Addressing Lapses in Professionalism

by Beth Flippin, Pharm.D., PGY1-Pharmacy Practice Resident, VA Maryland Health Care System

Professionalism in the health professions has been defined as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served”.¹ Professionalism serves as the basis of a contract between patients and healthcare providers. Teaching professionalism has become a core concept in health professional education, both in the didactic and experiential setting. However, with advances in medical technology and increased utilization of social media, it can be difficult to ensure that learners are maintaining expected standards of professionalism.

Common Professional Lapses2

· Lack of initiative to assume responsibility / role · Misrepresentation or falsification of actions / information · Failure to take responsibility for actions · Abuse of privileges · Inadequate rapport with patients · Insensitivity · Disrespectful language · Inappropriate interactions with groups · Lack of professional appearance

So how should lapses in professionalism be addressed and corrected? One study published in the Academic Medicine Journal found that the most effective methods were to address lapses in a timely manner and to provide constructive feedback rather than punish the learner.³ Several tips for approaching learners who have a lapse in professionalism have been published.⁴  

Modeling professional behavior is one of the key remediation strategies.² Learners mimic their preceptors, regardless of whether the behavior is appropriate or not. Modeling involves all aspects of behavior in the practice setting, from one-on-one interactions with other professionals, patients, and caregivers; interprofessional team interactions, such as rounds or peer discussions; maintaining privacy; appropriate documentation, and adherence to timelines. Everyone must be mindful of the presence of learners in the experiential learning settings, because learners are observing the actions and demeanor all practitioners in order to help develop their own professional identity. Modeling appropriate professional behavior by all members of the interprofessional team serves as a link between didactic teachings and practical experience.⁴

The next tip is to acknowledge the hidden curriculum.  Instructional regarding professionalism in preclinical years is sometimes contradicted by unprofessional behaviors observed in the clinical settings.⁵ These observations are not just of the learners’ direct preceptor, but medical attending physicians, residents, social workers, pharmacists, nurses and any other personnel involved in patient care. It is important to acknowledge that learner’s may, at times, receive conflicting messages regarding professionalism from their observations.  Having conversations with the learner about lapses in professionalism committed by more senior practitioners can be a simple way to address inappropriate professional behavior so that the learner isn’t left with the impression that such behaviors are acceptable.

It is also important to be familiar with the institution policies and procedures for addressing lapses in professionalism.⁴ The institution or department policy should have clear procedures for how information regarding lapses should be documented, who should receive the information, and what the potential consequences are. This is beneficial for both the learner and the preceptor, as the expectations and consequences are clearly outlined at the beginning of the learning experience.

The next set of tip involves data gathering and fact checking. It is very important to ensure you have objective evidence to support the perceived lapses in professionalism.⁴  Because learners often model their behaviors based on observations, it is important to gather information from multiple sources that have had interactions with the learner and can provide first person testimony, documentation, or evidence of the learner’s behavior. This can also help to identify potential reasons behind the lapse, as well as ways to address the lapse in the future.

It’s important to have an experienced educator or mentor available for advice when needed. This person should have experience with learners in different types of situations. It’s important to clearly articulate your questions to your peer, as well as state how the learner expectations where outlined. The trusted advisor can provide perspective and help develop the plan for providing feedback to the learner.⁴

Next the preceptor should be ready to have a conversation with the learner regarding their professional behaviors. During the encounter, remember to be a good listener. Learners should have the opportunity to voice their perceptions of the situation. At times, perceived lapses may be a result of lack of understanding or misinterpretation of their role.  Be sure conduct the conversation in an environment where the learner feels safe, somewhere private and discrete so that the learner does not feel that they are being publicly reprimanded. Be care in your word choices. Use a non-accusatory approach. You don’t want the learner to feel attacked or become defensive about their actions. The preceptor should present to the learner the objective evidence gathered, then allow time for the learner to reflect. The preceptor should provide direct and explicit feedback to the learner. The learner should leave the encounter with a clear understanding of why the behavior is considered a lapse and how to improve in the future.⁴

Finally, the preceptor should close the loop.⁴ Preceptors should help the learner make a behavior change by ensuring the learner develops his/her decision-making skills. The preceptor can present hypothetical situations and have the learner voice the steps necessary to make a decision.  This is a helpful way to develop these problem-solving and ethical reasoning skills. Helping learners to recognize the impact that their behaviors may have on patient outcomes can also be motivational.⁴ Learners should be encouraged to continuously think about professional values and ways to develop their skills.

