have attempted to figure out ways of making the transition from an education system that focuses largely the had focused in the past with you on teaching the one that would begin to hold itself accountable for things student learning now I'm not going to spend any any kind this morning defining the hidden curriculum for you except just to draw the distinction between your formal curriculum that what you say you do your curriculum of paper if you will what you intend to do and and that man as Mars who said this just is a small part of the overall learning that goes on for students it's an important part but it's still a it's only part of what students learn there's a variety of idiosyncratic and happenstance learning that goes on and interactions between and among students between faculty students and there's also the learning that goes on the students we that if you will leave the organization your organizational culture of what the organization bounds in terms of how curriculum is organized in terms of how buildings that the so-named laid out students are very smart they pick up a lot of things when they read the space if you will between the formal and the info that example maybe would be difference between the mobile speed limit the Minnesota at seven but that's not real speed limit and when the real speed limit is somewhere between 75 and B and everybody operates on that informal not the formal and most organizations run on the informal rules with the polls on coming to play when the info offended too much so what might be some an example of some of these informal messages all right I know a school that says we have an integrated curriculum and it's true the horses have been that the melted materials has been synthesized but what happens when two faculty maybe say a basic science vacuuming the clinical faculty say different things about the same issue the same time well one thing that often happens at the school is nothing it's rare for course director to say to the faculty reconcile better yet what happens when we come to an exam and one answer on an exam question is is right if it was tied to battle da and one answer is writing books time to faculty be well this is resolved by telling the students to answer the question depend upon depending upon the runner so what our students learning about an integrated curriculum or even mean what it means to be integrating back to the curriculum of part of the literature in this evolving limits on the curriculum that's outlined up there focused on in its high school to make teaching in the professions more for the ship from learning about professionalism largely through any formal curriculum a tacit learning process to one that was more embedded in the formal curriculum so you started to have at every medical school another courses on professionalism now there's nothing wrong with this except that work because we're in the beginning of this movement that you know special as a movement we're also in the beginning of of the unanticipated consequences if you are at least in the short run as students learn about for example only definitions of professionalism they're introduced to the positional charter that are told about the HDTV competencies and they're pulled about how the ACGME defines and assesses professionalism and they begin to run into riffs or inconsistencies between what they're being formal and what they're seeing perhaps in the clinic are the wards and out of this clash between these two realities has been and or in it a bit now sort of push back by students on and sometimes a certain degree of cinna city on their part about this new professionalism and one of the things that I wanted to point out you in one of the handouts was was this quote here taken from a day 2007 not specialist it was a November issue of academic medicine the event editor Lakewood home had put together a variety of articles on the formal teaching of professionalism at a dozen medical schools across the country but he chose to purposely chose to preface the review of these programs with an article written by two medical students on professionalism and this quote is taken from that article it it's not necessarily a pleasant article to read but it is all about the tacit messages that we can send the students about what is really important in terms of their education now out of all of this go back to 31 dash a the double AFC and the AMA within the to holders if you will be else the two parents for the lvm II decided that they needed to somehow come up with a new standard that would bridge would deal with the fact that it wasn't going to be enough anymore to to just focus on what was taught number of hours number of beds all the horrible things that organizations do run Frank's and they were asked to to put together a white paper for them and I think it was it's on the timeline but it was in 2002 got a chance to go and talk to me I'll see me about what then was informally called the hidden curriculum standard I happen to like learning environments a whole bunch more then calling it a hidden curriculum standard but this is the consequence of if you will is merging a rather long standing movement that's still ongoing and a conceptual framework for trying to think about things I have a small problem with it and the small problem being that the LCR me at least technically ties in normal types of lessons can be to professionalism only and if one wants to respond to that's 31 vashe specifically all one has to deal with issues of professionalism would have brought I would have rather they broadened it at the top of medical education at all so how are we going to respond to how the medical education will respond when mr. in one fashion I suspect in some respects it's going to be very much like residency education has