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Chapter 6. Enhancing Interprofessional Professionalism: A Systems Approach
Rebecca Saavedra, EdD
The University of Texas Medical Branch (UTMB) has a long-standing commitment to promoting interprofessional professionalism (IPP). A 2007 Academic Medicine article, “The Journey to Creating a Campus-Wide Culture of Professionalism,”1 described our philosophy, definitions, and initiatives to instill professionalism that began over a decade before. Since then our professionalism endeavors and understanding of interprofessionalism have continued to evolve. Today we recognize the significance of IPP as a strategic priority and component of not only our institution’s success but key to better integrated care outcomes. This paper bridges what was initially undertaken as a campus-wide interdisciplinary professionalism effort with our current understanding and emphasis on interprofessional practice.
UTMB’s campus-wide approach to interdisciplinary collaboration was undertaken to link all members of the university community to the principles and behaviors focused on patient-, family-, and client-centered care. Today’s brave new world of health care is altering practice and relationships so significantly that in the near term academic health centers (AHCs) will need to have fully transformed into new collaborative partnerships among practitioners, patients, and their families. The “core of professionalism” involves “those attitudes and behaviors that serve to maintain patient interest above physician self-interest.”2 These principles remain fundamental and timeless but with a freshly imbued sense of urgency and inclusiveness.
Once the concern was that the coming changes in the health care delivery system would “reduce the status of patients to commodities” and “have a negative impact on the professional behavior of physicians.”2 Today we understand that AHCs must address environmental challenges that require integrated care models, better outcomes, lower costs, and enhanced patient satisfaction. The emphasis on new models of care relies on collaborative effective interprofessional teams as a strategic foundation to achieve a patient-centered organization that fully engages patients in their care. IPP is no longer an ideal; it is a pragmatic reality.
Over the past almost two decades, UTMB has established a systematic mix of programs—clinical- and academic-based—to meet the new challenges and adapt in a dynamic health care environment. UTMB’s systems approach instills a focus on action to promote interprofessionalism across the institution for students, faculty, and employees. These processes are aimed at understanding, influencing, monitoring, and adjusting our efforts based on experience and lessons learned to accelerate our progress toward a more interdependent professional environment. This approach builds in opportunities for dialogue, evaluation, and improvement, thus allowing for organizational transformation. The organizational vision is set by executive leadership whose actions demonstrate their commitment and systematic focus on professionalism as a standard of conduct for everyone at UTMB. As the UTMB Professionalism Charter states: “The foundation for UTMB’s culture of professionalism is rooted in the trust placed in those who deliver patient care, conduct research, educate future health care professionals, provide administrative support, maintain a supportive environment and strive to learn.”3
The transformation begins
Establishing a culture of IPP can only succeed if there is critical leadership sponsorship and an infrastructure in place to ensure that policies and systems support skilled practitioners who work respectfully and collaboratively in effective teams. The UTMB Professionalism initiative has been in place continuously since 1998, spanning two university presidencies to the present. UTMB Presidential sponsorship is indispensable in not only guaranteeing necessary resources but also in elevating activities to institutional prominence.
Additional strategic partnerships have been forged with the Provost/Dean of Medicine; Deans of Health Professions, Nursing and Graduate Schools; CEO of the Health System; and the Executive Vice President of Business and Finance. These individuals serve as members of the President’s Executive Committee and set the tone of collaboration and respect across the institution. The Executive Committee is a critical ally in crafting and delivering the message to the various segments of the campus community.
Over time, UTMB has established a matrix of institutional programs, initiatives, and monitoring systems to create a focus on action and engagement by the campus community to form a collegial and patient-centered environment. Early on, discussion forums were held to define and reflect on the concept’s meaning across disciplines. Meetings with department chairs, faculty senate, and student senate were a part of a “listening tour” to determine the readiness of the campus culture to adopt a multidisciplinary perspective. The outcome underscored that what unites the education, research, and patient care missions of the organization is a patient-centered focus and that professionalism is a collective obligation.
In the beginning, the university’s IPP philosophy was not embraced by all members of the campus community. Bridging differences and rejecting an entitlement mentality were essential to merge individual and discipline expertise into a common multidisciplinary understanding. The strategy focused on the mutual goal of improved treatment outcomes and patient care, de-emphasizing competition and accentuating a shared vision of high functioning teams.