Know when to call for back-up. There are always going to be situations or learners who are difficult or when unexpected issues emerge. It’s important for the preceptor to know his/her limitations.

Addressing lapses in professional behaviors can daunting. The right tools can help preceptors feel more confident in addressing these lapses. Preceptors should have a plan to effectively address professional lapses in a timely fashion. Professionalism is vital to building a trusting patient-provider relationship, so it is important that future practitioners are aware of the importance of professionalism and how lapses can negatively impact relationships with patients and colleagues.

References:

1. Gibbs, T.  The changing face of professionalism: Reflections in a cracked mirror. Medical Teacher. 2015; 37:9, 797-798
2. Ainsworth, M. Medical Student Professionalism: Are we measuring the right behaviors? A comparison of professional lapses by students and physicians. Academic Medicine. 2006; 81(10); S83-S86
3. Ziring, D. How do medical schools identify and remediate professionalism lapses in medical students? A study of U.S. and Canadian medical schools. Academic Medicine. 2015; 90:(7) 914-920
4. Rougas. S et. Al. Twelve tips for addressing medical student and resident physician lapses in professionalism. Medical Teacher, 2015; 37:10, 901-907
5. Goldstein, E. Professionalism in medical education: an institutional challenge. Academic Medicine, 2006:81(10); 871-876

Personality Tests for Learners – Discovering Your Learning Style

by Stella Chan, PharmD, PGY-1 Pharmacy Resident, MedStar Union Memorial Hospital

You have probably taken a personality test. It might have been as simple five question online quiz or as involved as the Myers-Briggs personality inventory.  Most people are curious learn more about their personality type.  But have you ever taken a learning style questionnaire?  Everybody has their own learning style, and these questionnaires were developed to help shed some light on how we best learn.  Knowing your learning style can help you learn more successfully; and as teachers, it is important to help your students understanding their learning styles.   There are a few different types of surveys out there which provide “insight into the ways learners perceive, interact with, and respond to the environment in which learning occurs.”¹

First, let’s talk about the different learning styles known as VAKT (which stands for Visual, Auditory, Kinesthetic-Tactile).  These learning styles related to how we learn in response to environmental stimuli.² Visual learners learn best through interpreting graphics, body language, and facial expressions during lessons.  Visual learners often prefer sitting at the front of the room to have a clear view of the presenter.  And they tend to like diagrams, illustrated text books, videos, and colorful handouts.  Auditory learners learn best through lectures, discussions, talking things through problems, and listening to what others have to say.  They can interpret the underlying meanings of speech based on tone, pitch, and speed of the presenter’s voice.  Auditory learners also like to record lectures and listen to them later.  Kinesthetic/tactile learners learn best through a hands-on approach.  They may find it hard to sit through a long lecture without some sort of activity in the middle.

Kolb’s Learning Style Inventory (LSI) combines two major cognitive dimensions:  the active-reflective dimension and the abstract-concrete dimension.³  From these dimensions, Kolb developed four learning styles:  diverger, assimilator, converger, and accommodator.  However, research has shown that the LSI had low predictive validity and thus, the Learning Style Questionnaire (LSQ) was subsequently developed by Honey and Munford. Similar to Kolb’s Learning Style Inventory, the Honey and Munford learning style questionnaire reveals  four distinct preferences:  Activist, Theorist, Pragmatist, and Reflector.  Honey and Munford believe that individuals move between the four different preferences depending on the situation and their level of expertise in the subject, rather than being locked into one.⁴  These learning style tests include not only perception but also information processing rather than just focusing on the environmental stimuli (such as with the VAKT learning styles test).  Activists are students who enjoy being challenged by new experiences and being involved in projects with others.  Theorists prefer to think through problems systematically and understand the theories behind what is being taught.  Pragmatists learn best when they are able to apply what they learn to real life stituations.  These students may benefit most from case studies and discussions about what others have experienced in the real world.  Reflectors learn by observing activities and drawing conclusions about what they see; they prefer receiving feedback from others and having time to review concepts prior to applying them.⁵

