7 February 2018

Early intervention: nipping poor practice in the bud

Education Ethics

Older doctors are not the only ones facing added scrutiny as a result of the Medical Board’s latest push to improve patient safety.

The board wants to see a sharper focus on professionalism and ethical behaviour of junior doctors and students, saying early breaches can signal worse problems to come and “irremediable” cases should be weeded out.

In the next 12 months, the board will refer the issue to the Australian Medical Council, which is responsible for accreditation, and will alert the medical deans, universities, colleges and other education providers to its concerns.

The move on students and trainees is in parallel with controversial new rules for senior clinicians. On reaching the age of 70, and every three years thereafter, doctors directly caring for patients will be required to undergo health checks, including cognitive screening and, where indicated, peer reviews.

Both initiatives were outlined in the board’s long-awaited report, Building a Professional Performance Framework, released in late November, based on investigations by its expert advisory group on revalidation.

The expert group did not refer to any specific failings in the Australian medical training system, but said poor behaviour among medical students and recent graduates was recognised internationally as an indicator of future unprofessional performance.

“The public is therefore at risk if poor professionalism in medical students and early-career doctors is not satisfactorily addressed,” it said.

“Lack of professionalism is also recognised as an extremely difficult deficit to address and as such, if necessary, preventing unfit students from entering the profession or unfit trainees from becoming specialists is critical to prevent adverse outcomes.”

The expert group called for further curriculum development and advocacy, saying teaching strategies that promoted good professional behaviours were “not fully developed”.

Signalling a more rules-based approach, it said appropriate professional behaviours should be a mandatory requirement for graduation and specialist qualifications.

One point of agreement among medical academics and recent graduates is that the teaching of professionalism and ethics in medicine has come a long way in a short time.

Professor David Ellwood, dean of medicine at Griffith University, presides over a medical school that devotes about 20% of its curriculum to medical law, ethics and professional behaviour, yet during his own medical studies in the UK these things were never spoken of.

“I’m not sure we had any real insight into the regulatory processes, whereas I think our students these days have a great deal of insight,” Professor Ellwood said.

Griffith attaches particular importance to instilling habits of reflective practice, with students obliged to record a journal of clinical experiences, and the seeking of feedback to help students improve their practice.

“It’s certainly an expectation that our students and graduates have, that they will be given feedback on their performance. If you went back 30 years, you would find that was not part of mainstream medical culture.”

Professor Ellwood indicated more could be done in the selection process for medical school, where judging for aptitude and character began.

“I think often the more confident, outgoing students do very well at interviews compared with those who are more thoughtful and reflective,” he said.

“Sometimes, you may mark students down because they are not particularly outgoing and confident, whereas their potential for being a good professional may be much higher.

“I think it’s an area where there needs to be much more research into the things that predict poor professional behaviour and how we can select for them.”

The challenge also remained to determine to what extent professional behaviour could be taught, and to what extent unprofessional behaviour in medical school manifested itself in unprofessional clinical practice, he said.

“There is some evidence that one translates into the other, but I don’t think we know what is best practice. There are simple things, such as the ability to work in teams, to prioritise, to manage time effectively and recognise conflicts of interest; these are skills that we would hope to be able to teach.

“But occasionally we see quite worrying behaviours, such as people being untruthful, academic misconduct, cheating at exams …

“You’ve also got to be mindful of the fact that that you are looking at students who are developing as professionals,” he said.  “They are not the finished product.”

Sarah Winch, head of medical ethics, law and professional practice at the University of Queensland’s School of Medicine, says UQ’s strategy relies on vigilance from all faculty members and providing students with very clear expectations from the start.

“We expect a good doctor to be honest, we expect them to be compassionate, we expect them to be humble, and to seek out new knowledge,” Dr Winch said.

“If we feel they do not have the character and temperament to be a modern doctor, and we have enough evidence before us to demonstrate that, they will be removed from the program.”

Where ethics and professionalism were an “external” element only 10 years ago, they were now a central part of UQ’s medical curriculum, she said.

“We have a motto: Professionalism is everyone’s business.

“We are looking for all staff to be teaching professionalism so we can provide not only the theoretical information but the modelling, and develop the character traits that are compatible with what the profession and the community want to see in a doctor.”

At their very first lecture, UQ medical students are told they are registered with AHPRA and can expect to face a higher level of professional and community expectation than they have known before.