The professionalism committee instrument for change
In 1998 the UTMB Professionalism Board was formed to develop a multidisciplinary approach to advancing professionalism, recognizing that a fundamental concern for the patient should characterize all members of the AHC community. The Board’s charge was to launch a comprehensive set of professionalism initiatives throughout the institution and to transform the culture of health care training and practice.
The Board has evolved over time to become the Professionalism Committee, and has played a central role in executing and linking key professionalism initiatives. It has met continuously since 1998, proactively addressing campus issues and changes in the health care delivery system that impact professional behavior and the healing environment. The Committee regularly monitors results of institutional climate surveys, and meets with the President, Provost, Deans, and Student Government to proactively address ethical challenges and provide recommendations and seek action as needed.
Membership continues to include individuals from across the mission areas and workforce segments (e.g., academic and health system administration, physicians, nurses, faculty, and students from all four UTMB schools). The broad representation ensures that messages can be tailored to suit respective points of view. Members are appointed by the President and have demonstrated a commitment to professionalism and, because of each member’s specific role, serve as knowledgeable and effective change agents.
Given the diversity and breadth of roles, the committee is able to address matters related to IPP across the enterprise and to recommend and influence solutions in the academic and clinical arena. Four of its members have attended the highly recognized Vanderbilt University Disruptive Behavior Conference and provide valued insight and direction. In addition, UTMB has within its ranks recognized leaders in the field of professionalism, professional identity formation, and bioethics. These experts provide invaluable guidance to the institution and committee.
Putting the charter into practice
Starting in 2000 a series of university programs were developed to build awareness about exemplary models of professional behavior. These included: Going the Extra Mile, a campus-wide program for staff, students, and faculty to recognize outstanding professional qualities of their peers; the John P. McGovern Academy of Oslerian Medicine, which endows School of Medicine faculty who exemplify ideals of professionalism and humanism; and You Count employee surveys to solicit perceptions about workforce culture.
In 2002, the effort to define professionalism on campus gained momentum with the publication of the Physician Charter in the Annals of Internal Medicine4 and Lancet,5 which identified and defined the principles and commitments of professionalism. With a grant from the American Board of Internal Medicine, UTMB began to explore the Physician Charter’s application to the university. The result is the UTMB Professionalism Charter,3 which extends the professionalism themes and standards of conduct to everyone at UTMB—faculty, staff, and students.
The university’s position was pioneering and has proven to be an important strategy to address the critical success factors in today’s academic health systems. Health care’s future is systems-based and embraces team-based practice to improve clinical outcomes and effective care coordination. The core of these relationships is interprofessionalism, focused on greater collaboration, respect, and effective communication.
The UTMB Charter was written with this integrative model in mind to encompass the campus as a whole, recognizing that all members of the AHC community share equal responsibility for its professional commitments, “from the clinician who ensures quality care, to the staff member who ensures confidentiality of patient records.”1 The Charter’s mandate therefore is to hold every member of the UTMB community accountable for acting with integrity, compassion and respect towards one another and those we serve.3
The UTMB Professionalism Charter is a living document that is regularly reviewed and updated. The Charter serves as a capstone for all discipline-specific standards and codes of conduct. It is a unifying set of beliefs and behaviors that are professed to the community. The ten commitments have been written so that a “line of sight” is meaningful from wherever in the institution one stands or whatever role one has. “Everyone who works or studies at the University of Texas Medical Branch is a member of a community of professionals dedicated to advancing UTMB’s mission, vision and values.”3 The Professionalism Charter is utilized in our orientation and leadership programs. All fundamental efforts to improve the capability and capacity of our workforce are inextricably linked to the standards outlined in the Charter.
The Charter’s main objective is to build strong understanding and consensus, while generating a culture that allows and encourages dialogue that is both candid and meaningful.