Anthony Grasha and Sheryl Reichmann developed the Grasha-Reichmann Learning Style Scales in 1974 to determine college students' preferences for classroom participation.  The questionnaire has a series of statements that the student can rate from 1 (strongly disagree) to 5 (strongly agree) including: “I enjoy discussing my ideas about course content with other students,” “I can determine for myself the important content issues in a course,” and “I prefer to work on class related projects by myself.”⁶  The responses are then tallied up to determine what preferred social learning preferences the student has:  Independent, Dependent, Avoidant, Participant, Collaborative, and Competitive.  Independent students prefer to think for themselves and work on their own.  Dependent students generally only learn what is required of them and look for specific guidelines on what to do and how to do it.  Avoidant types are not enthusiastic about learning the content and will require a lot of coaxing to complete activities.  Participant students enjoy taking responsibility for getting the most out of their lesson.  Collaborative describes students who enjoy sharing their ideas and working in groups.  Competitive students learn content in order to achieve a better grade than their peers or to receive the teacher’s praise.⁷

There are many questionnaires available that can inform students about the learning strategies that work best for them.  These questionnaires focus on different learning style preferences and probably yield the best results when a few questionnaires are used.  By figuring out which VAKT learning style learners are most drawn to, they will understand what type of environmental stimuli they learn best from.  Using Honey and Munford’s questionnaire, learners will understand how to best process the content delivered to them.  By utilizing the learning scale developed by Grasha and Reichmann, learners can determine whether they work best in groups or alone.  By putting all of these learning scales together, students can better understand how they learn, can select courses that use methods they are more likely to enjoy, and adjust their study habits to learn most effectively!

References:

1. Brown BL. Teaching style vs. learning style. Educational Resources Information Center: Clearinghouse on Adult, Career, and Vocational Education; 2003.
2. Coffield F, Moseley D, Hall E, et al. Learning styles and pedagogy in post 16 learning: a systematic and critical review. The Learning and Skills Research Centre; 2004 [cited 2015 Oct 9].
3. Allinson CW and Hayes J. The learning styles questionnaire: an alternative to Kolb’s inventory? Journal of Management Studies. 1988; 25(3): 269-81.
4. Honey P and Mumford A.  The learning styles helper’s guide. Maidenhead: Peter Honey Publications Ltd; 2000 (revised edition 2006).
5. Mobbs R. Honey and Mumford. University of Leicester. Leicester, UK. [cited 2015 Oct 20]
6. Grasha-Reichmann student learning style inventory. Office of Information Technology: Claremont, CA. Claremont Graduate University [cited 2015 Nov 9].

Beyond “You Can Do It!” — Supporting Learner Autonomy

by Jessica Biggs, Pharm.D., PGY2 Pediatric Pharmacy Practice Resident, University of Maryland School of Pharmacy

If you are a teacher reading this blog now, I’m sure you would agree that some students seem more motivated than others. While this may be the case, not all students respond the same way to motivators. In other words, motivation is not fully explained by HOW motivated students are, but also by WHAT is motivating them. Are they studying diligently for that pharmacology test with the hopes of getting an A to please their parent? Are they studying because they have a genuine interest in the topic? Or is it a combination of these factors? Autonomous motivation, or a desire to learn due to a genuine interest, has been associated with greater effort and higher academic performance.^1,2 Unfortunately, many educators fail to create an environment that fosters learner autonomy.

According to the self-determination theory (SDT), some learners are motivated primarily by controlled motivation.  Others are motivated more by autonomous motivation.  Controlled motivation refers to a student learning something due to external pressures (such as a parent or teacher), internal pressures (such as guilt or stress), or to gain a reward (such as a passing grade or screen time).³ This form of motivation can be seen in B.F. Skinner’s behaviorism studies.  Behaviorists often use a system of rewards (and punishments) to motivate learner participation. On the opposite end of the spectrum, autonomous motivation refers to learning that resulted from a genuine, internally perceived personal value or interest.³ Simply put, controlled factors are not the primary, or sole, source of motivation. In reality, for most students, the source of motivation is not so black and white.  Motivators often overlap.

