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About
The VCU School of Medicine Professionalism Committee was formed in 2000 to study professional behavior in the medical school. Their proposed Standards of Professional Behavior have since been integrated into the curriculum.
The VCU School of Medicine Professionalism Committee was formed in 2000 to study professional behavior in the medical school.
Letter from the Dean of the School of Medicine
The Dean’s letter outlines the School of Medicine Professionalism Initiative, including the Standards of Professional Behavior and the process for resolving concerns, and asks each recipient to sign-on to the initiative.
View the letter, then complete and submit the commitment form:
Pocket Cards
Pocket cards, sized to fit into white coat pockets and containing the Standards of Professional Behavior, provide a handy reference for busy medical students and faculty.
For printed copies, contact:
Debbie Stewart
Phone: 804-828-6591
Email: deborah.stewart@vcuhealth.org
Poster: Standards of Professional Behavior
Poster: Standards of Professional Behavior
Standards of Professional Behavior posters are displayed throughout the School of Medicine to reinforce the principles that characterize medical professionals.
For printed copies, contact:
Debbie Stewart
Phone: 804-828-6591
Email: deborah.stewart@vcuhealth.org
ACGME Milestones Professionalism is one of the six general competencies in the ACGME’s Outcome Project.
The Cases
Case 1
A 65-year old man has abdominal surgery to remove a malignant tumor. For weeks after the procedure, he experiences severe pain and runs a slight fever. He visits his physician complaining of intense discomfort and the physician orders a CT scan. The scan reveals a lap pad that was mistakenly left inside his body after surgery. The man then undergoes a second surgery to remove the lap pad and recovers without incident.
Case 2
A 23-year old G1P0 arrives 39 weeks pregnant, in active labor. She delivers an eight-pound baby girl by spontaneous vaginal delivery and has a second-degree vaginal laceration. A sponge is used at the site of repair for the laceration. Three days after discharge she spikes a fever and has intense vaginal pain. Upon examination in the physician’s office, a sponge is found and is removed from the patient’s vagina.
Commentary
Although the cases described above are fictional, they are representative of what can and has occurred.
Discussion Points
Remember: Nothing gets left behind
Provided by the Office of Performance Improvement
L. Dale Harvey, M.S., R.N., Coordinator
The Case
Mrs. Jane Smith, a patient admitted to a medical-surgical unit, had an order to receive a routine chest x-ray in the Radiology Department. A transporter came to the unit to take Mrs. Smith for her test. The nurse caring for Mrs. Smith informed the transporter that Mrs. Smith had a thoracic spine fracture and needed to remain flat and to not be log rolled when transferring between beds. Mrs. Smith’s nurse also informed the transporter that Mrs. Smith was pretty sleepy because she had just received some pain medicine for her back pain.
When the transporter delivered Mrs. Smith to the Radiology Department, the staff asked him to place her in the holding area because they were behind schedule. The transporter obliged and left to take another patient back to their hospital room. After several minutes, the radiology staff brought Mrs. Smith into the room for her x-ray. To maximize the quality of their study, they placed Mrs. Smith in an upright position. After the x-ray was completed, another transporter was asked to take her back to her room.
Mrs. Smith arrived back to the medical-surgical unit and was placed in her room. When Mrs. Smith’s nurse came in to give her scheduled medications she was shocked to see her sitting in an upright position. She immediately lowered the head of the bed and called the patient’s physician. A neurologic exam revealed that Mrs. Smith could no longer move her legs.
Commentary
Although the case described above is fictional, it is representative of what can occur when handoff communication is inadequate.
Action Points
For more information about strengthening handoff communication, contact:
Jill Mercier
Patient Safety Officer
Phone: 804-828-0506
E-mail: jmercier@mcvh-vcu.edu
Kay Davis
Nursing Director, Professional Practice
Phone: 804-826-1506
E-mail: kdavis2@mcvh-vcu.edu
Provided by the Office of Performance Improvement
L. Dale Harvey, M.S., R.N., Coordinator
Case 1
Albert A. Raxton was seen by Dr. Smith in Ambulatory Clinic 9 for a groin nodule. Albert B. Raxton was also seen in Clinic 9 for an upper respiratory infection—he has a history of lymphoma.
