E
d it o r ia l
MILITARY MEDICINE, 180, 5:488, 2015
P ro fe s s io n a lis m : A S tu d e n t P e rs p e c tiv e ENS Dawn P. Callahan, MC USN INTRODUCTION Before commissioning as an officer in the U.S. military, the topic of professionalism had always seemed akin to modern art, easy to point out yet hard to describe. I had never really given it any significant thought beyond an unconscious attempt to portray it; whatever “it” was. The military has introduced me to the concept of explicitly train ing professional behaviors and helped me to define specific characteristics of professional behavior. What was once seemingly indefinable has become a conscious and prac ticed set of skills. At the Uniformed Services University of the Health Sci ences (USU), professionalism is emphasized as a require ment for graduation in accordance with Liaison Committee on Medical Education 2014 Core Competencies.1 As a medi cal student surrounded by military custom day-in and dayout, my understanding of “military” professionalism had been established with training, and reinforced with daily practice. The concept of “medical” professionalism, however, was not as clear to me. Military professionalism appears black and white, with clear regulations about right and wrong. Medical professionalism, on the other hand, is more “gray,” with an unwritten scale of what appears to be accept able professional behaviors. In medical school, we are explicitly evaluated on our fund of knowledge and medical communication with patients and staff. We are also evaluated on “professionalism,” however because of a lack of well-defined metrics, this is often sub jective. Much research has been published attempting to define medical professionalism and how to measure it. One proposed measurement tool is the Professionalism Mini-Evaluation Exercise (P-MEX).2 The P-MEX has been shown to be a valid and accurate measurement of profes sional behaviors in medical students.3 This tool highlights 24 professional behaviors in four primary domains: (1) Doctor-Patient Relationship (2) Reflective Skills
Uniformed Services University of the Health Sciences. Bethesda, MD 20814. doi: 10.7205/MILMED-D-14-00587
488
(3) Time Management (4) Interprofessional Skills As a “dual hatted” military and medical officer, it is has been easier for me to describe examples of military professionalism compared to medical professionalism. The P-MEX domains have helped me to better understand medical professionalism in the context of my own mili tary experience and can provide an important evaluation tool for all medical educators. DOCTOR-PATIENT RELATIONSHIP What makes an ideal doctor-patient relationship? I would argue that no two patients are alike and the perfect inter action is based on the personalities of both provider and patient. The same is true in the military hierarchy; however, in the military, there are clear boundaries and an explicit chain of command. Military rank and culture exist to pro vide order and set expectations. This delineation leaves no room for interpretation and no gray area. Everyone plays an important role in accomplishing the mission within their sphere of influence and responsibility. In medicine, the goals of any patient visit may vary and the patient/provider may not be on the same page or have different agendas. As a result, a physician may need to play several roles to meet patient-driven needs within the context of safe and appro priate care. This leaves abundant room for interpretation as to how best to react and perform in different clinical set tings. The bottom line is that the military has defined roles, but everyone understands that team-based performance promotes mission accomplishment. In medicine, the goals of any patient visit may vary and the patient/provider may have different agendas. As a result, a physician needs to be flexible to meet patient-driven needs within the context of safe and appropriate care. REFLECTIVE SKILLS Reflection is arguably the most difficult and obscure factor playing into the concept of medical professionalism. How much reflection does it take to determine deficits and how does one effectively do that? Recognizing gaps in knowl edge, rusty procedural skills, or bad communication techniques
M ILITA R Y M E D IC IN E , Vol. 180. May 2015
Editorial
is only a portion of establishing a reflective practice. Making personal changes to transform identified deficits into posi tive outcomes is a difficult, but necessary, key to profes sional success. The military accomplishes this through annual performance reviews. This gives service members the explicit opportunity to reflect on their accomplishments and deficits and make changes for the better. Promotion to a higher rank hinges on outstanding performance reviews, providing ample motivation to succeed. Similar to the military performance reviews, medical learners receive formative and summative performance feedback on a regular basis. Unfortunately, this feedback, as noted in the common expression “you are doing a good job,” is often nonspecific and does not provide explicit guidance for performance improvement. Good, constructive feedback takes time and effort on the evaluator’s part. Often this is low on the list of competing priorities that medical educators all face. Without personal reflection and thoughtful feedback, however, identifying and changing unprofessional behaviors is unlikely to happen. TIME MANAGEMENT Timeliness is the most objective and measurable factor that plays a role in professionalism. Military culture can take timeliness to the extreme as exemplified by the saying “If you are 15 minutes early, you are late.” Time management is ingrained in military personnel from the first moments of training. In my experience, the medical culture has become complacent with this ideal. The importance of timeliness is often easily dismissed. Patients often expect not to be seen at their scheduled appointment time. Although some patients need additional attention and therefore inevitable delays arise, the failure to acknowledge tardiness and apologize to the patients for this lacks professional detail. Every patient’s time is just as valuable as yours. The end goal for both military and medical professionals is the same, respect for others and their precious time. INTERPROFESSIONAL SKILLS Patient encounters are one example of the many relation ships necessary to function effectively and efficiently as a medical team. Modem health care is a team sport and the interactions between physicians and support staff establish the dynamics for the entire practice. In the military, cus tomary courtesies (greetings, salutes, and use of profes sional titles) are grounded in a core of common respect. As a medical student, however, I have witnessed more non
