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To the Editor:
This letter is intended to address the need for standardized professionalism training in the osteopathic family practice residency training.
With the advent of social media, and changing society of American culture, there is a need to mandate professionalism training and testing in the graduate medical education field of family medicine. This training should be standardized and documented, so that the osteopathic family practice community can have proof that they are training their residents in professionalism. One way that this type of training can be tested is with the use of simulation medicine. Professionalism complaints against doctors are growing at an alarming rate, and many of these complaints are in regard to physician/patient communication breakdown. These professionalism complaints are leading to malpractice cases, and “a breakdown in physician-patient communication is cited in more than 40% or more of malpractice suits.”1 As osteopathic family physician medical educators, we need to show proof that we are properly training our residents in professionalism and that we are taking the necessary precautions to ensure that our residents are trained and armed with the appropriate tools to be professional, competent physicians.
Physician’s private lives are under public scrutiny, and some physicians’ personal lives are easily followed on social websites and other social media sites. The distinction between private and public lives of physicians are harder to divide due to the availability of Google® and other Internet search engines. Some physicians are choosing to be available to their patients on social media sites online, and choosing to provide patients with multiple ways of communication. These communications are often recorded via text or written messages, which can sometimes be evaluated differently than verbal communication. Some insurance companies are now offering incentives to making physician records compatible to online management.2 With the impact of instant messaging and email, many patients want physicians to be available around the clock. With all of these new definitions of physician availability come the possibility of professionalism complaints and lawsuits. Many of these lawsuits involve written data from doctors who text, instant message, face book message, and tweet patients.3 In these circumstances sometimes the physician/patient relationship lines get blurred. Technology will continue to evolve and the osteopathic family practice community must come up with ways to maintain professionalism in the digital world.
The importance of work/life balance has been researched extensively, and residency training hours have changed to provide for a proper balance. Some activities that resident physicians chose to do in their private lives, may not be things they would want to share with their patients. Every picture or written document that a resident posts on the Internet can have long term effects on their career, and could be used in a court of law against them. HIPPA laws protect patient identity and all physicians all reminded that practicing medicine is a privilege that can be taken away if we do not maintain professionalism.
Miscommunication among patients and physician make up a large amount of the professionalism complaints and malpractice suits against physicians suits.4 These communication problems can be seen in inter-professional relationships, as well. It was found that doctors who get training in communication skills have a “12% higher patient adherence rate than doctors who do not.”5 Many professionalism complaints in hospitals against residents are often by nurses, or other non physician staff members.
A way to help doctors get training in professionalism and communication skills is through simulation training. Simulation medical education can provide a work station where the residents can deal with pressing issues that may put their professionalism standards to the test, while doing this in a safe environment with no risk to patients and other professions. The residents can also be tested in professionalism and their competency in this field can be documented, so that as a profession, we can assure that we are training physicians in professionalism. If osteopathic family medicine resident graduates with professionalism complaints against him/her and a complaint are placed against them in the future, the state medical boards may find fault with the graduate training. The osteopathic family practice community cannot risk patient care or safety by graduating residents who do not pass the minimum competency for professionalism. By having residents pass an exam, the medical education faculty has proof that their residents passed a training program during their residency and this can assure state medical boards that the osteopathic family physician community is doing their part in training professional doctors.
Since the ACGME has changed their graduate medical education system from a time based system to a competency based systems (with the competences being knowledge, patient care, interpersonal and communication skills, professionalism, practice based learning and improvement, and system-based practice) there has been a rise in Simulation Training in graduate medical education.6 Simulation medicines have been proven to improve patient safety while improving resident training.7 It is “inevitable that trainees will occasionally cause preventable patient injures,” and one way to prevent this is using simulation training exercises.8 These simulation testing exercises can be done in a controlled environment are will be recorded and can be used to make sure that the resident is professionally competent before graduation.
Simulation training is required in many of the ACGME’s specialty colleges (such as General Surgery, Emergency Medicine, Anesthesiology, and Pediatrics College requirements. The ACGME also states that “the major components of professionalism are commitment, adherence, and sensitivity.”9
The AOA competency professionalism standards include honesty, altruism, and heroic behaviors. The AOA also states that professionalism includes “life long learning, and maintenance of competence.”10 The AOA also mentions the importance of professionalism in their osteopathic pledge, which all DOs take. As of today there is no formal simulation requirement by the AOA for simulation medicine. The idea of mandating a simulation requirement for professionalism in osteopathic family medicine residency programs, will not only serve the goal of ensuring professionalism, but will also allow for a requirement of simulation testing to be fulfilled. Since a major aspect of residency training is to “expose residents to the demands of real-life practice,” simulation training can serve as a way to do this is a safe environment.11 The professionalism test will serve as a competency basis for residents’ professionalism. The simulation exercise will test cultural competence and communication skills, by exposing the resident to case scenarios that test professionalism. All osteopathic family practice residents would need to fulfill at least one standardized professionalism simulation requirement before graduation. This requirement can be fulfilled in the form of an exam or a training curriculum.
