A Multipronged Effort to Incorporate Professionalism Into Campuswide Programming Through a Center for Professionalism Open Access

Professionalism is a core competency for graduate medical education accreditation¹  and requires formal education.²  In 2013, Baylor College of Medicine (BCM) established the Center for Professionalism (Center) in response to the vision of our President, Paul Klotman, MD, and his commitment to institutional professionalism. The BCM Code of Conduct had been established previously, and the Center amplified these tenets through engaging programming and consistent approaches to perceived lapses in professionalism. While some organizations focus their professionalism efforts on remediating poor professionalism, the Center focuses on remediation as well as training in and validation of positive professionalism. This brief report shares the feasibility and acceptability of using a structured approach to increase professionalism awareness and accountability in the learning environment.

A private health sciences university located in Houston, Texas, BCM is affiliated with 4 geographically separate hospitals and regional affiliated campuses. BCM annually trains approximately 720 medical students, 645 graduate students, and 230 allied health students, with approximately 1600 trainees participating in 30 Accreditation Council for Graduate Medical Education (ACGME) residencies and 81 ACGME fellowships annually.

Although many of the Center’s programs are solely for trainees, in an effort to fully imbed professionalism within the learning environment, it offers services to everyone in the college, across all institutions, including administrative staff.

Primary drivers to enhance a culture of professionalism were identified through input from key institutional partners, responses to institutional and national surveys, peer-reviewed literature, and institutional core values. Educational content was incorporated through a variety of interactive, andragogical approaches: large-group sessions, departmental sessions, retreats, and workshops. A partial list of programming is in Table 1. Four exemplars are highlighted below:

1. The Resident Professionalism Breakfasts are 1-hour, peer-led gatherings where residents discuss challenges related to professionalism through 2 specialty relevant vignettes. The lead resident identifies relevant practical issues, edits Center-provided vignettes, and is instructed on the approach to these sessions by a representative of the Center. Trainees focus on realistic professionalism concerns that they have had or are likely to have and develop successful management strategies.

2. The Threads Among Us: Improving Interprofessional Civility and Empathy in Health Care Teams³  (Threads) is a 1-hour, interactive workshop that promotes respectful interprofessional collaboration. Initially funded by a Josiah Macy Jr Foundation President’s Grant, the program includes a 7-minute video followed by a facilitated discussion and reflection exercises. The program teaches the importance of being kind not only to patients, but also to each other.

3. The Power of Professionalism (POP) Award empowers peers and others to nominate a BCM community member for observed act(s) of exemplary professionalism. Unlimited awards are given year round shifting attention to highlight positive professionalism and demonstrate the institutional commitment to professionalism.

4. The Professionalism Mini-Grant Program provides $300 to $3,000 in funding to support professionalism-related research. These grants facilitate projects and encourage scholarship that involves learners, residents, and fellows.

The Center fosters individual accountability through a multipronged approach. The Integrity Hotline utilized 24/7 by our Compliance Department was modified to accept professionalism concerns. While intake is available 24/7, professionalism concerns are addressed during business hours within 2 weeks. Callers may be self-identified, confidential, or anonymous. Calls are triaged and may be referred directly to Human Resources, Title IX, or the Center.

The Center adapted and modified the Cup of Coffee approach, championed at Vanderbilt University⁴  to respond to an initial concern with an informal conversation. If additional concerns arise, there is a predictable, consistent, and fair pyramid of escalation of interventions. Remediation efforts are supportive, initially nonpunitive, and founded on the principle of respect for all and a desire to help individuals develop strategies to manage perceived lapses in professionalism. If additional professionalism concerns occur, there is a predictable path of escalation which can lead to mandatory investigations or termination.

Content is evaluated for each offering. Large educational offerings are evaluated with anonymous satisfaction surveys. The Professionalism Breakfasts and Threads workshops were evaluated with metrics specific to those offerings. Feedback metrics are collected separately for the POP Award, the Mini-Grant Program, and Cup of Coffee. Periodic needs assessments are carried out to assure the most pressing topics are addressed by the programs.

This project was approved by the Baylor College of Medicine IRB H-54108.

All Center educational and support programs are voluntary. Over the past 11 years there has been growth in attendance and requests for additional programming. More than 1950 individuals, including trainees, students, staff, and faculty, have provided feedback. This number of participants represents only those individuals who have completed an evaluation survey and therefore underrepresents the full audience.

