모든 unprofessional한 행동이 같은 것은 아니다: 나쁜 행동의 체크리스트 (Med Teach, 2017)

모든 unprofessional한 행동이 같은 것은 아니다: 나쁜 행동의 체크리스트 (Med Teach, 2017)

Not all unprofessional behaviors are equal: The creation of a checklist of bad behaviors

Michael J. Cullena, Mojca R. Koniab, Emily C. Borman-Shoapc, Jonathan P. Bramand, Ezgi Tiryakie, f, Brittany Marcus-Blanka and John S. Andrewsa

aGraduate Medical Education, University of Minnesota, Minneapolis, MN, USA; bDepartment of Anesthesiology, University of Minnesota, Minneapolis, MN, USA; cDepartment of Pediatrics, University of Minnesota, Minneapolis, MN, USA; dDepartment of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA; eMinneapolis VA Health Care System, Minneapolis, MN, USA; fDepartment of Neurology, University of Minnesota, Minneapolis, MN, USA

도입

Introduction

연구에 따르면 팀워크와 존경과 같은 전문적인 행동은 환자 결과의 개선, 환자 만족도 향상 (Grumbach & Bodenheimer 2004), 치료 계획 준수 강화와 관련이 있음을 보여주었습니다 (Beach et al. 2005). 반대로 프로답지 않은 행동은 프로페셔널리즘에 대한 교수들의 부정적인 평가 (Stern et al. 2005)와 나중에 국가 의료위원회 (Papadakis et al. 2005)의 징계 조치와 관련이있다. 개인에 대한 영향 외에도 전문성 위반은 의료계 자체의 명성에 부정적인 영향을 미침으로써 상당한 집단 차원의 비용을 초래할 수 있습니다.

Studies have shown that professional behaviors such as teamwork and respect are correlated with improved patient outcomes, higher patient satisfaction (Grumbach & Bodenheimer 2004), and greater adherence to treatment plans (Beach et al. 2005). Conversely, unprofessional behaviors are associated with negative faculty assessments of professionalism (Stern et al. 2005) and later disciplinary action by state medical boards (Papadakis et al. 2005). In addition to their effects on individuals, breaches of professionalism can have significant group-level costs by negatively affecting the reputation of the medical profession itself.

연수생, 환자 및 직업에 대한 의사의 부정 행위의 결과가 심각하기 때문에, 프로페셔널하지 못한 행동을 감지하기위한 "조기 경보 시스템"이 필요하다.

The serious consequences of physician misconduct on trainees, patients, and the profession argue in favor of an “early warning system” for detecting unprofessional behaviors.

전문성 문제를 확인하기위한 공식적인 시스템 외에도 직접 관찰 도구가 개발되었습니다. Mini-Clinical Evaluation Exercise (Mini-CEX) (Norcini et al. 2003) 및 Professionalism Mini-Evaluation Exercise (P-MEX)와 같은 도구가 포함됩니다 (Cruess et al., 2006).

In addition to formal systems for identifying professionalism issues, direct observation tools have been developed. These include tools such as the Mini-Clinical Evaluation Exercise (mini-CEX) (Norcini et al. 2003) and the Professionalism Mini-Evaluation Exercise (P-MEX) (Cruess et al. 2006).

P-MEX는 환자와의 만남, 소그룹 세션 및 사인 아웃 라운드를 포함 해 의대생의 행동을 관찰 할 수있는 모든 상황에서 사용할 수 있도록 설계되었습니다. P-MEX는 mini-CEX를 기반으로 관찰해야 할 더욱 구체적인 행동을 식별하여 개발되었다.

The P-MEX was designed for use in any situation where a medical student’s behavior can be observed, including patient encounters, small group sessions, and sign-out rounds. It builds upon the mini-CEX by identifying a set of even more specific behaviors to be observed.