If this requirement is implemented by the ACOFP the osteopathic community can identify any trainees that may have trouble with medical boards in the areas of cultural competence, professionalism, or patient safety issues. These trainees can be identified and remediate, before they are a risk to patient care. Simulation medicine can help with inter professional communication as well, and can prepare the resident for patient safety issues they will encounter. As osteopathic family physicians we can feel confidant that the residents that graduate from our programs are properly trained, and not a risk to patients. If implemented, it can potentially prevent lawsuits and future professionalism complaints.
Mandating this component may have some financial constraints and many postgraduate programs are already dealing with financial constraints. There is the question of who is responsible for the extra cost this training could entail, and the question of whether third party payers or grants can finance some of the costs has yet to be swerved or researched. Some of the stakeholders for the idea of mandatory simulation training would be simulation training companies (companies who sell simulators/training manuals). These companies would have a financial incentive for mandatory training, as would companies who provide standardized patients (SP) and SP trainers.
Another stakeholder would be simulation centers. There are now companies who provide state of the art simulation centers that are housed in a van. These “sim vans” can travel from institution to institution, helping with the problem of assess.
Simulation and professionalism training is already in use by major government and legal institutions already. Some hospital systems are mandated by their malpractice insurance providers to do simulation training exercises before opening new units in the hospital. Malpractice insurance companies and lawyers like seeing that a hospital is prepared for many sentinel events that can occur. Simulation and standardized patients are currently used after a poor patient outcome or lawsuit, to see if things could have been done differently and to try and prevent the outcome from happening again.
Many osteopathic medical schools use simulation/standardized patients already in their curriculum, so this mandate would continue with the training they had received in their medical schools. A lot of research opportunities can come out of this mandate.
Mandating a professionalism simulation competency test will take a lot of effort, and possibly, extra faculty for training. It also may take a lot of money to provide training, to keep up with the demands of a competency exam. At this time it is unknown where the financial burden will fall. Some osteopathic family practice residents will not realize and appreciate the benefits in taking a professionalism simulation test and they may be upset about the fee, if we chose to make the resident financial responsible for the competency test. A pilot study can provide research needed to make sure it is beneficial to the trainee, patients and the osteopathic community.
A professionalism competency is needed in the osteopathic family practice field, and using simulation to mandate it is a perfect opportunity to fulfill both competences. As graduate osteopathic medical educators we have a duty to make sure we are training our physicians right and appropriately in regards to professionalism. We must give them the professionalism training needed in the new technological society, and advance their skills in communication.
Finally, the old way of having the doctor at the top of the hierarchy pyramid is no longer valid. We realize now how important it is to be a team player. Residents and interns must learn how to communicate with all members of staff, and many are now being evaluated using the 360 degree evaluation. Simulation can provide a means of helping trainees learn the skills of inter professional communication and professionalism. Simulation medical education training can provide opportunities for professionalism testing in a non threatening, non risky environment.
Bernadette Riley, DO
Medical Director of Long Beach Group Practice
Coordinator of Simulation Medicine and Research
Long Beach Medical Center
Long Beach, NY
REFERENCES:
1. Landro, Laura, “The Talking Cure- improving the ways doctors communicate with their patients can lead to better health care- and lower costs.” The Wall Street Journal. April 9, 2013, R1.
2. Kamp, Jon, “Updating Doctors’ Offices Via Cloud Services”. The Wall Street Journal. April 17, 2013, B7.
3. DeCamp M, Koenig TW, Chisolm MS. Social Media and Physicians’ Online Identity Crisis.JAMA. 2013;310(6):581-582. doi:10.1001/jama.2013.8238.
4. Landro, Laura, “The Talking Cure- improving the ways doctors communicate with their patients can lead to better health care- and lower costs.” The Wall Street Journal. April 9, 2013, R1.
5. Landro, Laura, “The Talking Cure- improving the ways doctors communicate with their patients can lead to better health care- and lower costs.” The Wall Street Journal. April 9, 2013, R1.
6. Satava, R. (December 2009). The Revolution in Medical Education- The Role of Simulation. Journal of Graduate Medical Education, Vol 1 No 2, 172-175.
7. Satava, R. (December 2009). The Revolution in Medical Education- The Role of Simulation. Journal of Graduate Medical Education, Vol 1 No 2, 172-175.
8. Zig, A., Wolpe, P., Small, S., Glick, S. (August 2003). Simulation Based Medical Education: An Ethical Imperative. Academic Medicine, Vol 78, No8, 783-787.
9. ACGME program requirements
10. AOA Professionalism Guiding Leadership
11. Ludwig, S., Day, S., The ACGME 2011 Duty Hour Standards, Chapter 7: New Standards for Resident Professionalism: Discussion and Justification, pgs. 47- 51.