UTMB Professionalism Charter Commitments
- Commitment to a culture of trust
- Commitment to diversity
- Commitment to competence and growth
- Commitment to confidentiality
- Commitment to honesty
- Commitment to the responsible use of resources
- Commitment to value
- Commitment to appropriate relations
- Commitment to manage conflicts of interest
- Commitment to the appropriate discovery and use of knowledge
While the UTMB Charter was being developed another IPP endeavor was occurring across campus. It is important to acknowledge the role students played in the progression of IPP at UTMB. Their passion, compassion, and altruism were a source of vitality to the movement. It began with efforts of the Medical School Student Honor Education Council, which saw a need to educate and address academic integrity issues that were driven from students’ perspective and yet complementary to institutional efforts. The students’ close association with other health professions student organizations quickly resulted in IPP becoming a multidisciplinary effort and the development of a four-school unifying statement of IPP.
On my honor, as a member of the UTMB community, I pledge to act with integrity, compassion, and respect in all my academic and professionalism endeavors.
Each word was deliberated at length, with students and faculty reflecting on the values that are inherent in the various codes of conduct and standards of the health professions. The honor pledge encapsulates the key values of IPP. It is a measure of the professional and academic evaluation of students in all courses and complements the UTMB Student Conduct and Discipline Policy.
Honor pledge plaques and signs are displayed throughout UTMB, serving as a reminder of the basic principles. The pledge is introduced to new students at the All School Orientation and New Student Welcome events, which themselves are examples of UTMB’s interprofessional tradition.
The orientation includes new students from each of the four schools and includes a Welcome Weekend of team building and networking activities. The program is a collaborative university event that is hosted by passionate volunteers of second-year students from all four schools, faculty, and staff who serve as facilitators and staff. The All School Orientation and Welcome Weekend showcase UTMB values and mission and set expectations that students are members of a diverse community of professionals who share a common set of professional values.
Becoming a professional
UTMB also has augmented student development activities with formal course work to engrain professionalism and interprofessionalism throughout the curriculum of the four schools. For example, the Graduate School of Biomedical Sciences convenes an annual seminar on ethics of scientific research, the School of Nursing has classes on ethical practice and cultural sensitivity, and the School of Health Professions and School of Medicine (SOM) have embedded professionalism in the students’ training and curriculum.
In 2005, the SOM introduced professionalism with five longitudinal themes across the medical curriculum to ensure broad integration with medical training. During the first and second years, the practice of medicine course6 engages students in small group discussions about health care delivery, interprofessional teamwork, and ethical practice. The sessions encourage opportunities for reflective growth. The faculty continues to seek opportunities to enhance the professionalism themes within existing and new classes, programs, and activities.
UTMB has implemented an Interprofessional Education program with courses open to all students for credit. These include: Foundations in Patient Safety and Health Care Quality; Spirituality and Clinical Care; and Global Health Interprofessional Core Course. An Interprofessional Pediatric Advocacy Program is designed to have students work in interprofessional teams with Child Protective Services caseworkers and families. Pediatric End-of-Life Simulation brings students together from all of the schools to participate in a high-fidelity simulation focused on the care of an infant and family as a child faces cardiopulmonary arrest. Annually, UTMB hosts Interprofessional Education Day, which features a keynote speaker and a series of simulation workshops involving interprofessional teams of students with a trained facilitator.
UTMB has augmented the curriculum with experiential opportunities for interprofessional teamwork through intentional student community service learning projects.7 Frontera de Salud and St. Vincent’s Free Clinic are student-run community service projects that were founded and staffed by medicine, nursing, and health professions students to provide community-based health programs. Both student organizations promote opportunities for our students to work with interprofessional teams. Our students’ evaluations of these experiences continue to be positive year after year.
“Do as you say, not as you do”
Jordan Cohen, president emeritus of the Association of American Medical Colleges states, “Unless we convert our learning environments from crucibles of cynicism into cradles of professionalism, no amount of effort in the admission arena is going to suffice.”8 Bullying behavior is inimical to interprofessional professionalism. Verbal and physical harassment and intimidation are unfortunate standard examples of mistreatment endured by health care learners operating through informal clinical and classroom interactions forming what is known as the hidden curriculum.9 On July 9, 2008, the Joint Commission published the Sentinel Event Alert, Issue 40, that declares, “Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care and cause qualified clinicians, administrators and managers to seek new positions in more professional environments.”10
UTMB is committed to providing the best educational climate possible and recognizes the need to safeguard students who may be the victims of or witnesses to unprofessional and disruptive behavior by faculty. The inherent vulnerability of students and their dread of reprisal may leave them reluctant to protest such behavior. In 2004, UTMB introduced an online mechanism for students to report unprofessional behavior or mistreatment—whether from a resident, faculty member, fellow student, or staff.