“We tell our first-year students who have come from programs that are not under the public eye, you are always being scrutinised, so, please, don’t put on a set of scrubs and dance on tables, because we will hear about it.

“That has not happened in a long time,” she added. “They are a very observed group in the university.”

Red flags that would mark a student for counselling, or an investigation of their welfare, could include disrespect for colleagues, sexist remarks, poor attendance and angry outbursts.  Students were encouraged to be frank about stress in their personal lives, rather than boil over in a professional situation.

“This is not a profession where you can take your anger out on your colleagues,” Dr Winch said.

Educators and recent graduates agree that the weak link in professionalism and ethics training comes when medical students enter the workplace.

“Students are more inclined to learn from the behaviour of senior clinicians than to be guided by something they hear at university,” Dr Dominique Martin, senior lecturer in ethics and professionalism at Deakin University, said.

“They come back from clinical placements asking for advice, sometimes because they felt a doctor didn’t give a patient the time to ask questions or give the information for informed consent. It’s fantastic that our students raise these questions; they are the ones who are thinking and questioning, and demonstrating that they are reflecting.”

Professor Ellwood said it was important to prepare students for the fact that not everybody they interacted with in a workplace would behave well, and that some would behave poorly.

“What we try to do is ensure they are well equipped to recognise behaviours that are unprofessional.  There’s a lot of evidence that junior doctors and medical students learn a lot from role models and clinical mentors – and it’s important they pick good ones,” he said.

Recent graduate James Lawler said the proposed strengthening of professionalism and ethics could focus more on the transition to work and offer more support for life-long learning, in step with workforce needs.

“Reflecting on practice and measuring performance outcomes is not done as well (as it could be) in medical school, at least in terms of objective reflection. These are really useful skills to have,” he said.

He noted that the largest workforce deficiency was in rural GPs, and the group the board was most worried about, singled out in the November report, were practitioners working alone or in professional isolation from their peers.

“Also, for the expanding group of young doctors who are left after internship and before being accepted for a training program, they are going to need to keep up to date and improve themselves or they will never get on a training program.

“I would have thought that life-long learning and improvement was the most important area of work for medical schools.”

Dr Lawler suggested there was also room for improvement on “what it means to be professional in an intercollegiate sense”, in response to issues such as bullying, sexism and discrimination in the workplace.

“There are quite clear policies in every workplace against those things,” he said.

Dr Lawler, a former president of the Australian Medical Students Association, who completed his PGY1 training year in 2017, said the transition to work could expose a disconnect between teachings and reality.

“At medical school, you are taught about the importance of being professional in all these different ways,” he said.

“Then you enter the workforce and see that your peers, or the people who supervise you, don’t take these issues so seriously. I think that is more influential in how you will see these issues later on.”

After having been taught to write comprehensive and detailed clinical notes, for instance, junior doctors struggled with time constraints and observed experienced doctors who were not as diligent in their note taking, he said.

“Over time, junior doctors tend to write shorter notes, or not write notes at all.”

Compared with a generation ago, medical students are older and tend to have work experience and a previous degree, usually in the sciences. Nearly 60% of Australia’s graduating medical students in 2016 had entered their medical education as post-graduates.

According to Dr Martin, part of the challenge of teaching ethics is that the concepts are ill-defined, and any possible resistance is harder to gauge than egregious departures from accepted behaviour.

“It’s also a learning curve for educators,” she said, referring to the current generation of students’ greater experience in taking feedback and working in teams.

“Some teachers are not comfortable with someone sitting in on their class. For some people, it is threatening,” Dr Martin said. “Clinicians will often seek feedback and debriefings informally from their peers, but a more formal process is necessary.”

But while the emphasis on professionalism and ethics was important, some junior doctors fear the emphasis could be starting to verge on overkill.

“To be honest, I’m not too sure how much more they could emphasise it without pushing out some of the scientific content,” one trainee at a major regional NSW hospital, who asked to remain anonymous, told The Medical Republic.

“We actually had a junior doctors’ forum recently to discuss other issues in the hospital, and it came up that many junior doctors were dissatisfied because there was so much ethics and professionalism content (in in-house education) that it crowded out important clinical learning,” she said.

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Carolyn Baume
Carolyn Baume
1 month 10 days ago

Once upon a time a good hospital unit “firm “provided the necessary role models for ethical, professional behaviour as well as moral support for all.
Regular periodic peer meetings provide natural opportunities of similar kind