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Chapter 2. The Problem with Professionalism
Catherine R. Lucey, MD
Although we may disagree with the size or the cause of the problem, many educators, practitioners, leaders, and unfortunately patients would agree that the medical profession currently has a problem with professionalism. All too often we have seen headline stories about physicians engaged in behavior that is not only unprofessional but criminal: murder, pedophilia, and financial fraud. While these are horrific, the profession generally has no difficulty in responding quickly to sanction or remove a physician who has engaged in these types of behaviors.
Unfortunately, these unusual circumstances represent the tip of the iceberg of professionalism problems. Our commitment to professionalism as a community is more often damaged by behaviors that can be seen daily in every care arena. Examples include overtly disruptive behaviors such as abuse of power manifested by failure to comply with evidence-based safety practices, and intimidation of others by yelling, profanity, and threats of physical violence. Also common are covertly disruptive behaviors such as failing to answer pages or complete essential paperwork on time. Even more common are daily incivilities: sarcastic comments on rounds about patients, specialty bashing, and snarky comments about learners. Perhaps most threatening to a culture of professionalism is our collective tolerance to these behaviors: many articles document the failure of physicians to step in and correct unprofessional behavior despite a commitment to professional self-regulation.
The causes of our problem with professionalism are complex and controversial
Many have hypothesized that the problem with professionalism is a result of changes in the generational commitment to professionalism as a result of the ACGME-mandated work hours restrictions, enacted across the country at the beginning of the twenty-first century. But in reality, concerns about the state of medical professionalism, as reflected in the exponential growth of peer-reviewed literature on this topic, began in the early 1980s.1 This occurred in parallel with a number of significant events that disrupted the way that physicians related to each other, their patients, the health care systems in which they worked, and the learners they taught.
In the mid 1980s, the shift from pure fee-for-service reimbursement to a strategy based on diagnosis-related groups (DRG) dramatically shortened the number of days that patients spent in the hospital and increased the pressure on physicians to rapidly admit and discharge patients. The tragic death of Libby Zion ushered in an era in which the length of time residents spent in the hospital was dramatically curtailed. In the mid 1990s, fraudulent billing by some physicians led to the implementation of Physicians at Teaching Hospitals (PATH) regulations that changed the work flow of teaching hospital rounds. Teams could no longer share the work of documentation, and time for teaching decreased. In the late 1990s, the Balanced Budget Act plunged many academic medical centers into the red overnight and an era of high-volume-throughput medicine began. This further shortened already abbreviated hospital stays, making the development of relationships between residents and their hospitalized patients more difficult. The Institute of Medicine reports on medical errors in 1999 and quality in 2002 publicized the difficulty of providing consistently high quality safe patient care. The move to shorten residency work hours across the country and in all disciplines clearly has impacted the ways in which we work and how learners view their roles, but this was only the most recent of a long line of challenges to professionalism.
Different types of problems require different types of solutions
A problem exists when there is a gap between the realities we experience and the ideals to which we aspire. In the world of problem solving, there are two types of problems: technical and complex adaptive problems.2,3 Technical problems are easy to recognize and define. All who experience them agree on the nature of the problem and the characteristics of the desired state. Technical problems either exist in isolation or are relatively unaffected by changes in the environment. Solutions to technical problems are well established, can be found in a book on a shelf or an article on the Internet, and can be outsourced. Once fixed, a technical problem tends to stay fixed. Classic technical problems are fixing a flat tire or a dripping water faucet.
In contrast, complex adaptive problems are characterized by controversy and volatility. They arise insidiously out of seemingly stable environments. People will disagree about the extent, nature, or cause of the complex adaptive problem and often they will disagree on the characteristics of the ideal state. Complex adaptive problems are highly influenced by the environments in which they exist and thus are always changing. The controversial and complex nature of these problems means that no “off-the-shelf” solution is possible: the people who experience the problem must work and learn together to address the problem using multiple lenses. Because they are highly susceptible to environmental influences, complex adaptive problems are almost never permanently solved; they are merely managed as well as they can be within their existing contexts. They require continuous tending. Classic complex problems include poverty, drug addiction, underperforming schools, and teenage pregnancy.
The clues to the nature of the problem of professionalism are evident in the published literature and in presentations at national meetings. Articles have carefully explored beliefs about professionalism, searched for causes of deteriorating culture of professionalism, and called for a renewed commitment to professionalism. Debates are heard throughout academic medical center: Is professionalism worse than it has been in the past? Is it a pervasive problem or one that is isolated to a few bad actors? Is this a problem with the new generation of physicians or the most seasoned generations? We might similarly disagree on the future ideal: is altruism an outdated idea in the era of regulated work hours?