What exactly does the term “autonomy” refer to? Autonomy is synonymous with volition. When students are autonomous, they act on their internal desire to align the learning activities with their sense of self.³ It is important to note that autonomous learning does NOT require students to work alone or without assistance.

At this point you may be thinking: How is it possible for students to be autonomously motivated?  There’s no way that they will be interested in absolutely everything I teach?  Autonomous motivation is still possible even if the student is not truly interested in the subject matter because autonomous learners are able to identify the value and personal importance of what they are learning.³ For example, as a pharmacy resident, I am not genuinely interested in learning how to perform open-heart surgery.  I do not wish to be a surgeon. On the other hand, I would gladly accept the opportunity to shadow a cardiac surgeon performing open-heart surgery because I see the value in understanding the complexity of the heart and the cardiac anatomy.  This kind of knowledge would be relevant so that I better understand the cardiac medications that I work with and would be useful during my patient education sessions. I am able to see the value in this learning experience.

Even though I am early in my career, I already see the importance of fostering a sense of learner autonomy. In medical education, autonomous learning has been associated with enhanced learner effort, superior performance academically, as well as reduced learner exhaustion.^1,2  Since I was given opportunities to act autonomously both as a pharmacy student and as a first-year resident, I can attest that I have more energy to take on learning tasks that align with my goals and my performance is better.

So how can we support this type of learning? Small group teaching, problem or case-based learning, and a gradual escalation in learner responsibility and tasks are all appropriate methods.³ Asking students to lead patient case discussions in a small group environment (with other students or pharmacy residents) is an effective tactic. With increased autonomy however, it is also essential to provide constructive feedback, acknowledge students’ perspectives, and ask for learner goals and preferences.⁶ All of these learning opportunities should be done in a structured manner with an appropriate level of learner challenge because allowing a student to “run wild” with their own learning is not what is meant by autonomous learning.

Admittedly, it is often a struggle to achieve a balance between fostering learner autonomy and providing adequate supervision. How can a resident (or pharmacy student) gain real-life experience, including the opportunity to take care of patients autonomously, while also being appropriately supervised to ensure patient safety?⁵  Many teachers struggle with this balance and some micro-manage student activities when it comes to patient care. In these situations learners may feel their ability to make their own choices and decisions, one of the important aspects of autonomy, is compromised.¹

As a second-year pharmacy resident I have witnessed the progression of learner autonomy, both as a learner and now as a supporter of students who seek greater autonomy. Personal experience has proven to me that practicing in an environment that fosters autonomy will give a learner the best chance to shine and demonstrate their intrinsic motivation. It is the job of educators to support learner autonomy – to help students view the materials they are studying or the tasks that they are completing as opportunities that will pave the way to the future goals that they hope to achieve.

References

1. Kusurkar RA, Croiset G, Galindo-Garre F, Ten Cate TJ. Motivational profiles of medical students: association with study effort, academic performance and exhaustion. BMC Med Educ. 2013; 13: 87.
2. Kusurkar RA, Ten Cate, TJ, Vos CM, Westers P, Croiset G. How motivation affects academic performance: a structural equation modelling analysis. Adv Health Sci Educ. 2013; 18: 57-69.
3. Kusurkar RA and Croiset G. Autonomy support for autonomous motivation in medical education. Med Educ Online. 2015; 20: 27591.
4. Deci EL, Ryan RM. The “what” and “why” of goal pursuits: human needs and the self-determination of behavior. Psychol Inq. 2000; 11: 227-68.
5. Hoffman BD. Using self-determination theory to improve residency training: learning how to make omelets without breaking eggs. Acad Med. 2015; 90: 408-410.
6. Cate TJ, Kusurkar RA, Williams GC. How self-determination theory can assist our understanding of the teaching and learning processes in medical education. AMEE Guide. 2011; 33: 961-973.