프로페셔널리즘 문제를 발견하기위한 모든 직접 관찰 도구의 한 가지 일반적인 특징 (Arnold et al., 1998; Reed et al., 2008)은 긍정적이거나 부정적인 전문성 행동의 관측적인 "체크리스트"를 사용하는데, 직접적으로 평가되거나, 척도의 형태로 행동 앵커로 사용된다. 이러한 체크리스트는 개선 노력을 안내하는 데 도움이 된다는 점에서 가치가 있습니다. 몇몇 연구자들은 치료가 목표 일 때 특정적이고 관찰 가능한 전문적이지 않은 행동에 초점을 맞추는 평가 방법이 도움이된다고 주장했다 (Hawkins et al., 2009). 

One common feature of all direct observation tools for detecting professionalism issues (Arnold et al. 1998; Reed et al. 2008) is that they employ an observational “checklist” of positive or negative professionalism behaviors, which are either rated directly or serve as behavioral anchors in a scale. Such checklists have the value of being specific, to help guide remediation efforts. Several researchers have argued that when remediation is the goal, an assessment method that focuses on specific, observable unprofessional behaviors is helpful (Hawkins et al. 2009). 

지금까지 설계된 점검표의 중요한 한계는 행동의 심각성을 구분하지 않는다는 것입니다 (Arnold 2002). 특히, 현존하는 전문성 체크리스트는 

• (a) 개별적으로 발생하는 행동의 상대적 중대성 비교 여부를 비교하지 못하며

• (b) 행동의 중대성이 발생 빈도에 영향을 받는지 여부를 구분하지 않습니다. 

An important limitation of the checklists designed so far is that they do not distinguish between the severity of the behaviors on the lists (Arnold 2002). In particular, existing professionalism checklists do not 

• (a) distinguish between the relative egregiousness of behaviors that occur in isolation or 

• (b) indicate whether the egregiousness of behaviors is affected by their frequency of occurrence. 

우리는 프로페셔널하지 못한 모든 행동을 개별적으로 보면, 모두 동등하지는 않을 가능성이 있기 때문에 이러한 구분이 중요하다고 생각합니다. 

• 예를 들어, 약물 남용의 징후를 표시하는 등 일부 행동은 너무 심각하여 단 한번만으로도 즉각적인 개선을 필요로 할 수 있습니다. 

• 대조적으로, 일부 행동 (예 : 비판에 방어 적으로 반응)은 잘못된 행동의 패턴이 시간이 지남에 따라 나타납니다. 

따라서 이러한 고려 사항을 고려한 전문성 체크리스트를 개발하는 것이 바람직합니다.

We believe these distinctions are important because it is possible that not all unprofessional behaviors are equally serious in isolation. 

• For instance, some behaviors (e.g. displaying signs of substance abuse) may be so serious that a single occurrence of the behavior requires immediate remediation. 

• In contrast, some behaviors (e.g. reacting defensively to criticism) may only be concerning when a pattern of misbehavior emerges over time. 

It would be desirable, therefore, to develop a professionalism checklist that takes these considerations into account.

정책 캡처는 의사 결정자가 평가 판단을 내릴 때 이용 가능한 정보를 사용하는 방법을 평가하기 위해 연구자가 사용하는 방법입니다. 이 방법론의 목적은 개별 심사 위원의 의사 결정 정책, 즉 정보의 가중치, 결합 또는 통합 방법을 포착하는 것입니다. 의사 결정자에게 여러 수준의 하나 이상의 설명 요인을 설명하는 일련의 시나리오를 판단한 다음 통계적 방법을 사용하여 의사 결정자가 자신의 의사 결정 프로세스에서 각 요소에주는 중점을 결정하도록 요구하는 것이 포함됩니다 (Zedeck 1977).

Policy capturing is a method employed by researchers to assess how decision makers use available information when making evaluative judgments. The purpose of this methodology is to capture individual judges’ decision-making policies, that is, how they weight, combine, or integrate information. It involves asking decision makers to judge a series of scenarios describing various levels of one or more explanatory factors, and then using statistical methods to determine the emphasis decision makers give to each factor in their decision-making process (Zedeck 1977).