Sustaining professionalism is a complex adaptive problem
It is clear from these questions that the problem of sustaining professionalism meets all the criteria of a complex adaptive problem. Despite this, the medical profession has approached the problem as a technical one: seeking the single true cause and best solution even though the complexity of the problem mandates a different approach. The reliance on technical approaches stems from a commonly held assumption that professionalism is a dichotomous virtue—either present or absent in any given individual. The technical approach that follows this perspective is illustrated as a series of sequenced strategies, largely concentrated in the medical education environment. The strategies: recruit the right people, teach them the rules of professionalism, expose them to role models who skillfully apply those rules in the clinical environment, and then reward them with an MD degree and release them into the public. During this process, assess them carefully and be ready to impose sanctions or remove them from the profession if they commit a professionalism lapse. There is some data to suggest that the medical education environment does have a role as a gatekeeper for professionalism. In a seminal article in the New England Journal of Medicine, Papadakis and colleagues documented that physicians who were sanctioned by medical boards for unprofessional behavior were more likely to have been the recipients of more than one professionalism complaint during their medical school careers.4
Our current solutions are insufficient or ineffective
But if one reviews the literature that evaluates the success of interventions aligned with this approach, the results are disappointing. The problem with optimizing recruitment as a strategy for enhancing professionalism should be evident. Little data exists at the time of admission to medical school that could or should predict an individual’s ability to live the values of professionalism in the clinical environment.5,6 Scores on standardized exams, whether they test knowledge of the life and physical sciences or the social and behavioral sciences, may indicate whether the individual has mastered knowledge that would help an individual understand a particular challenge, but not whether he or she then will act in a desired fashion when confronted with that challenge. Interview questions and essays may uncover whether a potential student can articulate the values of professionalism and identify those who aspire to live those values. However, very few applicants to medical school have had the opportunity to test their ability to live those values in the stressful environment of health care.
The idea that professionalism can be taught as a series of rules has also proved to be problematic. On the surface, it is attractive to translate the abstract constructs of professionalism (altruism, respect, confidentiality, integrity, professional self regulation) into desired rules and behaviors. Campbell’s survey of over 1,000 internists demonstrated that while the vast majority of physicians surveyed agreed with the tenets of professionalism, many were aware of instances in which they themselves or their colleagues did not live up to those values.7 Huddle noted that this disconnect between intent and behavior was such a common situation that the ancient Greeks had a specific word for it: akrasia, meaning that the spirit was willing but the flesh was weak.8
The story becomes more complex still when we rely on the teaching of rules to educate and assess professionalism. In a series of elegant experiments, Ginsberg and colleagues concluded that the rules of professionalism are not static and universal, but highly contextual.9 Additionally, faculty physicians provided with several exemplar cases of professionalism challenges were both externally and internally inconsistent in their decisions about what was the professional thing to do and why.10 In one scenario, faculty were asked to identify the right response of a medical student who, after being instructed by his faculty physician not to inform a patient of a new diagnosis, is specifically asked by the patient to disclose the diagnosis. Some faculty stated emphatically that the student should reveal the diagnosis because the student should never lie; others said that the student should lie to the patient under these circumstances. Furthermore, those physicians who maintained that students should never lie to a patient subsequently suggested that there were cases in which the right response might be to lie. This work suggests that professional responses to complex situations are nuanced and not reducible to a core set of rules or commandments. In light of the variability of “correct responses” by different faculty, it also raises the concerns about the validity and reliability of assessing professionalism based on the response to isolated incidents.