Albert B. finished his appointment and was directed to the clinic scheduler for a chest MRI appointment while Dr. Jefferson was still completing the notes on his chart. While Albert B. was sitting there, Dr. Smith came out and gave the scheduler Albert A.’s chart that contained an order for a biopsy of the groin nodule. The scheduler made the appointment for Albert A. and handed an appointment card to Mr. Raxton (Albert B.) sitting in front of her. He was relieved to hear he is having a biopsy, even though he and Dr. Jones did not specifically talk about it—he knows that a new lump may be a bad sign of lymphoma recurrence.
One week later, Albert B. appears for his biopsy. He is registered by the registration staff and sent back for his procedure. Susan Talley brings the patient back to the room for the biopsy. She verifies the patient is “Albert Raxton” and that he is having a biopsy. Just after completing the procedure, Dr. Williams realizes that the patient who had the biopsy is not the same patient as the name on the paperwork.
Commentary
Although the case described above is fictional, it is representative of what can occur and has occurred in health care organizations throughout the nation.
“Wrong patient” events are among the most disturbing adverse events that occur in healthcare.
Particularly in a large complex health system such as ours, inadequate communication is a frequent contributor to such occurrences.
Communication between clinical areas and among individuals within the same area (registration clerk to technologist, physician to registration clerk) is often incomplete.
A standard process to verify patient identity, using two unique identifiers, protects patients from such occurrences.
Discussion Points
Case 2: Check the Wristband
Ms. Yeardley, a 28-year-old female awaiting ambulatory surgery, was very anxious about her impending surgery. She spoke English and appeared to be of average intelligence.
The circulating nurse went to the peri-surgical unit to meet her next patient. She picked up the chart next to this patient—it was the correct chart for her next patient. The nurse then verbally stated the patient’s name and this woman confirmed. She also confirmed other information, including the type of surgery.
Commentary
As occurs with many “near miss” and actual events, the incident involved several errors:
As is often the case, these errors appear to have been made by conscientious professionals.
The nurse had supplied much of the information for patient identification, rather than asking the patient open-ended questions and insisting that the patient provide correct identifying information, such as “What is your date of birth?” rather than, “Your birth date is May 1, 1976?”
Why would the patient answer all the nurse’s questions correctly? Many patients and families are quite anxious.
Adapted from AHRQ Web M&M, July 2003, psnet.ahrq.gov/webmm.
Case 3: Results Posted to the Wrong Medical Record
Mario B. Lopez, an 88-year-old male with a known history of meningioma, was referred for MRI to evaluate progression of the size of the tumor. Mario A. Lopez, a 40-year-old male, was also referred to MRI around the same date, for evaluation of neck and shoulder pain.
When Mario B. Lopez presented, he was registered as Mario A. Lopez due to an inadvertent selection of the wrong patient in the computer system. Thus, the cranial MRI report and films for Mario B. Lopez were generated with Mario A. Lopez’s name and medical record number and posted to Mario A. Lopez’s electronic record.
Mario A. Lopez, who had been referred for neck and shoulder discomfort, returned to the neurosurgeon for review of his films. The neurosurgeon reviewed the film and informed Mr. Lopez (erroneously) that he had a meningioma; surgery was recommended. After waiting three months, Mario A. Lopez was admitted for surgery. During a pre-op angiogram, it was discovered that Mario A. Lopez did not have a meningioma.
Commentary
Staff members involved in this case were all well-trained and well-intentioned. While it might be easy to blame the individual who registered the patient for MRI, there are actually a series of factors that, if different, could have prevented this event.
A simple slip of the hand can result in selection of the wrong patient from among a patient list in the computer. Such human errors are common, but can be easily detected through use of a standard process for patient identification, including:
Interesting article: Chassin’s “The Wrong Patient” Ann Int Med, v136, n11, June 2002. Other vignettes at psnet.ahrq.gov/webmm.
Provided by the Office of Performance Improvement
L. Dale Harvey, M.S., R.N., Coordinator
The Case
Early in the evening, Dr. Steve Adams, an attending physician, berated Dr. Johnson, the junior resident, at the nursing station regarding his care decisions for a patient on their service. Dr. Johnson was often intimidated by Dr. Adams, but was particularly embarrassed this time, as several of his fellow residents witnessed this public interaction.