The Professionalism Concern Report (PCR) is located prominently on the UTMB Professionalism website and allows students from all four schools to bring forward professionalism concerns to a neutral third party. The forms can be submitted anonymously by students; they may also meet with the Student Ombudsman or other officials as an option. The PCR is triaged by the co-chairs of the Professionalism Committee (a SOM faculty and a university administrator) and sent to the appropriate department chair/manager to resolve the student concern.
Examples of unprofessional behaviors reported include: verbal abuse, public belittlement, disparaging comments by faculty or other health care team members, discourtesy in the classroom by fellow students, or student cheating. The administrator is asked to address the issue by following up with the faculty, student, or employee within his or her department.
The action begins by a determination of what events can be validated. A conversation with the faculty or staff member is convened and then appropriate action is taken. The action might be as modest as a brief conversation and a verbal reminder of appropriate standards of conduct and behavior. With serious findings a more directive action plan might be the outcome. The intention of this process is to remind and remediate. Faculty and other members of the UTMB community have a responsibility to be accountable to one another and immediately address lapses in behavior and support the remediation of problems. Being accountable constitutes the essence of professional behavior.
Remediating student professionalism
Campus-wide remediation and intervention mechanisms have been introduced to address student professionalism. At UTMB, faculty and staff have an opportunity to assess student professionalism as a part of students’ academic evaluation across the four years. If faculty or staff observe behavior that is inappropriate by a student they may submit an Early Concern Note (ECN) for follow up action. The ECN is an informal intervention process that is separate from the academic record.
“[ECN] is a part of a campus wide initiative to heighten awareness of the importance of professionalism behavior.”11 It remains confidential between the student and the Associate Dean, unless and until a student receives three or more ECNs during matriculation. It is not anonymous and students receive a copy of the report as a part of the mentoring and guidance process. Some student behaviors, such as academic dishonesty and unlawful behavior, are not a part of this process and are administered through the Student Affairs office as a part of the University Conduct and Discipline Policy. The ECN is not punitive, but allows for unprofessional actions to be addressed quickly and may reveal patterns of behaviors that could advance to truly significant concerns over time.
Because UTMB undertook its professionalism initiative enterprise-wide to ensure an interdisciplinary approach, the initiative has utilized multiple modalities to promote and measure its program effectiveness. UTMB conducts a series of student, employee, and patient surveys to measure effectiveness of programs and activities that enable a professional environment. The student survey contains a series of questions that asks respondents to reflect and assess the institution’s commitment to professionalism and interprofessionalism, to faculty’s commitment to maintaining respectful professional relationships, and to the extent to which one has observed faculty and students modeling the Charter commitments.
Student satisfaction scores (from all schools) over three years (2011 through 2013) have overall sustained high marks, with recent slightly negative declines in some areas. For example, after several years (2002 through 2007) of positive gains, in 2007 96% of students rated professionalism as a priority at UTMB; in 2013, 95% of students from all four schools reported that professionalism is a priority at UTMB. In 2007, 93% students reported that they had been treated with courtesy and respect by faculty. In 2011, 92% of students reported that they had been treated with courtesy and respect by faculty; in 2013, the rate revealed a small decline to 89%.
The scores also decline slightly when the students are asked to assess their cohort’s professionalism. In 2011, 86% all students reported that students are courteous and respectful in the classroom; in 2013, it had fallen slightly to 83%. In 2011, 89% students indicated that “cheating is not a problem at UTMB”; in 2013 the score had changed to 87%. Survey written responses and forums with students and faculty have identified environmental, demographic, and technological disruptors that have provoked adverse outcomes.
In 2011, UTMB began to survey students about their interprofessionalism experiences. In 2011, 79% of all students reported “While at UTMB I have developed an appreciation for the value of inter-professional teamwork”; in 2013, it has risen slightly to 81%. The same holds true for “While at UTMB, I have learned about the role of different health care professions” (2011 82%; 2013 83%) and “I have had an opportunity to participate in inter-professional activities” (2011 77%; 2013 86%).