MILITARY MEDICINE, Vol. 180, M ay 2015
constructive criticism than collegial praise. Overcoming this “hidden curriculum” within medical education is long overdue. I would like to more often see a resident highlight the clinical thinking of a colleague or witness an attend ing physician thank the corpsman for attending to the small clinical details necessary for a successful visit. Outstanding patient-centered medicine requires a team effort. Team cohe siveness cannot be achieved if respect is not at the core. Personality conflicts are inevitable. However, as we salute rank in the military to show respect, we need to render similar respect to all members of the health care team, regardless of roles or differences in personality. CONCLUSION My time at USU has given me a unique perspective on what skills and behaviors define becoming a medical pro fessional. I feel fortunate to have chosen two careers that simultaneously emphasize the importance of profession alism. Although the ways in which professionalism is mea sured and achieved are different, having both experiences only strengthens the drive to perfect the skills necessary. My military training provides me with a strong foundation of professionalism upon which to build my ever-developing medical career. Using lessons learned at USU, my evolving definition of professionalism is relatively simple. For me, professionalism is applying skill and moral courage to exer cise personal attributes that benefit others and reflect posi tively on my chosen profession. “Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excel lence but rather we have those because we have acted rightly. We are what we repeatedly do. Excellence then is not an act but a habit.”—Aristotle4
REFERENCES 1. Liaison Committee on Medical Education: Functions and Structure of a Medical School, 2014. Available at http://www.lcme.org/publications .htm; accessed September 15, 2014. 2. Cruess RL, Herold-Mcllroy J, Cruess SR, Ginsberg S, Steinert Y: The Professionalism Mini-evaluation Exercise: a preliminary investigation. Acad Med 2006; 81: S74-8. 3. Tsugawa Y. Ohbu S, Cruess R. et at: Introducing the Professionalism Mini-Evaluation Exercise (P-MEX) in Japan: results from a multicenter, cross-sectional study. Acad Med 2011; 86: 1026-31. 4. Durant W: The Story of Philosophy: The Lives and Opinions of the World’s Greatest Philosophers. New York, NY, Pocket Books, 1991.
489
Copyright of Military Medicine is the property of AMSUS and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
d it o r ia l
MILITARY MEDICINE, 180, 5:488, 2015
P ro fe s s io n a lis m : A S tu d e n t P e rs p e c tiv e ENS Dawn P. Callahan, MC USN INTRODUCTION Before commissioning as an officer in the U.S. military, the topic of professionalism had always seemed akin to modern art, easy to point out yet hard to describe. I had never really given it any significant thought beyond an unconscious attempt to portray it; whatever “it” was. The military has introduced me to the concept of explicitly train ing professional behaviors and helped me to define specific characteristics of professional behavior. What was once seemingly indefinable has become a conscious and prac ticed set of skills. At the Uniformed Services University of the Health Sci ences (USU), professionalism is emphasized as a require ment for graduation in accordance with Liaison Committee on Medical Education 2014 Core Competencies.1 As a medi cal student surrounded by military custom day-in and dayout, my understanding of “military” professionalism had been established with training, and reinforced with daily practice. The concept of “medical” professionalism, however, was not as clear to me. Military professionalism appears black and white, with clear regulations about right and wrong. Medical professionalism, on the other hand, is more “gray,” with an unwritten scale of what appears to be accept able professional behaviors. In medical school, we are explicitly evaluated on our fund of knowledge and medical communication with patients and staff. We are also evaluated on “professionalism,” however because of a lack of well-defined metrics, this is often sub jective. Much research has been published attempting to define medical professionalism and how to measure it. One proposed measurement tool is the Professionalism Mini-Evaluation Exercise (P-MEX).2 The P-MEX has been shown to be a valid and accurate measurement of profes sional behaviors in medical students.3 This tool highlights 24 professional behaviors in four primary domains: (1) Doctor-Patient Relationship (2) Reflective Skills
Uniformed Services University of the Health Sciences. Bethesda, MD 20814. doi: 10.7205/MILMED-D-14-00587
488