responded to the ACGME six core competencies ACGME basically said that they were going to go into a 10-year project of reviewing over what was coming into them as residency programs who are credited amount of that process they were going to come up with best practices I don't consider this a negative statement but the the LCM II really doesn't have any upfront ideas about what's going to constitute an acceptable response to the standard so I suspect they're going to wait and see and we are all going to wait and see as schools is passed on the standard of being understanding and out of all of that over time we're going to have some idea about how we can approach all of this but that's kind of a defense of a reactive way to go and so I'm trying to think of some other ways of approaching this topic and then the next five of ten minutes I'd like to explore something that hadn't talked about in public before and see what you all think and excuse the water blend them I came down with a bad cold just before I came here are there are there ways other ways of a wait-and-see are the ways other than what you can see and I think there are first of all I think we do fundamentally have to believe that we're in learning business and not the teaching business and you know i'm going there then the ship Lily doesn't sail but the one possible tool we might want to play with in a tool that can highlight this connects and disjunctions is that work analysis as there's a formal methodology really haven't been applied to medical education yet so I want to walk you through a couple of examples and almost in a sense walked me through a couple of example and how we might apply them look analysis two issues first professionalism animal groton without the medical education in general first thing we want to do and what we have here is so we've got year one year to year three or four and think of the y-axis if you will is going from top to bottom beginning of the academic year and the the end of the academic year and each of these nodes represents a identified point in the formal curriculum where you say you teach professionalism so this is all bull cricket we're not going to talk about the info or curriculum at all yeah and so you do something up at the beginning of the year and you do something a little couple of things here later in the year there's more of the year too and there's more idea free and it's a couple of things I just made the sign but maybe maybe that dot is orientation or maybe that God is the white coat circle or maybe if there's pho the white coat ceremony in and orientation it should be too got something but first thing you're going to do is you're going to identify where it is second thing you're going to do every single note they're embedded underneath it is the what what are you doing what concepts what what orientation are you taking what are the basic messages principles whatever that you're trying to convey the next step then and we start within each of the years it is to figure out where things link up we're not going to talk yet about how they link up or whether they reinforce a little reader for us just whether they link up and again I just made this up as those go along and said all right whatever went on up here is not formally kite that's key you don't say nobody says along the way that this has anything to do with that if wait in the abstract but you don't say it whatever these two things are they're linked you say that ty you convey that to the students they have something to do each other over here and the two same type of thing we've got a variety of different linkages we've got a couple of things here there's one is not tied into anything this thing over here isn't tied into that you've got to kind of travel a bit to get from one to the other over here in the a3 I guess I've got to kind of carried away with block clerkships and just decided that okay this this stuff was tied together this time it's really tied together everything's connected one way another this is a little bit different it off here India for god knows what happens in the air for I still haven't figured out what behind medical education at the airport oh alright so now you've made the linkages now you need to characterize them a little bit remembering that underneath each of these nodes and materials do the formal messages that you're sending are they reinforcing each other we'll stay here yes they are but over here in the air to whatever is going on in these two things there's some disconnect either they're negating each other saying one thing do it another whatever it might happen to be at least initially for me it made sense to stay within the years as you try to figure out what was going on in it in your curriculum but at some point you're going to want to know the next step I took out the plus of the minuses just because it got too confusing for me to think about you got to start thinking about appreciate years across your curriculum after all you're not in the business of running a first-year medical school and then you graduate questioned in the second-year medical school etc and so I just tried to come up with some examples we're going to have some real life examples in just a second I'll of saying well you know we still have some problems here what's going on this this piece of our curriculum is just not connected to anything else same up here but you know we've got something over here it seems to be connected to a lot of stuff what is it what's going on in that course or plural clinical experience whatever it might be that as we look to other formal educational experiences their pipes and we say there are times now this is as far as as I took this very explicit way of trying to connect pieces of the curriculum the next step would be to take the informal