During the night, Dr. Johnson was called regarding abnormal laboratory test results on a different patient on the service. Despite his uncertainty regarding how to follow-up on the labs, and recalling the incident from earlier in the day, Dr. Johnson decided not to call Dr. Adams for assistance. Shortly thereafter, Dr. Johnson received an urgent page from the nurse on the unit that the patient’s vital signs were worsening. Dr. Johnson called the ICU resident and the patient was transferred to the intensive care unit where she was stabilized and ultimately was discharged to home.
Commentary
Although the case described above is fictional, it is representative of what can occur when communication between members of a health care team is compromised.
Ineffective communication among team members is the most frequently identified root (underlying) cause of sentinel events, both here at VCUHS, as well as nationally.
Discussion Points
“Listen to Me” (6/2004) and “Fumbled Handoff” (3/2004) cases on AHRQ’s Web M&M also focus on communication. psnet.ahrq.gov/webmm..
Provided by the Office of Performance Improvement
L. Dale Harvey, MS, RN, Coordinator
Goal
No patient at VCU Medical Center will ever have the incorrect procedure, incorrect site, or incorrect implant/device.
The Case
A bedside procedure was planned for Jane Smith, a patient in the step-down unit. The resident overseeing Jane’s care was due to go home. She “signed out” to Dr. Robert Jones, the resident for the day. Dr. Jones obtained informed consent and reviewed radiological films in preparation for the procedure. As Dr. Jones prepared for the procedure, Jane’s nurse, Laurie, was called out of the room to attend to another patient. Dr. Jones began the procedure on the left side. When Laurie returned to the room, she recalled the site as “right” on the consent she witnessed earlier. She checked the consent in the chart and found that she was correct. She immediately alerted Dr. Jones and the procedure was stopped. The right side was then prepared, and the patient underwent successful procedure.
Commentary
Although the case described above is fictional, it is representative of what can and has occurred. These wrong patient/site/procedure/implant events are not isolated to the Operating Rooms (OR) and interventional areas—patients undergoing procedures anywhere, including at the bedside and in the ambulatory setting, are at risk. Analysis of such events has revealed two primary causes:
Actions
*“Invasive Procedures” include those involving puncture or incision of the skin and insertion of an instrument or foreign body into the body (e.g., includes circumcision, biopsy, percutaneous aspirations); include anything that is more invasive than performing venipuncture, inserting a NG tube or foley.
Health, wellness and professional behavior are all interrelated.
Health, wellness and professional behavior are all interrelated. According to the American Association of Medical Colleges:
Medical school and residency training represent periods of intense study and training and can be very stressful life periods. There is a large literature on impaired physicians, addiction and substance abuse as unhealthy coping mechanisms. Identifying stressful situations early in one’s career, as a medical student or before, and providing models for healthy coping has the potential to reduce the likelihood that a physician will make poor choices later in life.
Click the panels below for more information on referral topics.
Understanding and Using the Conflict Dynamics Profile
After a brief overview of the causes and types of conflict, participants will use information from their Conflict Dynamics Profile (CDP) reports to examine personal approaches to conflict. The CDP measures behaviors from different vantage points:
Pre-registration is required to allow time for completing and processing the CDP survey. Course can be arranged for individual departments or units. Contact:
Karen Fields
VCU Human Resources Training
Phone: 804-828-1687
Other VCU Training
School of Medicine Faculty
PonJola Coney, M.D.
Senior Associate Dean, Faculty Affairs
Phone: 804-828-6594
E-mail: ponjola.coney@vcuhealth.org
VCU Faculty and Staff
Kawana Pace-Harding
Employee Relations Manager, VCU Human Resources
Phone: 804-828-1510
E-mail: klpaceha@vcu.edu
Housestaff and Residents
Stephanie Call, M.D., M.S.P.H.
Interim Associate Dean, Graduate Medical Education
Phone: 804-828-9783
E-mail: modonnel@mcvh-vcu.edu
Medical students
Susan DiGiovanni, M.D.
Interim Senior Associate Dean for Medical Education and Student Affairs
Phone: 804-827-1743
E-mail: susan.digiovanni@vcuhealth.org
Graduate Students (Ph.D., Master’s and Certificate Programs)
Jan Chlebowski, Ph.D.
Associate Dean, Graduate Education
Phone: 804-828-1023
E-mail: jan.chlebowski@vcuhealth.org
McGuire Veterans Affairs Medical Center (VAMC) Employees
Karen Sanders, M.D.