Given the poor performance of rules as a mechanism for teaching, one might conclude that professionalism education must rely upon assigning students to role models who have successfully learned to deal with the ambiguity of professionalism challenges and who can articulate why a specific response is appropriate in a given situation. Unfortunately, the literature on the impact of role models in teaching professionalism is also disappointing. Hafferty coined the term “the hidden curriculum,” describing the frequent disconnect between the lessons that are explicitly taught in the classroom and those that are modeled, learned, and rewarded in the clinical environment.11 The inability of all role models, particularly those that appear to be otherwise professionally successful, to apply the lofty professionalism values in the clinical arena contributes to cynicism in trainees that may progress during training.12
If recruitment strategies are unreliable, rules are ambiguous and contextual, and role modeling by professionals is inconsistent, then perhaps the solution to the problem of professionalism must default to aggressive assessment and removal of those who exhibit unprofessional behaviors. Unfortunately, this also is an incomplete solution to the problem. As noted previously, faculty disagree about what the “right” behavior is in given professionalism challenges. This means that whether a behavior exhibited by a learner is deemed unprofessional depends on who is doing the observation: hardly a strong basis on which to take action. Furthermore, those with the power or authority to take corrective action may not be present when learners are engaging in acts of unprofessional behavior. Finally, literature exists that documents that faculty who do witness unprofessional behavior may be reluctant to address that behavior in any way.13 Mizrahi was particularly dismayed by what he described as a set of maladaptive behaviors that physicians engaged in rather than confront a colleague who had made an error. He described these as denial (“It wasn’t unprofessional”), discounting (“It was unprofessional but it was warranted”), or distancing (“It was unprofessional but let’s just move on”).14 Faculty or colleagues may also fail to correct a professionalism lapse because they lack confidence in their ability to intervene successfully or they may be concerned that a report to a higher authority will result in sanctions that are disproportionate to the episode that they witnessed.
Evaluating professionalism lapses as a form of medical error
When problems cannot be solved with conventional approaches, new learning is required. In considering common professionalism lapses, we recognized that there are similarities between professionalism lapses and medical errors. Like medical errors, professionalism lapses are more common than we might think. They occur in predictable circumstances: when individuals are stressed, the situations are highly charged, and controversy is present. Professionalism lapses range in severity from largely invisible (for example, the faculty member who claims CME credit for a lecture he didn’t attend) to potentially fatal (the resident who leaves the hospital without checking on a post-procedure chest X-ray). As is the case with medical errors, those whom we otherwise consider to be good physicians commit occasional professionalism lapses; thus professionalism must result from a temporary mismatch between the individual’s knowledge, judgment, or skill and the complexity of the situation in which he finds himself. Finally, the systems in which we care for patients and educate learners may either help us sustain our professional values or set us up for failure.
If we consider professionalism lapses to be either analogous to or a form of medical error, we can apply the tools that have been useful in managing medical error to the problem of professionalism lapses. Establishing a “just environment,” in which people are encouraged to report professionalism challenges, lapses, and near misses can help us understand the spectrum of professionalism problems. Root-cause analysis may enable us to fully characterize the many causes of professionalism lapses. In combination, these tools can guide us in devising strategies to help all professionals and learners prevent or address professionalism lapses. Finally, the concept of active lapses (those caused by a physician) and latent lapses (those caused when the system fails to protect the vulnerable patient from the fallible physician) adds additional intervention points for leaders to consider.
Analyzing lapses: Conflicts abound and systems may set people up to fail
Analyzing articles written about professionalism challenges (difficult situations) and lapses (challenges that were not managed well) from the perspective of students, residents, faculty, practicing physicians, and scholars give insights into the root cause of professionalism lapses, as does our own experience in working with learners and faculty who have lapsed. Professionalism challenges tend to be crowded: they often require the clinician to simultaneously manage the needs and expectations of multiple people (the patient, peers, learners, faculty, nurses, administrators and others). In managing challenges, several conflicts are present (Table 1). Ginsberg and colleagues have described the challenge of values conflicts: when adhering to one professionalism value means subjugating another professionalism value. In addition to values conflicts, there may be patient conflicts: when attempting to be professional with one patient puts you at odds with another patient.15,16 Finally, the most common cause of lapses appears to be Maslow conflicts, when adhering to a professionalism value requires that an individual subjugate his fundamental physiologic, safety, belonging, or esteem needs.17 Maslow theorized that human beings, when faced with decisions on how to act, will predictably choose the decision that meets their deficit needs for food, water, sleep, safety, and belonging before acting selflessly.