방법

Method

역량 모델의 개발과 타당화

Competency model development and validation

Using the behaviors gleaned from this process, the first author rationally sorted them into seven “institution-level” professionalism dimensions and associated behaviors. In the creating the model, the focus was on identifying observable behaviors that could be reliably assessed by members of a trainee’s interprofessional team. The dimensions and facets (in brackets) included: 

• (1) Conscientiousness (dependability, planning/organizing, thoroughness), 

• (2) Aspiring to Excellence (work commitment, motivation to learn), 

• (3) Integrity (trustworthiness, discretion, personal conduct, organizational citizenship), 

• (4) Accountability (personal responsibility, self-awareness), 

• (5) Teamwork (cooperation, respectful interaction, team building), 

• (6) Patient-Centeredness (compassion, respect for diversity, humanism), and 

• (7) Stress Tolerance (situational stress tolerance, interpersonal stress tolerance). 

The first author used the behaviors contained within the dimensions to define each dimension and associated facet.

At this stage, the behaviors were phrased positively. For instance, within the Integrity dimension, the model included such behaviors as “demonstrates honesty in interactions with patients, families, and other health care professionals” and “protects confidentiality of sensitive patient and co-worker information.”

The final professionalism dimensions and facets are displayed in Table S1 (available online as Supplemental Material), and the final validation results are in Table S2 (available online as Supplemental Material).

프로페셔널하지 못한 행동의 리스트 생성

Generating a list of unprofessional behaviors

In order to generate a list of unprofessional behaviors that aligned with the professionalism model, we asked workshop participants to translate each positive behavior in the model into an equivalent negative behavior. For instance, the positive behavior from the Conscientiousness dimension “demonstrates regular and punctual attendance” became “arrives late for conferences, rounds, or other work-related meetings.” This translation exercise resulted in the generation of 70 non-overlapping negative professionalism-related behaviors. 

Determining the relative egregiousness of unprofessional behaviors

To determine the relative egregiousness of these 70 unprofessional behaviors, we asked workshop participants to indicate how concerned they would be if a trainee engaged in each behavior 1, 2, 3, 4, or “5 or more” times during a sixmonth period.

The concern scale ranged from 1 to 4 (

• 1¼not concerned, 

• 2¼a little concerned, 

• 3¼somewhat concerned, and 

• 4¼very concerned, a meeting with the program director is required). 

Thus, for each behavior, raters made five ratings, showing their level of concern for each of the five possible frequencies of occurrence. Using these ratings, we computed the mean concern rating for each behavior, for each possible frequency of occurrence.

To capture the “overall” level of egregiousness of each behavior across all frequencies of occurrence, we also created a “concern index” (CI) for each behavior by summing the scores for each behavior for each frequency of occurrence. Thus, 

• the maximum possible score on the CI for a behavior was 20 (i.e. a maximum mean rating of 4 for each behavior for each of the five possible frequencies of occurrence), while 

• the minimum was 5 (i.e. a minimum mean rating of 1 for each behavior for each of the five possible frequencies of occurrence).

Creating the final professionalism checklists

Table S3).

Results

Table S3 reveals that 14 behaviors were judged to be at least somewhat concerning if they occur even once. These behaviors included: 

(a) 물질 남용의 명백한 징후를 나타내는 것,

(b) 동료들에 대한 폭력적인 행동을 보여주는 것,

(c) 개인의 이익을 위해 의사로서의 지위를 이용하여,

(d) 환자, 가족 또는 다른 의료 전문가와 진실되게 상호 작용하지 못하고,

(e) 동료 나 환자를 차별하는 것,

(f) 연구 및 학술 활동에 대한 윤리적 기대를 지키지 못하고,

(g) 환자를 경멸하는 모습,

(h) 그들의 잘못이 아닌 오류에 대한 동료 비난,

(i) 사실을 허위 진술하거나, 공평하게 사실을 제시하지 못한 경우,

(j) 의도적으로 사이트 규칙 및 절차를 무시하고,

(k) 전자 의료 기록에 잘못된 정보를 포함하는 것,

(l) 공개적으로 동료를 비판하는 방식으로 비판하는 것,

(m) 환자의 필요를 환자의 필요 이상으로 두는 것,

(n) 환자 그룹에 대한 고정 관념.