Associate Chief of Staff for Education
Phone: 804-675-5249
E-mail: karen.sanders@med.va.gov
The VCU Health System Medical Staff Health Committee provides education and awareness of mental and physical impairments as well as a mechanism to address concerns regarding potential mental or physical impairment of a practitioner in a timely, effective and confidential manner. The Committee is comprised of physicians within the Health System as well as representatives from Human Resources, GME and Employee Health.
VIRGINIA HEALTH PRACTITIONERS’ MONITORING PROGRAM (VAHPMP)
The Department of Health Professions has a contract with Virginia Commonwealth University Health System, Department of Psychiatry, Division of Addiction Psychiatry, to provide confidential monitoring services for health practitioners who may be impaired by any physical or mental disability or who suffers from chemical dependency.
Available monitoring services include intake, referrals for assessment and/or treatment, monitoring, and alcohol and drug toxicology screens.
The Health Practitioners’ Monitoring Program requirements are:
For further information or referral, call HPMP toll-free at 1-866-206-4747 or visit Virginia HPMP’s webpage at https://www.dhp.virginia.gov/hpmp/default.htm
Information on how to report concerns is below.
Processes
Contacts
Hotlines
SOM Professionalism Committee Members - 2015-2016 Academic Year
contact information for reporting professionalism concerns
* = ex officio member
Faculty/Administrative Members - Position/Department
Cheryl Al-Mateen, MD - Chair
Kathy Kreutzer, MEd - Staff to Committee
*Julie Beales, MD - Interim Chief of Staff, McGuire VAMC
*Lelia Brinegar, BS, MEd - Assistant Dean, Curriculum Office
*Ellen Brock, MD, MP - Medical Director, Center for Human Simulation and Patient Safety
*Samantha Buery Joyner, MD - Inova Campus Assistant Dean for Student Activities
*Craig Cheifetz, MD - Inova Campus Associate Dean for Medical Education
*Jan Chlebowski, PhD - Associate Dean Graduate Education
*Ron Clark, MD - Chief of Staff, VCUHS
*Maria Curran, MA - Human Resources, VCUHS
Susan DiGiovanni, MD - Interim Sr. Associate Dean for Medical Education and Student Affairs
*Alan Dow, MD, MSHA - Assistant VP of Health Sciences, Interprofessional Education and Collaborative Care
Serina Floyd, MD - Inova Campus Obstetrics & Gynecology
*Alicia Freedy, MD - Inova Campus Assistant Dean for Curriculum
Anne Hawkins, MS, RN, NE-BC -Nursing Director of Psychiatry, VCUHS
*Lenore Joseph, MD - McGuire VAMC Associate Chief of Staff for Education
Mark Malkin, MD - Neurology
Beth Marshall, MD - Pediatrics
*Rosa Morales Theodore, MD - Chair, Multicultural Affairs Advisory Board
*Mary Alice O’Donnell, PhD - Associate Dean for Graduate Medical Education
*Edna Rensing, MA, MSHA, CPHQ, PMP - Performance Improvement Manager, VCUHS
*Michael Ryan, MD, MEd - Assistant Dean, Clinical Medical Education
*Karen Sanders, MD - Past Committee Chair; Deputy Chief Academic Affiliations Officer, Veterans Health Administration
Rita Shiang, PhD - Associate Professor, Human and Molecular Genetics
J.P. Verderese, MD - Inova Campus, Internal Medicine, Hospitalist
*Chris Woleben, MD - Associate Dean for Student Affairs
*Wilhelm Zuelzer, MD - Orthopaedic Surgery
Housestaff Representatives
Nathaniel Warner - Internal Medicine
Raj Ramanathan - Surgery
Medical Student Representatives
Jennifer O'Neil - M1, Class of 2019
Youmna Sherif - M3, Class of 2017
Postdoctoral Scholar Representative
Pretal Muldoon - Anatomy
Professionalism Committee Composition – Members Appointed by the Dean
The MCVH Ethics Committee meets two times a month to review cases and policies. These primarily involve patient care within VCUHS, but occasionally the committee reviews cases from outside institutions where our faculty also work. Anyone connected to a case can ask for the committee’s input—patient, family, nurses, students, housestaff, attendings, consultants, or others.
To speak with an ethics committee member call 804-828-0938.
Committee Members
Ethics committee list updated July 14, 2015.