|Table 1. Conflicts Are a Frequent Cause of Professionalism Challenges|
|Values conflict||An intern is expected to adhere to the professionalism value of excellence by leaving after she has been on a shift that exceeds work hours limits and to demonstrate altruism for her patient by staying to conduct a family meeting after that shift ends.|
|Patient conflict||A faculty member demonstrates compassion for a patient who has just received bad news by extending the length of that patient’s appointment; the subsequent patient views him as unprofessional for keeping him waiting.|
|A physician wants to maintain confidentiality about his patient’s communicable disease, but doing so puts other of his patients at risk.|
|A resident is trying to actively manage a dying cancer patient’s pain and therefore must defer seeing another patient whose nonmalignant chronic pain syndrome is not well managed.|
|Maslow conflict||A medical student is assigned to care for an angry patient in the middle of the night; he hasn’t eaten for fifteen hours and is very anxious about performing well.|
|Systems conflict||A resident is instructed to see all patients who are to be discharged now so that they can be out of the hospital by 11 am. She is repeatedly called to come to the emergency room to evaluate a new admission because the emergency room resident has been told to clear out the ED before 9 am.|
The concept of latent errors, or decisions made about how health care systems are run, also has relevance to the topic of professionalism lapses. Staffing and workload issues may cause significant stress and distraction for professionals, leading to many conflicts as they attempt to serve multiple patients simultaneously. Inconsistent, ambiguous, or conflicting expectations from employers or accreditors can also cause lapses, as is the case when residents are told to always put their patients’ needs above their own, but are then instructed that they must drop everything and leave when they have reached the maximum number of hours on duty. Institutional policy decisions about how clinicians are rewarded may prioritize high-volume throughput of patients over high-quality patient care and teaching. Legal policies and indemnity strategies may make it difficult for physicians and others to apologize when an error has been made. Finally, national health care decisions that leave millions uninsured or that prohibit conversations like end-of-life care may also set physicians and others up to fail.
A new perspective
With this analysis in mind, we propose a new perspective: we expect that all professionals will be deeply committed to living the values of professionalism but at times will be challenged by circumstances that are stressful and trying. To ensure that our profession meets our obligations to society, we must teach all professionals to anticipate and skillfully manage even the most challenging of professionalism circumstances. If successful, we will cultivate a generation of fully formed professionals who, as articulated by Leach, recognize that “Professionalism means going beyond the amateur in participating in the relationships . . . The fully formed professional is habitually faithful to professional values in highly complex situations.”18
Managing a professionalism challenge requires judgment and skill
Any time you routinely expect human beings to behave in a way that is counter to human instinct or human incentive, you are dealing with a challenge of acquired competency. Thus, preparing people to be habitually faithful to professional values in these complex situations means that we must view professionalism not as a character trait but as a complex, multidimensional competency. Like other complex competencies, the competency of professionalism must follow a developmental curve19 in which intent to comply and live values of professionalism is the entry into the profession, but mastering the skills and judgment to live professionalism despite hostile environments requires practice, reflection, and coaching. Lapses are likely to occur when the complexity of the situation exceeds the developmental level of the professional in question. Thus, an entering student can and should be able to articulate the values of professionalism in a context-free environment, but may stumble in solving a challenge that requires her to prioritize one value over another or one patient over another. A resident judged to be competent in professionalism may be able to successfully navigate a professionalism challenge between patients, but may be less adept when he is asked to do so after a long stretch of night float shifts. At the other end of the developmental spectrum, an established physician must be able to successfully navigate stressful situations as well as conflicts between patients and values despite having unmet deficit needs.
Teaching the seven skills of professionalism resiliency
Dealing with professionalism as a pedagogical challenge provides new opportunities. First, we can expand our teaching about professionalism beyond descriptions of behavior we expect and into skills that foster resiliency. None of these skills are routinely taught or assessed in our conventional courses on doctor-patient relationships but should be added to all medical curricula. They focus on skills to manage self as well as skills to interact effectively with all in the health care environment. Table 2 summarizes the seven skill sets needed for professionalism resiliency.
|Table 2. Seven Skills for Professional Resilience|
|1.||Situational analysis||Recognize when the situation involves conflicts among values or patients and what those conflicts entail.|
|2.||Self awareness and self control||Recognize personal triggers and signs of personal stress/anxiety; learn to assess for these before high-stakes or stressful encounters; develop strategies to optimize personal well-being in the moment and over the long term.|
|3.||Alternate strategy development||Devise strategies to obtain assistance quickly.|
|4.||Advanced communication: diplomacy, de-escalation, conflict management||Learn techniques to interact with patients and others within the health care environment.|
|5.||Managing professional boundaries||Recognize the risks of boundary violations and develop skills to avoid or recover from boundary crossings.|
|6.||Peer coaching and intervention||Develop skills to recognize when colleagues appear to be at risk of a professionalism lapse and to intervene before the lapse occurs; learn how to counsel someone after the lapse has occurred.|
|7.||Effective apologies||Learn to apply the elements of a successful apology when a lapse has injured a relationship.|
The first of these skills is situational analysis: helping learners and physicians to recognize when the situation in front of them is complex and may include values or patient conflicts. They must recognize the need to slow down and make an explicit decision about what to do, rather than simply responding with human instinct. There is a growing literature on the importance of switching between generally appropriate fast thinking and more methodical slow thinking that provides relevant models for this type of work.20–22
The second set of skills that must be inculcated comes from the emotional intelligence literature: the skills of self awareness and self control. Teaching residents and learners that they should pause and take stock of their own emotions before they deal with a predictably challenging situation can be life changing.
