Lisa Soleymani Lehmann, MD, PhD; Lois Snyder Sulmasy, JD; Sanjay Desai, MD; for the ACP Ethics, Professionalism and Human Rights Committee *
Acknowledgment: The authors and the ACP Ethics, Professionalism and Human Rights Committee thank peer reviewers Mark A. Levine, MD; John M. Spandorfer, MD; and Colin P. West, MD, PhD, and the many leadership and journal reviewers of the paper for helpful comments on drafts, along with Daniel Kim for research assistance and Kathy Wynkoop for editorial assistance.
Financial Support: Financial support for the development of this paper comes exclusively from the ACP operating budget.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-2058.
Requests for Single Reprints: Lois Snyder Sulmasy, JD, Director, ACP Center for Ethics and Professionalism, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Lehmann: 27 Trinity Terrace, Newton, MA 02459.
Ms. Snyder Sulmasy: Director, ACP Center for Ethics and Professionalism, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Desai: Johns Hopkins University, 1830 East Monument Street, Room 9029, Baltimore, MD 21287.
Author Contributions: Conception and design: L.S. Lehmann, S. Desai.
Analysis and interpretation of the data: L.S. Lehmann, L. Snyder Sulmasy.
Drafting of the article: L.S. Lehmann, L. Snyder Sulmasy, S. Desai.
Critical revision of the article for important intellectual content: L.S. Lehmann, L. Snyder Sulmasy, S. Desai.
Final approval of the article: L.S. Lehmann, L. Snyder Sulmasy, S. Desai.
Administrative, technical, or logistic support: L. Snyder Sulmasy.
Collection and assembly of data: L.S. Lehmann, L. Snyder Sulmasy.
Much of what is formally taught in medicine is about the knowledge, skills, and behaviors required of a physician, including how to express compassion and respect for patients at the bedside. What is learned, however, includes not only admirable qualities but also behaviors and qualities that are inconsistent with ethics and professionalism. Positive role models may reinforce the character and values the profession seeks to cultivate; negative ones directly contradict classroom lessons and expectations of patients, society, and medical educators. These positive and negative lessons, which are embedded in organizational structure and culture, are the hidden curricula conveyed in medical schools, residency programs, hospitals, and clinics. This position paper from the American College of Physicians focuses on ethics, professionalism, and the hidden curriculum. It provides strategies for revealing what is hidden to foster the development of reflective and resilient lifelong learners who embody professionalism and clinicians who are, and are perceived as, positive role models. Making the hidden visible and the implicit explicit helps to create a culture reflecting medicine's core values.
Table. Types of Curricula*
Appendix Table 1. Vignettes
Appendix Table 2. Strategies for Revealing the Hidden Curriculum
Appendix Table 3. Strategies for Mitigating the Risks of the Hidden Curriculum
Dinesh John, Tanya George
Syracuse VA Medical Center, SUNY-Upstate Medical University
April 24, 2018
In Deep Hiding: Error and Near Miss Reporting
I enjoyed reading ACP's position paper on the hidden curriculum referring to lessons embedded in culture. Having said that, I feel that an opportunity was missed to emphasize a key facet of patient safety culture-error and near-miss reporting. IF ethics and professionalism are considered to be the hidden curriculum, I consider near-miss reporting to be in 'deep hiding.' Attending physicians might pay lip service to this concept, but seldom use near-miss reporting as a teachable moment for house-staff and medical students. Healthcare remains decades behind so-called High Reliability Organizations or HRO's, for which near-miss reporting is a cornerstone of safety culture. I vividly remember my days as a trainee, where errors were routinely swept under the rug under the watch of the attending physician, and the concept of a near miss was nonexistent. We have made baby steps in this regard, but we have a long way to go before we can make a serious dent in the 250,000 or so lives that are lost every year due to medical error. References1. Makary MA, Daniel M. Medical Error- The Third Leading Cause of Death in the US. BMJ 2016;353:i21392. Van Spall H, Kassam A, Tollefson TT. Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare. Curr Opin Otolaryngol Head Neck Surg. 2015 Aug;23(4):292-6
Mano Soshi, Yasuharu Tokuda
April 26, 2018
Unprofessional behaviors of medical doctors in Japan are currently at issue
The necessity of professionalism education for undergraduate medical students is increasing in Japan, and many universities are in the process of establishing ways to evaluate professionalism among Japanese medical students. One of Japan’s solutions is to identify and penalize medical students who conducted seemingly unprofessional, or sometimes disruptive, behaviors. We think this solution poses a serious issue because this tries to assess not only the behavior (or the “doing”) of medical students but also their character or personality (or their “being”). What we truly need to assess is “whether a behavior is professional”, not “whether a medical student is professional” since medical students are amid becoming professional. We should focus more on behaviors themselves and share the experiences and insights between universities, medical students, and medical doctors to enhance the learning of professionalism through open discussion. The assessment may better be evaluated through 360-degree style by peer students, teachers and other university staff. A professional is introspective about he/she’s own behavior and is willing to take accountability for he/she’s own actions and it is important what and how we use its assessment criteria for nurturing this attitude be nurtured using.ReferencesArnold L, Stern DT. What is medical professionalism? In: Stern DT, editor. Measuring Medical Professionalism. New York, NY: Oxford University Press; 2006. p. 15–37.Mak-van der Vossen M, van Mook W, van der Burgt S, Kors J, Ket JCF, Croiset G,Kusurkar R. Descriptors for unprofessional behaviours of medical students: asystematic review and categorisation. BMC Med Educ. 2017 Sep 15;17(1):164.
Lisa Soleymani Lehmann, MD, PhD Lois Snyder Sulmasy, JD Sanjay Desai, MD
Johns Hopkins, VA, ACP
June 8, 2018
We appreciate the insightful comments of our readers and agree with John Dinesh and Tanya George that near-miss reporting is buried deep in our clinical culture. Attending physicians should seize the opportunity to create a culture of speaking up by encouraging discussion of potentially harmful errors that serendipitously did not result in patient harm. Reporting these close calls and taking the time to reflect on why the near-miss occurred, what harm was averted, and how we can develop systems to prevent the error is essential to creating a culture of improvement in which patient safety is paramount. The ability to infuse ethics and professionalism into our learning environments can also help us address human behavior in complex systems. A punitive approach to errors that are secondary to faulty systems is bound to lead to fear of reporting errors, fewer errors being reported, and missed opportunities to improve our systems to ensure safe patient care. We share the concerns about Japan's approach to evaluating professionalism among medical students. Educating students about professionalism, having positive role models, and coaching students when corrective action is indicated can help create safer patient care. Lisa Soleymani Lehmann, MD, PhD Lois Snyder Sulmasy, JD Sanjay Desai, MD
Lehmann LS, Sulmasy LS, Desai S, for the ACP Ethics, Professionalism and Human Rights Committee. Hidden Curricula, Ethics, and Professionalism: Optimizing Clinical Learning Environments in Becoming and Being a Physician: A Position Paper of the American College of Physicians. Ann Intern Med. 2018;168:506–508. [Epub ahead of print 27 February 2018]. doi: https://doi.org/10.7326/M17-2058
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Published: Ann Intern Med. 2018;168(7):506-508.
Published at www.annals.org on 27 February 2018
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