types of learning that the MS 31 dash a talks about maybe we could put up squares there and begin to do the same paper process as we try to link together all of the things that going on within our curriculum and then link it together with all of the things that are going on within student learning now there are actual tools that computer driven tools that we can use to do some of this stuff here's a real life example of a just a very small piece of data that came out of a class experience where a faculty member had a students prior to coming to medical school in this part is important to do an exercise and then his first class one that was on day five and on day five he asked them whom did you talk to about this exercise there's nothing sophisticated who did you talk to about the exercise well hypothetically we could have 54 dots up there that are not connected in any way whatsoever nobody talked to anybody what part of the assignment nobody was told to to do this in a group way but are they five years who did you talk to and what and this is what we got and what's interesting to me is first of all we didn't expect this amount of interconnectedness but the longest of kinds i've gone through thinking about medical education in a very incorrect way i had thought about individuals interacting with the medical school environment individuals in some sense don't exist we exist as part of collectivities and groups and relationships and here's a network of relationships that exist at the very beginning of medical school that's the first thing everybody's connected with everybody else everybody's connected with somebody else there's nobody that's outside of any connection now some of them this person down in the 18 even hot or she talked to anybody somebody talked to that person we have lifts another person out here nobody talk to that person but they did talk to a couple of other people but we also have individuals that were highly connected at a house here's the most connected individual in the class here the next two who are these people how are they come to be so chemical if you will to the information flow of the class five days of the medical school now it turns out that here there are numbers associated with the with the nose but those are real people you know they have the Apple graphics they have academic performance one of the things that's fascinating to media is is how this might change over time how does it how does a medical school class of all around issues of learning and there are a variety of hypotheses that we might we might generate with with respect to these linkages one of success in medical school is do as much to one's raw academic horsepower do as much to one's network of relationships as one for academic horsepower where we could hypothesize that that when it comes to forming their academic networks not only do gutters associate mainly with gutters but maybe those students who perpetually hover around 70 are also more likely to associate with with similar peers but it's the ones that unconnected that get into academic maybe our medical school for example is as a mission for rural health p.m. well I mean morality for the longest of times has been associated with a variety of individual characteristics of somebody from a rural community so who's grown up and more likely the lateral community but maybe maybe individuals who go to rural communities or inner city or go to certain specialties what there any pathologist here good what what a pathologist the future pathologists look like up there that was right off the cuff and that's for you to do individuals going into different specialties have different relationship patterns don't know we don't know a lot of this the thing is we can also forget if you will that these are individuals people and attend just for a second that these are courses and that this is a map of the curriculum at all and that each node is course and and again begin to ask yourself what is this course contributing to the overall educational environment in contrast to these educational experiences and again what are they and what are they doing and what are they accomplishing you can even have some fun yet I assume that most of you in one way or another heard of that game it's now on the web you can just go and get the information called six degrees of Kevin Bacon think there's a there's another link you can do baseball players while I was in my room this morning how many degrees of separation is there between babe ruth the marathons and who are the players that link them together there's a there's actually a game that mathematicians not a game but there's Paul Erdos is a famous mathematician and and mathematicians have an Erdos number did they work with him van a venir this number of one do they work with somebody who worked with him they have an address number 2 etc etc same thing as Kevin Bacon well um we can do the same thing with concepts we could do the the six degrees of hans a dog craps I mean what are the core concepts in medical education and what are their linkages to other core concepts we can do that with this type of methodology and with the algorithms that underlie these types of analytical tools and all of a sudden you can actually and again have been done and it's going to be very hard to do but you can actually measure a curriculum you can measure how tightly integrated I can a curriculum is overall you can measure pieces of that curriculum you can break it down into the first year of hacking organizers University of a second conversion fourth you can even do it within a particular course the unit of analysis there might be election or teaching experience and how well-connected was on the parts of that course part now other other things to do skip over that there are I think one thing that