Poster Presentations
Click the panels below to view Professionalism resources
Articles on Professionalism
Some of the following articles require subscriptions. Wherever possible, these are provided freely to the VCU community via the VCU Libraries' proxy server. Visitors from outside VCU may need to check for local availability.
Presentations
General
Evaluation of students
This section includes expected standards for behavior, attire, lifelong learning, confidentiality and humanism or sensitivity.
This section includes expected standards for behavior, attire, lifelong learning, confidentiality and humanism or sensitivity, together with guidelines of when to offer help or seek help. Listed below are additional standards and policies.
Key Standards and Policies
Related Policies at VCU and VCUHS
Professional behavior is supported by policies that can be consulted when problems are perceived.
Standards of Professional Behavior
These standards describe behaviors expected from all members of the School of Medicine (SOM) community, in educational, clinical, research and administrative settings. Professionalism is expected during all interactions, whether face-to-face or via telephone, video, email, or social networking technologies.
Members of the SOM Community will:
These standards were proposed by the Professionalism Committee, adopted by the School of Medicine in September 2001, and updated in September, 2010. The standards are also available in print in the form of pocket cards and posters. For print copies, contact:
Debbie Stewart
Phone: 804-828-6591
E-mail: Deborah.Stewart@vcuhealth.org
Recommendations for Professional Attire (All Students)
It is important that everyone who works at VCUHS present a professional appearance to patients and families. The purpose of the dress code is not to inhibit personal freedoms, but rather to acknowledge the unique role that physicians and medical students have in patient care. Each clinical department or division has the right to establish dress codes specific for their area and patient population, but here are some general guidelines.
Uniforms or business attire, representative of your professional career, are expected and should be clean, neat and of appropriate size. Appropriate dress for male medical students is shirts, ties, and pants. Female medical students should wear dresses or skirts of knee length or longer or dress pants and blouses. Exposure of the abdomen or chest due to low cut blouses or pants, is not appropriate.
Please follow these other specific requirements as well:
Wearing your VCUCard is required as well. All persons who provide care or services to VCUHS must display proper identification that includes their name, job title, and the department to which they are assigned. The VCUCARD MUST be worn at all times, face forward and above the waist, so you can be easily identified. Failure to wear your ID could result in your being denied access to your clinical assignment area. Always wear your white coat and name tag, unless in the prison unit or directed otherwise by the unit.
Your first goal should be to provide the best health care for your patient. Effective communication is an important part of that process. Your appearance counts!
Faculty, housestaff and students should:
Comments on Lifelong Learning from VCU SOM Teaching Excellence Award Winners:
Rita Willett, M.D.
“In the first month of my internship, I helped care for a dying man whose disease had not been described at the time of my medical school graduation.”
“In July of 1981, the first month of my internship, a thin young man with odd scattered purple skin nodules and pneumonia was admitted to the General Medicine team. He had recently moved from Florida to his parent’s home in North Carolina because he was too ill to care for himself. None of us understood why he was so ill. A third-year resident matched his story with a June 5th Morbidity and Mortality Weekly Report description of homosexual men with pneumocystis carinii pneumonia. We saw the fear in the young man’s eyes and the grief of his parents as he was transferred to intensive care where he would eventually die. We witnessed the discomfort and intolerance of some hospital staff toward his partner, sitting at his bedside and holding his hand. None of us understood how to treat this illness.
In the first month of my internship, I had helped to care for a dying man whose disease had not even been described at the time of my medical school graduation. The memory of that experience has been with me for over twenty years, a dramatic illustration that I would need to continue learning throughout my career in medicine. As I reflect on those early years of the AIDS epidemic, I am also struck by how much we taught each other, not just about the ever-expanding research data, but also about ourselves as doctors and our capacity to care for frightened patients and the loved ones who held their hands.”
Rita Willett, M.D.
Associate Professor of Internal Medicine
Foundations of Clinical Medicine Course Director
1999 Teaching Excellence Award for Educational Innovation
George W. Leichnetz, Ph.D.
“To me, a conscientious faculty member should demonstrate continued evidence of true scholarship.”
“To me, a conscientious faculty member should demonstrate continued evidence of true scholarship: reading and publishing in his/her area of clinical or basic science expertise, creating new devices for the dissemination of knowledge in his/her field (e.g. development of computer-based instructional materials), conducting clinical or basic science research, attending scientific or clinical meetings, staying engaged with the faculty member’s chosen field.