UTMB conducts an employee satisfaction survey regularly to measure workforce climate. The survey asks employees to assess “The person I report to treats me with respect” and “UTMB treats employees with respect. In 2011 using a Likert scale of 1 = strongly disagree to 5 = strongly agree, the responses were 4.25 and 3.72 respectively; in 2012, 4.23 and 3.70 respectively, and in 2013, 4.22 and 3.67 respectively. These responses have trended down slightly.
Monitoring and measuring professionalism and interprofessionalism outcomes are crucial to understanding institutional performance and avenues of improvement. Results from various student, patient, and workforce surveys indicate that progress continues to be made, but that we have not achieved our objective. Senior leaders utilize survey and quality data to initiate two-way communication, reinforce behavior, and improve performance. A focus on behavioral aspects of performance and interpersonal relationships complements institutional quality initiatives and strategic objectives.
Advancing IPP during a stable environment is problematic; attempting to improve interprofessional collaboration, communication, and respect during turbulent financial and environmental conditions is even more difficult. Health care reform, financial challenges, consumerism, and value-based purchasing are just a few of the changing environmental forces impacting education, research, and health care. Reviewing survey results allows us to gauge our success, improve our knowledge, and address opportunities for continuous improvement. The slight downturn in performance has resulted in the organization developing action plans, deploying additional targeted “pulse surveys,” and increased communication between learners and faculty and employees and managers to determine the root cause of issues. UTMB is approaching the challenge as an opportunity to role model transparency and collaboration among its leaders.
The assessment tools enumerated above reflect only a small part of UTMB’s effort to measure the impact of professionalism and interprofessional activities. UTMB is committed to maintaining high standards of excellence, integrity, and accountability, whether it involves academic or research activities, clinical practice, or institutional decision-making by faculty and employees.
UTMB hosts a Professionalism Summit biennially to address the pedagogy of professionalism and the importance of addressing unprofessional behaviors. The speakers list is a who’s who in the field of professionalism. In 2004, Maxine Papadakis, MD, lectured on the association between unprofessional behavior among medical students and subsequent disciplinary action by state medical boards.12 Her pioneering work was foundational in UTMB’s development of the Early Concern Note process. In 2009, David Leach, MD, presented on “Creating a Culture of Professionalism: Reconnecting Soul and Role. In 2011 and 2012, Gerald Hickson, MD, presented “A Complementary Approach to Professionalism: Identifying, Measuring and Addressing Unprofessional Behaviors” and “Dealing with Behaviors that Undermine a Culture of Safety.” Dr. Hickson’s presentations engaged clinical chairs and health system leadership in a critical dialogue on the importance of proactively addressing disruptive behaviors.13 In 2014, Barbara Balik, RN, MS, PhD, delivered “Interprofessionalism—Why Bother?” Dr. Balik’s session emphasized the impact and attributes of a high functioning team.
These presentations were instrumental in guiding and informing our journey and provided an opportunity to listen and interact with innovative national experts in the field. The insights gained ignited candid debates about the hidden curriculum, self-regulation, and the strategic challenges AHCs are facing. Annually UTMB hosts either the biennial Summit or informal “brown bag” workshops. These events are powerful reminders about our responsibility as role models and about the obligation to speak out and engage those who act unprofessionally.
Interprofessional professionalism as a strategic objective
Professionalism is recognized as critical to the organization’s future success. The Professionalism Charter’s mandate to “hold every member of the UTMB community accountable for acting with integrity, compassion and respect toward one another and those we serve” is one of the institutional strategic goals. UTMB has deployed systematic approaches to develop and assess workforce engagement and climate. High performance is characterized by effective communication, patient/client/student focus, knowledge, skills, and respectful behaviors. Transforming our internal relationships requires proactive intentional processes put in place to reinforce professional values and ethical business practices.
IPP is more than a theoretical concept or an ideal; it is a strategic imperative and core competency of today’s AHC. Societal, economic, and technological innovations are disrupting not only traditional hierarchical structures and relationships among health professionals, but the relationships between provider and patient as well. Innovative training and IPP education can provide health professionals with opportunities to gain the skills, knowledge, attitudes, and behaviors needed to fully participate in integrative health care delivery systems.
