Med School Faculty Behavior Should Match Class Teachings, ACP Says

Marcia Frellick

February 26, 2018

Out-of-class behavior by medical school faculty members should match in-class lessons on ethics and behavior, the American College of Physicians (ACP) says in a new position paper published today in the Annals of Internal Medicine.

Lisa Soleymani Lehmann, MD, PhD, lead author of the work on behalf of the ACP Ethics, Professionalism and Human Rights Committee, and colleagues describe the "hidden curricula" as the positive and negative lessons students absorb from medical school faculty members' attitudes and behavior.

A positive example might be observing physicians visiting patients after clinic. A negative example might be referring to a patient who has had several recent visits as a "frequent flier" or making disparaging remarks about a specialty.

"Learners should not experience disconnects between what they are taught about ethics and professional behavior and what they see demonstrated by faculty and others," ACP President Jack Ende, MD, said in a news release.

However, data tell a different story, the authors say, and the effects have lasting consequences.

Graduates Report Differences

More than half of medical school graduates in 2016 said they saw differences between what they were taught about professional behaviors and what faculty members demonstrated outside the classroom, according to the paper.

The authors say that over time, observed behaviors can change the culture of medicine. They describe a hidden systemic bias against primary care, for example, that "contributes to the U.S. health care system being unprepared to meet the needs of an aging population. Negative comments from leadership and greater financial rewards for subspecialists can discourage students from choosing primary care despite societal need, intellectual rigor, and the importance of longitudinal healing relationships."

Ann Brown, MD, MHS, vice dean for faculty and professor at Duke University School of Medicine in Durham, North Carolina, said she has witnessed such bias against certain specialties and steering of students toward research or clinical paths in different academic environments where she has worked.

Formalizing Expectations

She told Medscape Medical News that she applauds the ACP for formalizing expectations for professional behavior among medical school faculty, just as there are formalized policies for students and research misconduct and sexual harassment.

"I think it's really important that we state that we, as a community of faculty, should be accountable for what we project to our learners about what professional behavior is," said Brown, who was not involved in ACP's effort.

The timing is important, too, as physicians are being asked to do more in less time. There is less time to think about interactions among members of a clinical team, she said, when even time to interact with a patient is limited.

The principles in the ACP paper effectively say, "we care about each other and how we treat each other, and we care about the climate we build together," said Brown, who has led a professionalism initiative among Duke faculty. That effort arose from a focus on professionalism in the research arena that spread to clinical realms.

Having a formalized statement helps when someone crosses a boundary or behavior borders on being unprofessional, she said. Leaders can point to a document and say "this is what we stand for."

"Schools have different approaches to it, but I think we're all struggling with this, to one extent or another," she continued.

The ACP paper makes three main recommendations:

  • "Hidden" lessons must become a positive curriculum that parallels formal education. Faculty and senior staff members should model empathy, encourage reflection, and encourage students to talk about positive and negative behaviors in training. Lessons in the classroom must be reinforced and enhanced outside the classroom.

  • The learning environment should encourage respect and honesty and welcome questions about ethics, professionalism, and care delivery. Teamwork must be taught and demonstrated.

  • Leaders should clearly communicate values in everyday decision making and expectations of professionalism in a culture where patient well-being is a core value.

"The hidden curriculum in medicine presents challenges but also opportunities to help reshape not only education but also the culture of medicine," the authors conclude.

One coauthor reports employment with the American College of Physicians. The other coauthors and Brown have disclosed no relevant financial relationships. Financial support for the paper comes exclusively from the ACP operating budget.

Ann Intern Med. Published online February 26, 2018. Article

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