I'm in the emirate with is the longitudinal clerkship movement has also begun to walk this at the at the residency level at UCSF and other places where the notion of integrated and one to denote are part of the of the formal teaching message there are also some initiatives that I won't go into within interestingly in the physics education where physicists are led by a Nobel Prize would have named our one with a wily are trying to to revamp how the sciences are being caught and how to interject some more interactive and linking ways within a traditional lecture format but just to draw things to a close the the basic message support today regardless of the tools is that it take the lessons of the hidden curriculum apart and go up find out what your students are learning in particular the past lessons that they pick the tacit knowledge the skills the values that they are informant picking up from peers of faculty what they learn from the organization itself and then you've designed your formal curriculum then the hallways and should be a full curriculum that's the heart of thing but you're designing with those other kinds of learning in mind because it's just simply not a good idea to keep on delivering what is essentially decontextualized blocks of all instruction and pretend that that is good pedagogy thank you very much for your time and your consideration and I don't know how good I told marcia i don't know what i am going to be with questions i have a pretty severe hearing loss to begin with and now with a cold she said it the best I feel like I'm about four feet under water and things are just kind of floating around me so she may have to translate but again thank you for coming thank you very much we have some time for questions and I will ask you to speak clearly and i'll do some translating an indie dr. happy thank you angry talk my question follows up on dr. couch eyes which is this I think there's a long-standing principle in education and in medical education that the most powerful teacher and therefore the most powerful learning tool is modelling is modelling so I guess I'm started wondering is anything work there than that have you ever discovered that there is something it works better for two people strictly and best learn from those who they learn from by others I think well first of all there's this been a little no not in in this formalizing of things role models a traditional vehicle of medical education I think it always will always should be emphasized too should but remember Lou model doesn't need to know that their role model I decide to my role model sorry you don't decide that you're a role model for me the mentor is in a bit of the formalizing of a robot amada sorry that came out kind of atom where now you have explicit responsibilities to me almost do in terms of my learning now one of that globalization is good about it certainly doesn't make the role model go away the part that excuse me captivates me I mean you know we could do them to the network thing I get it comes in robots matter of fact everybody in this room on some level because your faculty I'll just make that generic statement oh it's supposed to be a role model for me because you've been sort of anointed by the the University and and yet we know just like there's variation in and medical practice all doctors don't do the same things and there's a great deal of variability in impatient outcomes and medicine is a very messy business not allow certainty so how do I take pieces from from you I the role modeling that goes on for physicians is vastly different than the world modeling that goes on for clergy where they're hooked up with principally one and role model or teacher education you're assigned to do student teaching with another teacher and role models I get everybody in all of you and how do I make sense of the variety of ways that you approach professionalism there's a very interesting studies jam and the england journal Annals for this journal medicine the lead author and many of them is guy named Campbell one of the ones I'm thinking about right now without mask do you agree with court professionals and principals and there's great agreement across the profession as to what folks believe them but then when said what do you do I'm being too simplistic here but just what do you say what do you do it is great inconsistency in people admitting that they don't a bunch of scenarios were it would develop for them to answer how would you behave under these circumstances and I know it's not real behavior it's what they say but this was a because was a jamming article that that deals with this underlying tension between how I'm believes and how an ex and that they're not necessarily the same and so as as a as a role model I'm not sure how to sort all that out and yet I can't imagine this is an apprenticeship tradition that goes back in a little judias and I have a lot of deal with medicine and I can't imagine that that there should be anything other than wonderful role models for students to learn from although residency work hours and Duty hours and stuff is having some effect here too well our hour is up I'm sorry to say I hope we will continue this conversation after the end of the formal program if you like I invite you to come back next week when we have the Richardson lecture of the school of medicine that deals with medical error and patient safety the title of the program is disclosing medical errors to patients recent developments and future directions and we'll be hearing from Tom Gallagher from the University of Washington and Mary hardy who's a nurse clinician here in the medical intensive care unit so I'd ask you to join us then and please join me now and thank you fred happening you

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