The third set of skills includes the ability to generate alternate strategies for action that go beyond the first instinctive response. Formal training in diplomacy, conflict de-escalation, crisis communication, and negotiation can be useful in helping professionals defuse tense situations, whether they occur between professionals or with patients. These are different skills than the usual relationship building or transactional information gathering skills that are included in doctor-patient relationship courses.
Education about and skill in identifying and maintaining appropriate professional boundaries is currently a focus in the training of psychiatry residents, but all professionals should be skilled in this competency.
A core responsibility and value of professionalism is professional self regulation: the responsibility of the profession to police itself. Physicians must be taught how to intervene when a lapse seems imminent and how to coach peers who have committed a lapse.
Finally, recognizing that lapses will occur even in the best of circumstances, we must teach our professionals how to express a genuine and effective apology if their behavior or words have injured another.
Shaping the system to support professionalism
As leaders in the health care environment, we must shape our care delivery systems to support a culture of professionalism. All, not merely those who work in education, must recognize the existence and the danger of the “hidden curriculum.” We must work to develop a culture in which all welcome an intervention by a colleague if a professionalism lapse is imminent or has occurred. We should champion positive examples of professionalism so that the stories that circulate among our learners and our peers are those describing us when we are at our best, not gossiping about us when we are at our worst.23 We must facilitate interprofessional teamwork, incorporating shared values of professionalism and welcoming support and coaching from all in the health professions. We should take steps to remove unnecessary stressors by ensuring that institutional policies and procedures reinforce rather than undermine desirable behavior. We must devise service recovery systems for all who have been harmed by a professionalism lapse.24 All organizations should support reflection and renewal through both environmental and event planning. Quiet rooms for professionals to go to gather their thoughts, calm down, and recommit to professionalism values should be available on all patient care units. Events that celebrate and create community are essential to establishing the positive culture of professionalism.
Recalibrating our approach to professionalism lapses in learners
As educators, we need to engage in continuous formative evaluation of professionalism. We should test professionalism skills in our learners in varied situations, both real and simulated. We should use root-cause analysis to identify and debrief professionalism lapses and to teach our learners to do the same. We need to use a developmental lens when assessing professionalism lapses in trainees so that the intervention is proportionate to the severity, and tailored to address the root cause of the lapse in the learner. Disciplinary action should be reserved for individuals who refuse to engage in honest self-reflection, are unwilling to accept responsibility for their behavior and other’s perceptions of their behaviors, are resistant to coaching and counseling, or who demonstrate recidivist behavior despite educational interventions.
Encouraging continuing professionalism education
Finally, as in ethics, advances in biomedical science, care delivery, and health care economics will bring new challenges to professionalism.
|Table 3. Biomedical and Social Advances that May Present Professionalism Challenges|
|Risk sharing in the Affordable Care Act||May create an appearance of conflict of interest if physicians are incentivized to limit care because of costs to the system.|
|Returning pleiotropic results from genetic testing to patients||Physicians who disclose all possible implications of genetic testing may cause harm to patients; those who select which information to share may be charged with paternalism or lying.|
|Cord blood testing for perinatal diagnosis of genetic risk for adult disease||Physicians disclosing risk to parents about conditions that will not appear before adulthood may be violating patient confidentiality.|
Table 3 summarizes recent advances that may have implications for appropriate professional behavior. While we have accepted the need to continuously update our biomedical knowledge, we have treated professionalism as a label that is earned once and assumed to be stable throughout the course of a career. It is time for professionalism as a renewable competency to also be reflected in continuing medical education courses.
If we wish to fulfill our commitment to society to educate and sustain health care professionals who are committed to and capable of living the values of professionalism, we can no longer afford to assume that professionalism is a character trait that is established at the time of entry into medical school. Instead, we must embrace the concept of professionalism as a complex competency. We must seek ways to prepare our physicians to exercise, adapt, and improve the judgment and skills needed to remain professional despite the dynamic and stressful environment in which health care is delivered. As a community, we must also take responsibility for shaping the systems in which we practice so that they support our core values. The work is hard, but the reward will be great if we as a profession embrace this challenge.
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Updated on May 14, 2015.
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