(a) displaying obvious signs of substance abuse, 

(b) demonstrating abusive behavior toward co-workers, 

(c) using one’s status as a doctor for personal gain, 

(d) failing to interact truthfully with patients, families, or other healthcare professionals, 

(e) discriminating against co-workers or patients, 

(f) failing to uphold ethical expectations of research and scholarly activity, 

(g) showing disrespect toward patients, 

(h) blaming co-workers for errors that were not their fault, 

(i) misrepresenting facts, or failing to present facts impartially, 

(j) knowingly disregarding site rules and procedures, 

(k) including erroneous information in the electronic medical record, 

(l) criticizing co-workers in public in a non-respectful manner, 

(m) putting one’s individual needs above the needs of patients, and 

(n) stereotyping about groups of patients.

Behaviors with the lowest concern indices included: 

(1) 결과 또는 만족도를 결정하기 위해 환자를 추적하지 못한 경우 (CI = 14.66),

(2) 환자들에게 질문을하도록 권유하지 않는 것 (CI14.50),

(3) 팀 상호 작용을 부적절하게 지배 (CI14.50),

(4) 비 체계적으로 업무에 접근 (CI 12.23),

(5) 회의, 라운드 또는 기타 업무 관련 회의에 늦게 도착한 경우(CI 11.18).

(1) failing to follow up with patients to determine outcomes or satisfaction (CI ¼14.66), 

(2) not encouraging patients to ask questions (CI ¼14.60), 

(3) inappropriately dominating team interactions (CI ¼14.50), 

(4) approaching work tasks unsystematically (CI ¼12.23), and 

(5) arriving late for conferences, rounds, or other work-related meetings (CI ¼11.18).

Table 1 provides CI for professionalism dimensions across all behaviors in each dimension. The professionalism dimension with the greatest overall average CI is Integrity (average CI ¼18.47) and the professionalism dimension with the lowest overall CI is Conscientiousness (average CI ¼14.77). Table 1 suggests that while all professionalism breaches are important, breaches of the Integrity domain are viewed to be most concerning.

고찰

Discussion

우리는 프로페셔널리즘 역량 모델을 검증하고 교육 전문가들의 평가에 기초한 "요약" 및 "확장"전문성 체크리스트를 작성했습니다. "요약" 점검표는 문제가 발생하는 경우 해당 문제가 발생했는지, 치료가 필요한지를 식별한다. 두 번째 "확장 된"체크리스트는 우려가 되고 교정이 필요한 덜 심각한 행동에 대해서 패턴을 확인한다.

We validated a professionalism competency model and created both a “brief” and “extended” professionalism checklist based on ratings by education experts. The “brief” checklist identifies those behaviors that are concerning, and require remediation, if they occur at all. The second “extended” checklist identifies patterns of misconduct in less serious behaviors that are concerning and require remediation.

• 첫째, unprofessional 행동은 egregiousness의 정도가 다르다는 것을 보여줍니다.

• 둘째, 우리의 연구는 독립적으로 발생하는 unprofessional 행동과 행동의 패턴을 대표하는 것과 비교하기위한 프레임 워크를 만듭니다.

• 셋째,이 연구는 초기 징후 의사를 확인하고 문서화하는 데 어려움을 겪을 수있는 경험적으로 입증 된 전문성 체크리스트 2 개를 생성했습니다.

• First, it demonstrates that unprofessional behaviors vary in their level of egregiousness.

• Second, our work creates a framework for comparing unprofessional actions that occur in isolation to those that represent a pattern of behavior.

• Third, this study generated two empirically validated professionalism checklists that can be used for of trouble in identifying and documenting early signs physicians.

