In 2009, Putting the Charter into Practice grants were awarded to several organizations that developed initiatives to advance the professional values and behaviors articulated in the Physician Charter among practicing physicians.

We worked with the Council of Medical Specialty Societies and a consumer representative to award grants to projects that offered diverse approaches to advancing professionalism. We also encouraged networking among the grantees to create a community of medical professionalism researchers.

The 2009 grantees and their projects include:

Cleveland Clinic - Increasing Empathic Behaviors of Staff Physicians through Reflective Writing

Empathic communication means understanding the patient’s perspective. It is crucial to promoting the primacy of patient welfare, a principle of the Physician Charter.

To bolster physician empathy, Cleveland Clinic investigators developed a six-session reflective writing course. The investigators recruited 40 staff physicians; assigning 20 of them to an intervention group and 20 to a control group.

The intervention group received course readings prior to each session and participated in reflective writing and sharing in groups of four to five physicians, along with a trained physician facilitator. Session topics included:

  • an introduction to reflective writing and narrative medicine;
  • the patient experience of pain and suffering
  • empathy across cultural barriers;
  • the use of literature in empathic understanding;
  • empathic communication of treatment plans/health literacy; and,
  • the use of mindfulness to improve both quality of care and empathic engagement in patient care.

Upon completion of the course, the intervention group showed a statistically significant improvement in empathy compared to the control group, as measured by the Jefferson Scale of Empathy. Their findings were published in an International Journal of Medical Education article.

Johns Hopkins Bayview - Readmissions: A Missed Learning Opportunity for Hospitalists

Johns Hopkins Bayview researchers implemented a program to address the Physician Charter commitment to engage in quality improvement.

As part of the program, house officers are notified about all readmitted patients who were under their care during their initial hospitalizations. They were then given the opportunity to participate in facilitated reflections on what factors contributed to the readmission.

Twenty-seven hospitalists completed reflection exercises on their rehospitalized patients and also completed pre- and post- intervention surveys. The surveys showed statistically significant changes in behavior among participating hospitalists following the reflection activities. These changes included:

  • an increased likelihood of contacting the primary care provider after discharge;
  • usually or always conducting “teachbacks” (having patients explain their post-discharge instructions back to the hospitalist to assess their understanding); and,
  • usually or always communicating with the readmitting provider if the patient returned to the hospital.

Findings from this project were presented at several national meetings, including the Society for General Internal Medicine and Society of Hospital Medicine’s annual meetings. Johns Hopkins Bayview has since maintained the notification program for hospitalists and readmitted patients.

National Physicians Alliance - Promoting Good Stewardship in Clinical Practice

The National Physicians Alliance (NPA) addressed how physicians in internal medicine, pediatrics and family medicine can adhere to the Physician Charter’s commitments to putting the patient’s interests above all else, social justice and using limited resources prudently.

Project leader Dr. Stephen Smith noted in a post on The Medical Professionalism Blog, “I have faith that most physicians have enough professional pride and integrity to do the right thing once they actually think about it.”

To encourage physicians to act as responsible stewards of resources, the NPA convened working groups to develop “Top Five” lists for internal medicine, family medicine and pediatrics. The lists consisted of tests and procedures which are commonly used but may be unnecessary and/or cause harm. The lists underwent field testing with over 200 practicing physicians to ensure that the recommendations were valid and relevant to everyday practice.

The project and resulting lists were described in an Archives of Internal Medicine article and made available on NPA’s website; the release of the lists generated extensive media coverage. This project also provided a successful model for the ABIM Foundation’s Choosing Wisely® campaign in which medical specialty societies, along with Consumer Reports, identified tests or procedures commonly used in their field, whose necessity should be questioned and discussed.

Additionally, the NPA received a 2011 Putting the Charter into Practice grant to develop training videos for physicians to improve their communication skills around the “Top Five” recommendations. Part of NPA’s grant included a plan to pilot the use of the videos in practices around the country.

Ohio State University - Putting the Physician Charter into Practice for Central Ohio Physicians

The appreciative inquiry approach is based on the belief that focusing on positive examples of what works is a more powerful driver of change than focusing on problems. A project team from Mt. Carmel Health System, OhioHealth and The Ohio State University Medical Center combined appreciative inquiry and storytelling to collect stories of when local physicians felt they were at their best professionally, and shared these interviews through educational programming.