Being a senior unfunded faculty member does not diminish the importance I place on scholarship. I continue to read actively in the field of neuroscience and never give the same lecture to medical or graduate students twice. Updating lectures includes incorporating new information as well as improving my presentation skills and teaching images. To enhance teaching we are currently developing a new computer-based instructional program on neuroanatomy for medical and graduate students. Regular attendance of professional meetings allows me to stay abreast of changes and exciting new developments in the field so I may bring this perspective to my course and lectures. Our younger faculty and my students also help me to continue and promote scholarship as I mentor their development of professionalism and teaching skills. ”
George W. Leichnetz, Ph.D.
Professor of Anatomy
Course Director, M1 Neurosciences
2004 Teaching Excellence Distinguished Mentor Award
Linda Costanzo, Ph.D.
“The most significant lesson we leave in the classroom is that our own learning is a work in progress.”
“The most significant lesson we leave in the classroom, more than facts and concepts, is that our own learning is a work in progress. We should relish, even seek, opportunities that reveal to our students that we are also students. They should know that their questions have us scrambling to the library, that we burn the midnight oil, and that we still have a surprising number of ‘aha’ moments.
Of course, there is a critical line between revealing our own learning to be a work in progress and demonstrating appropriate command of our subject. The teacher who steps to the podium saying, ‘Gee, I’m not sure, maybe, does anyone know?’ is a disaster, not a work in progress. The effective teacher has presence, is certain of facts, is planful, and has firm understanding. Yet, the teacher is also a lifetime student who reads, questions, and constantly revises that firm understanding.
Bob Downs tells a great story about his biochemistry professor at Duke Medical School (around 1970), who ended the course with this message: ‘I must tell you something before we end. There are these new chemicals, just discovered, called prostaglandins. They are ubiquitous, and I suspect they will be found to be important. I don’t want you to leave my course without hearing the word ‘prostaglandins.’ Keep your eyes open for them.’ Knowing Bob, he probably does remember most of the facts he learned in biochemistry, but his professor’s best message and most enduring legacy was this: ‘we leave off here; you are responsible for the rest.’
What I love most about the prostaglandin story is the urgency. There is a clear sense, not only of his professor’s unabashed scholarship, but also his sense of responsibility—time is up, but don’t go, there’s one more thing. Professional attitude is ‘do as I do.’”
Linda Costanzo, Ph.D.
Professor of Physiology
Course Director, M1 Physiology
1999 Faculty Teaching Excellence Award (VCU SOM’s highest recognition for teaching)
Alpha Omega Alpha Medical Honor Society
Robert J. Glaser Distinguished Teaching Award for 2004
Joann N. Bodurtha, M.D., M.P.H.
“Life involves discovering your talents and using them to help others.”
“It is a wonderful gift to be able to be a doctor. Life involves discovering what your talents are and using them to help others. Each patient and student raises questions that require investigation—sometimes as simple as reviewing a metabolic pathway and sometimes as complex as writing an R01 or training grant. It is easier to rest at night if you are conscientious. Lifelong learning helps prevent the brain from shriveling up, as does nurturing/teaching others and spreading gratitude and healing.”
Joann Bodurtha, M.D., M.P.H.
Professor of Human Genetics and Pediatrics
1999 Teaching Excellence Award for Educational Innovation
Cynthia M. Heldberg, Ph.D.
“Learning means developing a keen sense of the intellectual and emotional status of those around you.”
“Carrying out my academic responsibilities in a conscientious manner means caring for students as an advisor, counselor and mentor with an awareness of the long ranging effects of words and attitudes on a student’s vision of themselves. In order to do this even reasonably well, one must commit to learning as a daily experience. Learning cannot be viewed as the acquisition of facts and data only. Learning means developing a keen sense of the intellectual and emotional status of those around you. To do that, each of us must spend as much time and energy reaching out to diverse people as we do on reading books. With every conversation with a new applicant or student, I realize that I still have much to learn about the human condition and each individual’s response to it. I believe that I will never stop learning about others until I can no longer see, feel or hear.”
Cynthia M. Heldberg, Ph.D.
Associate Dean for Admissions
2002 Teaching Excellence Distinguished Mentor Award
Robert A. Adler, M.D.
“It will never be possible to know everything; even as I have written this, new information has been published.”