이 작업에는 한계가 있습니다. 첫째, 체크리스트의 개발은 필연적으로 주관적이다. 그것은 임상 학문, 기관, 그리고 가장 중요하게는 문화 전반에 걸쳐 의견을 넓히려는 미래의 노력으로부터 이익을 얻을 것입니다. 최근 연구에 따르면 unprofessional 로 간주되는 행동에 관한 중요한 지역적 차이가있을 수 있습니다 (Chandratilake 외. 2012; Jha 외 2015). 따라서 이러한 행동의 순위는 다른 국가의 의료 시스템의 문화적 맥락과 고유 한 특성에 따라 다를 수 있습니다.

There are limitations to this work. First, the development of the checklist is necessarily subjective. It would benefit from future efforts to broaden input across clinical disciplines, institutions, and most importantly, across cultures. Recent research suggests that there may be important regional differences regarding which behaviors are considered unprofessional (Chandratilake et al. 2012; Jha et al. 2015). Thus, the rankings of these behaviors may vary depending on the cultural context and unique properties of healthcare systems in different countries.

개선 방안과 관련하여 우리는 "간단한 체크리스트"행동이 발생할 때마다 개입하기로 결정했습니다. 왜냐하면 이러한 행동이 한 번 발생하더라도 최소한 정의에 따라 다소 "somewhat concerning"하기 때문에 개입하기로 결정했습니다. 마찬가지로 확장 된 체크리스트의 모든 행동에서의 부정 행위 패턴이 동일한 우려 수준에 도달하면 개선 조치가 나타납니다.

Regarding the triggers for remediation, we have decided to intervene whenever any of the “brief checklist” behaviors occurs since even one occurrence of these behaviors is by definition at least “somewhat concerning”. Similarly, remediation is indicated when a pattern of misconduct in any behavior in the extended checklist reaches the same level of concern.

접근 방식에 관계없이 평가의 모범 사례는 두 가지 체크리스트에 대한 피드백이 여러 출처에서 나와야하며, 학습자의 interprofessional team에서 가능한 많은 구성원을 포함해야한다고 제안합니다 (Goldie 2013). 이러한 다중 소스 피드백 시스템은 업계에서는 빈번하게 사용되지만 의료 환경에서는 그다지 일반적으로 사용되지 않습니다 (Hawkins 외 2009).

Regardless of the approach taken, best practices in assessment suggest that feedback for both checklists should come from multiple sources, and include as many members of a learner’s interprofessional team as possible (Goldie 2013). Such multisource feedback systems are used frequently in industry, but less commonly in medical settings (Hawkins et al. 2009).

또한 여러 평가자의 통찰력을 포함하여 여러 평가자 그룹이 학습자를 보는 방법을 비교할 수 있으므로 학습자에게 피드백을 제공 할 때 도움이 될 수 있습니다. 관찰 된 행동에 대해 학습자에게 피드백을 제공하는 것은 모든 치료 계획의 핵심 부분이지만, 누구나 그러한 피드백을 제공하는 전문 기술을 가졌을 것으로 생각해서는 안된다.

In addition, including insights from multiple raters allows for a comparison of how different rater groups view the learner, which can be helpful when providing feedback to learners. The provision of feedback to learners about behaviors observed is a key part of any remediation plan, and expertise in providing that feedback should not be assumed.

교수진이 연수생에 대한 부정적인 평가를 꺼리는 까닭에 (Albanese 2000; Boon & Turner 2004), 교수가 unprofessional한 행동을 문서화하는 것이 중요한 이유를 교육하는 것이 필수적입니다. 잘못된 행동 패턴이 probation을 필요로하거나, 드물지만 termination이 필요한 경우에는, 프로페셔널리즘 문제에 관한 문서화가 중요합니다.

Due to the reluctance of faculty to give negative evaluations of trainees (Albanese 2000; Boon & Turner 2004), it will be essential to train faculty about why documenting unprofessional behavior is important. Documentation of professionalism issues is crucial if a pattern of misbehavior requires probation, or in rare cases when termination is required.