Feedback surveys indicate that programs with mixed demographics are highly acceptable, providing trainees, faculty, and staff opportunities to engage in multigenerational conversations. Moreover, the Center has received requests from at least 15 medical schools to seek guidance on the establishment of a Center at their institutions.

Table 2 summarizes feedback from highlighted programs. Aggregated feedback from across the Center’s activities indicate the majority of participants (70%-98%) would recommend participation in the programming to colleagues. Before one of the professionalism workshops, 56% (n=64) of participants felt uncomfortable/very uncomfortable addressing workplace incivility; 74% (n=84) felt comfortable/very comfortable addressing workplace incivility after (see Table 2). The Threads Among Us video continues to be utilized throughout the college and has received at least 23 381 views on YouTube.³  Participants in professionalism activities have reported that the POP Award combats poor morale, cynicism, and physician burnout. The Mini-Grant Program has fostered an environment of and provided funding for scholarship on professionalism topics. It has resulted in 16 funded investigators, 10 peer-reviewed manuscripts, and 169 scholarly presentations.

The Center’s efforts with the Cup of Coffee⁴  program have been utilized by more than 85% of Clinical and Basic Science Departments within BCM. The Integrity Hotline has referred 95 individuals to the Cups of Coffee program. In total, 296 individuals have received services. At least 83% of individuals who received an initial intervention did not receive a second report in 10 years of monitoring, similar to rates reported by other institutions.⁹  However, the low rate of persistent professionalism concerns monitored by the Center may underrepresent the number of individuals with ongoing problems, if individuals were subsequently managed through another pathway, such as human resources.

Discussions of professionalism are often thought of as solely a means to correct unprofessional behavior.^4,10  The BCM Center for Professionalism has taken a different approach to incorporate professionalism into our learning and work environment through programming, which raises awareness of the positive aspects of professionalism and the significance of individual accountability through formal education, programming, and processes. This allows trainees and faculty to have consistent and clear messaging about the values and behaviors they are expected to demonstrate with patients and colleagues. Overall, the self-reported feedback from participants and additional feedback from chairs and program directors indicate that the Center is feasible, acceptable, and has had a positive influence on attendees and the learning and working environment.

Limitations of this work include that many of the Center’s outcomes are constrained to self-report by participants and are based on one institution’s cultural expectations without the availability of national standards. Additionally, our current evaluation is focused on individual programs rather than the institution as a whole. These limitations are, in part, reflective of the lack of national standards. There is a need for systematic evaluation of institutional culture change as well as the establishment of national standards and benchmarking to assess institutional professionalism and compare across settings.

Establishing a culture of professionalism with an intentional approach to professionalism education relies heavily on the involvement of institutional leaders. Typically, centers for professionalism do not generate directly billable services. Internal and/or external financial support is necessary to support administration, programming, and evaluation. The Center was originally established with a modest budget and no external funding. Sustainability depends on the vision and commitment of institutional leadership. Seeing the value in the Center, BCM leadership has increased support for the Center over time. The Center began with one 0.5 full-time equivalent (FTE) director (physician), one 0.2 FTE faculty (PhD), and one full-time administrator. With documented success, the Center has grown to include one 0.5 FTE director (physician), one 0.5 FTE Associate Director (physician), one 0.3 FTE Assistant Director (PhD), one 0.2 faculty (PhD), and one full-time administrator. The Center continues to have a modest budget for outside speakers, mini-grant funding, supplies, and refreshments for trainings. The Center occupies 3 rooms and a small conference room. The continued financial investment in the Center has allowed for continued growth in programming and the ability to develop more robust methods of evaluation.

A center for professionalism is feasible and acceptable in a health science system. We have demonstrated it can contribute to the learning environment, both through formal education that highlights positive professionalism and by addressing perceived lapses in professionalism in a respectful, consistent, and fair manner.

Funding: The BCM Center for Professionalism received funding in part by the Josiah Macy Jr Foundation President’s Grant in 2017. Dr Godwin is supported, in part, by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413). Dr Ali was supported by the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship in Health Professions Education, Evaluation, and Research.

Conflict of interest: The authors declare they have no competing interests.

Disclaimer: The authors alone are responsible for the content and writing of this article. The views expressed in this article are those of the authors alone and do not necessarily reflect the position or policy of the US Department of Veterans Affairs or the US Government.