(3) Time Management (4) Interprofessional Skills As a “dual hatted” military and medical officer, it is has been easier for me to describe examples of military professionalism compared to medical professionalism. The P-MEX domains have helped me to better understand medical professionalism in the context of my own mili tary experience and can provide an important evaluation tool for all medical educators. DOCTOR-PATIENT RELATIONSHIP What makes an ideal doctor-patient relationship? I would argue that no two patients are alike and the perfect inter action is based on the personalities of both provider and patient. The same is true in the military hierarchy; however, in the military, there are clear boundaries and an explicit chain of command. Military rank and culture exist to pro vide order and set expectations. This delineation leaves no room for interpretation and no gray area. Everyone plays an important role in accomplishing the mission within their sphere of influence and responsibility. In medicine, the goals of any patient visit may vary and the patient/provider may not be on the same page or have different agendas. As a result, a physician may need to play several roles to meet patient-driven needs within the context of safe and appro priate care. This leaves abundant room for interpretation as to how best to react and perform in different clinical set tings. The bottom line is that the military has defined roles, but everyone understands that team-based performance promotes mission accomplishment. In medicine, the goals of any patient visit may vary and the patient/provider may have different agendas. As a result, a physician needs to be flexible to meet patient-driven needs within the context of safe and appropriate care. REFLECTIVE SKILLS Reflection is arguably the most difficult and obscure factor playing into the concept of medical professionalism. How much reflection does it take to determine deficits and how does one effectively do that? Recognizing gaps in knowl edge, rusty procedural skills, or bad communication techniques
M ILITA R Y M E D IC IN E , Vol. 180. May 2015
Editorial
is only a portion of establishing a reflective practice. Making personal changes to transform identified deficits into posi tive outcomes is a difficult, but necessary, key to profes sional success. The military accomplishes this through annual performance reviews. This gives service members the explicit opportunity to reflect on their accomplishments and deficits and make changes for the better. Promotion to a higher rank hinges on outstanding performance reviews, providing ample motivation to succeed. Similar to the military performance reviews, medical learners receive formative and summative performance feedback on a regular basis. Unfortunately, this feedback, as noted in the common expression “you are doing a good job,” is often nonspecific and does not provide explicit guidance for performance improvement. Good, constructive feedback takes time and effort on the evaluator’s part. Often this is low on the list of competing priorities that medical educators all face. Without personal reflection and thoughtful feedback, however, identifying and changing unprofessional behaviors is unlikely to happen. TIME MANAGEMENT Timeliness is the most objective and measurable factor that plays a role in professionalism. Military culture can take timeliness to the extreme as exemplified by the saying “If you are 15 minutes early, you are late.” Time management is ingrained in military personnel from the first moments of training. In my experience, the medical culture has become complacent with this ideal. The importance of timeliness is often easily dismissed. Patients often expect not to be seen at their scheduled appointment time. Although some patients need additional attention and therefore inevitable delays arise, the failure to acknowledge tardiness and apologize to the patients for this lacks professional detail. Every patient’s time is just as valuable as yours. The end goal for both military and medical professionals is the same, respect for others and their precious time. INTERPROFESSIONAL SKILLS Patient encounters are one example of the many relation ships necessary to function effectively and efficiently as a medical team. Modem health care is a team sport and the interactions between physicians and support staff establish the dynamics for the entire practice. In the military, cus tomary courtesies (greetings, salutes, and use of profes sional titles) are grounded in a core of common respect. As a medical student, however, I have witnessed more non
MILITARY MEDICINE, Vol. 180, M ay 2015
constructive criticism than collegial praise. Overcoming this “hidden curriculum” within medical education is long overdue. I would like to more often see a resident highlight the clinical thinking of a colleague or witness an attend ing physician thank the corpsman for attending to the small clinical details necessary for a successful visit. Outstanding patient-centered medicine requires a team effort. Team cohe siveness cannot be achieved if respect is not at the core. Personality conflicts are inevitable. However, as we salute rank in the military to show respect, we need to render similar respect to all members of the health care team, regardless of roles or differences in personality. CONCLUSION My time at USU has given me a unique perspective on what skills and behaviors define becoming a medical pro fessional. I feel fortunate to have chosen two careers that simultaneously emphasize the importance of profession alism. Although the ways in which professionalism is mea sured and achieved are different, having both experiences only strengthens the drive to perfect the skills necessary. My military training provides me with a strong foundation of professionalism upon which to build my ever-developing medical career. Using lessons learned at USU, my evolving definition of professionalism is relatively simple. For me, professionalism is applying skill and moral courage to exer cise personal attributes that benefit others and reflect posi tively on my chosen profession. “Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excel lence but rather we have those because we have acted rightly. We are what we repeatedly do. Excellence then is not an act but a habit.”—Aristotle4
REFERENCES 1. Liaison Committee on Medical Education: Functions and Structure of a Medical School, 2014. Available at http://www.lcme.org/publications .htm; accessed September 15, 2014. 2. Cruess RL, Herold-Mcllroy J, Cruess SR, Ginsberg S, Steinert Y: The Professionalism Mini-evaluation Exercise: a preliminary investigation. Acad Med 2006; 81: S74-8. 3. Tsugawa Y. Ohbu S, Cruess R. et at: Introducing the Professionalism Mini-Evaluation Exercise (P-MEX) in Japan: results from a multicenter, cross-sectional study. Acad Med 2011; 86: 1026-31. 4. Durant W: The Story of Philosophy: The Lives and Opinions of the World’s Greatest Philosophers. New York, NY, Pocket Books, 1991.
489
Copyright of Military Medicine is the property of AMSUS and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