이 위원회의 두 가지 주요 목표는 체크리스트 데이터를 기반으로 언제 remediation을 해야하는지 결정하는 것과 어떻게 이를 효율적으로 수집할지에 대한 것이다.

Two key objectives of this committee will be to decide when checklist data should trigger remediation, and how to collect it efficiently.

프로페셔널리즘 점검표의 주요 목표는 비전문가 행동의 조기 파악이지만 전문직 정체성 형성 및 전문성 지식 개발 분야 (Goldie 2013)에서 총 피드백을 제공하는 데 사용될 수도 있습니다. 힐튼 (Hilton)과 슬롯 닉 (Slotnick, 2005)이 지적했듯이 프로페셔널리즘은 고정된 특성이 아니며, 시간에 따라 습득해가는 state에 더 가깝다.

Although the primary goal of our professionalism checklists is early identification of unprofessional conduct, they could also be used for providing summative feedback in the areas of professional identity formation and the development of professionalism knowledge (Goldie 2013). As Hilton and Slotnick (2005) have observed, professionalism is not a static trait, but an acquired state developed over time.

프로페셔널리즘 평가를위한 가장 중요한 이유 중 하나는 unprofessional한 행동의 조기 발견과 행동의 개선입니다.

One of the most important reasons for assessing professionalism is early detection unprofessional and remediation of behavior.

Policy capturing: 

A method employed by researchers to assess how decision makers use available information when making evaluative judgments. The purpose of this methodology is to capture individual judges’ decision-making policies, that is, how they weight, combine, or integrate information. It involves asking decision makers to judge a series of scenarios describing various levels of one or more explanatory factors, and then using statistical methods to determine the emphasis decision makers give to each factor in their decision-making process. The results indicate the relative importance of the various factors for the decision makers.

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Med Teach. 2017 Jan;39(1):85-91. doi: 10.1080/0142159X.2016.1231917. Epub 2016 Sep 27.

Not all unprofessional behaviors are equal: The creation of a checklist of bad behaviors.

Cullen MJ1, Konia MR2, Borman-Shoap EC3, Braman JP4, Tiryaki E5,6, Marcus-Blank B1, Andrews JS1.

Author information

1

a Graduate Medical Education , University of Minnesota , Minneapolis , MN , USA.

2

b Department of Anesthesiology , University of Minnesota , Minneapolis , MN , USA.

3

c Department of Pediatrics , University of Minnesota , Minneapolis , MN , USA.

4

d Department of Orthopaedic Surgery , University of Minnesota , Minneapolis , MN , USA.

5

e Minneapolis VA Health Care System , Minneapolis , MN , USA.

6

f Department of Neurology, University of Minnesota , Minneapolis , MN , USA.

Abstract

INTRODUCTION:

Professionalism is a key component of medical education and training. However, there are few tools to aid educators in diagnosing unprofessional behavior at an early stage. The purpose of this study was to employ policy capturing methodology to develop two empirically validated checklists for identifying professionalism issues in early-career physicians.

METHOD:

In a series of workshops, a professionalism competency model containing 74 positive and 70 negative professionalism behaviorswas developed and validated. Subsequently, 23 subject matter experts indicated their level of concern if each negative behavior occurred 1, 2, 3, 4, or 5 or more times during a six-month period. These ratings were used to create a "brief" and "extended" professionalism checklist for monitoring physician misconduct.

RESULTS:

This study confirmed the subjective impression that some unprofessional behaviors are more egregious than others. Fourteen negative behaviors (e.g. displaying obvious signs of substance abuse) were judged to be concerning if they occurred only once, whereas many others (e.g. arriving late for conferences) were judged to be concerning only when they occurred repeatedly.

DISCUSSION:

Medical educators can use the professionalism checklists developed in this study to aid in the early identification and subsequent remediation of unprofessional behavior in medical students and residents.

PMID:

 

27670731

 

DOI:

 

10.1080/0142159X.2016.1231917