The project engaged Ohio State University medical students in a summer project to conduct appreciative inquiry interviews with local physicians. The students then developed seven short audio recordings centered on seven themes that emerged during their interviews. The final recordings were:

  • Introduction
  • Becoming a Physician: The importance of active reflection and inquiry
  • Knowing Your Patients as Human: Offering a voice for patients in challenging situations
  • Collaboration is King: Teamwork is the way of the future
  • Ordinary and Extraordinary Care: Highlighting efforts to provide free care to patients in need
  • What’s Really Important: Listening remains at the heart of helping patients
  • Your Oxygen Mask: How physicians balance fulfillment in their professional and personal lives.

The recordings were shared at a 2010 showcase event of medical students’ summer activities at Ohio State University, seminars at Ohio Health and Mount Carmel Hospital, and at American College of Physicians Ohio Chapter meeting.

The project team also analyzed the recordings for similar themes. The Ohio State University School of Medicine Student Honor and Professionalism Council, a student elected body of peers, has chosen to continue the appreciative inquiry interviewing project. Students sign out a digital video or audio recorder and are given basic instruction on appreciative inquiry and interviewing. They then record professionalism stories, which will be housed in a media library.

Society of General Internal Medicine (SGIM) - Communicating about Professionalism

Good physician-patient communication is an essential aspect of medical professionalism. Recognizing this, the Society of General Internal Medicine produced a workshop on communication skills and professionalism. The workshop included videos and role-play training for physicians on:

  • Disclosure of a medical error;
  • Initiating conversations about palliative care; and
  • Discussing a perceived breach of confidentiality.

Trained faculty members administered the workshops to over 200 attendees at seven regional SGIM meetings, the 2010 national SGIM annual meeting and 2011 American College of Physicians annual meeting.

The project leaders also used their project as the basis for a communications workshop that was incorporated into the ambulatory residency curriculum at the University of Massachusetts and Brown University. Results presented at the 2013 Association of Program Directors in Internal Medicine Annual Meeting showed that a large percentage of residents found the workshops useful and used the communication skills in their subsequent residency training.

University of Chicago - Improving On-Call Etiquette among Internal Medicine Residents in Chicago: A Multi-Center Collaborative

While formal medical school and residency curricula may espouse the virtues of professionalism, the “hidden curriculum” of unspoken values and norms may encourage unprofessional behavior. Such behavior runs counter to many aspects of the Physician Charter, including the principle of the primacy of patient welfare and the commitment to professional responsibilities such as maintaining respectful relationships with colleagues.

With their Putting the Charter into Practice grant, researchers from the University of Chicago Medical Center, Northwestern Memorial Hospital and NorthShore University Health System confronted the hidden curriculum and provided residents with tools to navigate challenging professional situations by developing and implementing a workshop series on unprofessional behavior.

Three 60-minute workshops were offered to internal medicine and hospitalist residents and academic hospitalists across the three participating institutions. The workshops featured three video case studies:

  • Selling Your Tests: Physicians misrepresent a patient’s test as urgent to expedite care.
  • Attending Frowns: An attending physician disparages the ER for missing findings that were later discovered on the floor.
  • Scoring On Call: Physicians celebrate a blocked admission.

Participants viewed the videos and engaged in small- and large-group discussions led by faculty moderators using a moderator presentation, debriefing worksheets with an answer key, and a session evaluation. Two-thirds of participants reported an intent to change unprofessional behavior after attending the workshop. Further study results were presented in two Journal of Hospital Medicine articles (“Participation in unprofessional behaviors among hospitalists: A multicenter study” and “Promoting professionalism via a video-based educational workshop for academic hospitalists and housestaff”) and at several national conferences, including the Association of Program Directors in Internal Medicine (APDIM) Chiefs Resident’s Conference.

In addition to the workshop videos, the project leaders have made all workshop materials available via AAMC’s MedED Portal. These video teaching modules have also been incorporated into the Graduate Medical Education Orientation at the University of Chicago Pritzker School of Medicine.