“Being a student forever is one of the privileges and one of the responsibilities of the medical profession. The never-ending clinical challenges facing the practicing physician should make ‘keeping up’ a natural thing to do. The problem is that there are not enough hours in the day to do everything, and it is easy to fall back on old habits and knowledge rather than devote time to new learning. What to do?
I chose the easy way by becoming an academic physician. The students, house staff and other trainees bombard me with questions. I have to know the current medical literature. However, in return the trainees teach the professor. So, one way to keep current is to have students or residents work in your office. It is clearly a two-way street. Give them assignments on specific topics. Admit when you don’t know enough about a particular problem. When I attend on general medicine inpatient wards, I immediately tell the team that I don’t know everything—and that I am there to learn as much as they are.
A second method is to carefully choose conferences to attend. It is obvious that some are better than others. I attend medical grand rounds regularly because important topics in diverse areas are presented. I also attend grand rounds in my subspecialty, endocrinology. Be very careful of sessions sponsored by pharmaceutical companies. Some presentations are excellent and worth your time. Others are not. It is important to know the credentials of the presenter. Ask your colleagues or experts in the field so that you won’t find yourself trapped in a sales presentation. Be friendly and pleasant with the sales representatives, and have them leave literature rather than speak with you at length. Then you can separate the information provided by science from that provided by Madison Avenue.
Reading is essential. It can be done in small doses; often that’s the only way. I skim the abstracts of several general journals. I like the ACP Journal Club because it reviews many journals for me. There are other review services available. Try to skim the journal abstracts as the journal arrives rather than piling them up. I also get several subspecialty journals. Here I skim abstracts of articles of interest and have my secretary photocopy (or I will print from web editions) specific articles of greatest importance. These I will read in depth, when I can.
I use Up-to-Date as a first source for a clinical problem I need help on. Today, we have such easy access to information that learning about a particular problem is less trouble than the ‘good old days.’ Use Pub Med to search out a very specific problem. It is amazing how quickly you can find the key article that answers the question. Print out the abstract and have office staff find the article if necessary. For medical information that appeals to the general public, I look at the Health Section of The New York Times on the Web every day. This takes only a few minutes, and yet it provides information (or misinformation) that patients may bring to my office.
A little bit of humility goes a long way in the process of being a lifelong learner. It will never be possible to know everything because, even as I have written this, new information has been published. Accept the fact that there will be holes in your knowledge base, but keep trying to learn the most important things. After all, you are being paid to be a student forever. Is there anything better?”
Dr. Robert A. Adler, M.D.
Professor of Internal Medicine
2004 Teaching Excellence Award in Clinical Teaching
Maintain Patient Confidentiality
Faculty, housestaff, and students should:
Cases for teaching and discussion:
Case 1
You are a third year student on your first day of the outpatient Hem-Onc Clinic. At pre-clinic conference, as you review patients, one of the names is familiar and you suddenly realize that the patient is a female classmate, Susan. She does not end up being your patient in clinic that day, but you learn she has Hodgkin’s Disease and is receiving chemotherapy and radiation. One of your closest friends is also a close friend of Susan’s, and you are sure she does not know she is sick. Susan has been struggling academically all year and now you realize why. You are concerned and feel that if she had some more support from friends helping her by fixing meals and doing errands for her, she’d have an easier time, but as far as you know, she has never asked anyone for help. You’re tempted to tell your best friend about her illness so that you can both help Susan out during this time.
Developed by Kathy Kreutzer and Laurie Lyckholm, Bioethics and Humanities, VCU School of Medicine.
Case 2
You are working in a local family medicine office for your FCM preceptorship. On Thursday, one of your patients is a young woman with clinical findings consistent with a sexually-transmitted disease (STD). She receives counseling and tests are run for chlamydia, gonorrhea, syphilis and HIV. The results will be ready for her follow-up visit in one week. On Friday night you go to a cookout at your preceptor’s house. A friend who is also a medical student from VCU is there, and his date is the young woman you saw in the office the day before. You know that the test results are not back, but you feel sure she has at least one STD. What, if anything, do you do?
Developed by Laurie Lyckholm, Bioethics and Humanities, VCU School of Medicine.
Case 3
You hear from a fellow student that there are conjoined twins in the NICU. They are not expected to live for more than a few days, and the parents are keeping vigil around the clock at the incubator. You learn that quite a few medical students with no responsibilities in the NICU have donned their white coats and IDs and gone up to see the twins, saying they want a chance to see this unusual case. You are tempted to do the same as you plan to go into orthopedics and might never have another chance to see conjoined twins in person.