UTMB’s model for interprofessional professionalism
Promoting IPP is a multifaceted endeavor and requires a supportive infrastructure, leadership engagement, and strategic foresight to recognize the fundamental pressures effecting change at AHCs. It requires a matrix of policies, processes, and individuals committed to addressing unprofessional behaviors that negatively impact the team’s performance and patient outcomes. Significantly, it requires the passion and cooperation of faculty members who serve on the front line as health providers, colleagues, and teachers. As Hickson and colleagues note, “Every physician needs skills for conducting informal interventions with peers.”13 It is critical that faculty, residents, and senior leaders provide appropriate models of respect and inspire each other to act with integrity, compassion, and respect. Role models must be recognized, nurtured, and valued.
UTMB has implemented a comprehensive program to sustain professional behavior and enhance interprofessionalism. Strong leadership focus and a systems approach have shaped a culture of shared values and interdisciplinary collaboration at UTMB for fifteen years. The professionalism initiative is still on course with critical lessons learned and continued emphasis on sustaining an interprofessional professionalism culture:
- A reporting mechanism and clear policies are important to support the vulnerable members of the community and hold the individuals accountable.
- A vigilant effort is needed that promotes and continually reminds community members of the values and behaviors that are shared by all.
- Leadership and management training is necessary to provide skills to address poor performance and disruptive behaviors.
- Annual performance evaluation and satisfaction surveys must be deployed and results measured to effect change.
- Recognition that professionalism is a strategic objective that is foundational; it signifies the importance of civility and respect to other members of the health care team.
- AHCs are at a crossroads that demand an integrated and collaborative vision to improve interdisciplinary collaboration and professionalism in a patient-centered integrated-care environment. What will not change over time is a commitment to patients’ welfare, the duty to uphold scientific standards, and the importance of respectful engagement by all disciplines.
UTMB has developed a systems approach to address and sustain its commitment to professionalism and interprofessionalism. This strategy elevates the primacy of professional and ethical behavior and demands it as a core competency critical to the organization’s mission.
Professionalism is the standard of conduct for everyone at UTMB with a clear recognition that everyone at UTMB is a member of a community of professionals and it takes everyone to advance the university’s mission, vision, and values.
- Smith KL, Saavedra R, Raeke J, O’Donell AA. The journey to creating a campus-wide culture of professionalism. Acad Med 2007; 82: 1015–21.
- American Board of Internal Medicine. Project Professionalism. Philadelphia (PA): American Board of Internal Medicine. Available at http://www.abimfoundation.org/Resource-Center/Bibliography/~/media/Files/Resource%20Center/Project%20professionalism.ashx.
- University of Texas Medical Branch. UTMB Professionalism Charter. Available at http://www.utmb.edu/professionalism/about-us/professionalism-charter.aspx.
- ABIM Foundation, American Board of Internal Medicine; ACP-ASIM Foundation, American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med 2002; 136: 243–46.
- Medical Professionalism Project. Medical professionalism in the new millennium: A physician’s charter. Lancet 2002; 359: 520–22.
- University of Texas Medical Branch School of Medicine. Course Information: Year 2 Practice of Medicine. http://www.utmb.edu/imo/courses/year2/pom2.asp.
- Muller D, Meah Y, Griffith J, et al. The role of social and community service in medical education: The next 100 years. Acad Med 2010; 85: 302–09.
- Cohen J. Our compact with tomorrow’s doctors. Acad Med 2002; 77: 475–80.
- Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994; 69: 861–71.
- The Joint Commission. Sentinel Event Alert. Issue 40, July 9, 2008 Available at: http://www.jointcommission.org/assets/1/18/SEA_40.pdf.
- Ainsworth MA, Szauter KM. Medical student professionalism: Are we measuring the right behaviors? A comparison of professional lapses by students and physicians. Acad Med 2o06; 81 (10 Suppl.): S83–86.
- Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Acad Med 2004; 79: 244–49.
- Hickson GB, Pichert, JW, Web LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring, and addressing unprofessional behaviors. Acad Med 2007; 82: 1040–48.
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Updated on May 14, 2015.
© 2017 Alpha Omega Alpha Honor Medical Society