Developed by Kathy Kreutzer and Laurie Lyckholm, Bioethics and Humanities, VCU School of Medicine.
Case 4
While at the coffee cart, you overhear two residents talking behind you.
“How was your night?”
“Brutal! That breast patient on North 6 is a nightmare. Going down the tubes. I was up all night.”
“Oh, that’s rough, I hate that.”
“And her family is such a pain, too. I just hate dealing with them all—a huge time suck.”
What are the problems associated with this conversation being overheard? What, if anything, should you do to address this?
Developed by Kathy Kreutzer and Laurie Lyckholm, Bioethics and Humanities, VCU School of Medicine.
Case 5
Nancy Nosey is an undergraduate psychology major who works part time as a research assistant for a substance abuse study. Study participants are given a confidential, self administered questionnaire that asks questions about demographic characteristics, including employment status and occupation, as well as questions about past and present substance use/abuse. The questionnaire does not ask for any identifying data such as name, social security number, or date of birth. As part of her position, Nancy is responsible for subject recruitment, obtaining written informed consent and data entry.
One afternoon Nancy recruits a woman who looks very familiar but Nancy can’t remember from where she recognizes the woman. The woman gives no indication that she recognizes Nancy and goes on to sign the consent form and completes the questionnaire. After the woman hands in the questionnaire and has left the area, Nancy reads her responses to the questionnaire. In it the woman had admitted to past use of marijuana and cocaine. She also reported that she was employed in childcare. Nancy then looks at the signed consent form and recognizes the woman’s name as the head teacher for her three-year-old nephew’s daycare class. Nancy becomes alarmed and wonders whether this woman is endangering children at the daycare. She believes that she should report the teacher to the daycare.
Nancy approaches the study’s principal investigator for guidance. How should she advise Nancy?
Anika Alvanzo, 2003; used with permission. Developed as part of course requirements for MICR510, Scientific Integrity.
Case 6
Dave Hart has completed a research study using matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI) on serum specimens that had been routinely tested for prostate specific antigen (PSA) as part of patients’ ordinary medical evaluations. After the routine clinical testing and storage for a few weeks, the specimens would otherwise have been discarded without further testing. Hart had obtained approval from his local institutional review board (IRB) for the additional MALDI research testing as a pilot study to determine if there was any correlation between PSA values and protein patterns. Because the study was to be done retrospectively on pre-existing specimens not collected for research, because the specimens were to be stripped of patient identifying information, and because no medical records were to be reviewed to collect additional clinical information, the IRB approved the project without informed consent from the patients (exempt protocol).
The study revealed a striking correlation between total PSA concentrations and a few molecular fragments, although some specimens showed marked deviation from the general pattern. Hart thought the discrepancies might be due to treatments the patients had received or to prognostic factors for prostate cancer. He hoped that he could develop a new test for prostate cancer with better accuracy than PSA; however, he needed clinical information upon which to evaluate efficacy of his new approach. Although the specimens had all been anonymized for use in the research laboratory, Hart had not yet destroyed the master list of patient names and specimen numbers that he had used to select specimens while excluding duplicate ones from the same patient.
After Hart presented his findings and need for more information to a meeting of his research lab, several of the senior investigators ridiculed him for not proceeding immediately with a search of patient medical records for information about treatment and outcome that could strengthen his application for further research funding. They reasoned that Hart would perform no interventions on the patients, and so they should not have to give consent, and besides, studies like that had been going on for years without patient consent or IRB approval.
Hart was not certain that he should be limited only to those things specified in his original proposal and comes to you for advice.
Richard McPherson, 2003; used with permission. Developed as part of course requirements for MICR510, Scientific Integrity.
Faculty, housestaff and students should:
Cases for teaching and discussion:
Case 1: Inappropriate gesture
During your round with the housestaff team, a male staff member comes up to the group, places his arm around the waist of a female house officer, and thanks her for the terrific job she did taking care of one of his patients. You sense that the house officer is made uncomfortable by the gesture. What would be an appropriate first response from you (as an attending physician)?
Used with permission of Peter C. Williams, J.D., Ph.D., Division of Medicine in Society, School of Medicine, Stony Brook, NY 11794.
Case 2: Teaching techniques
Mary, a fourth year student rotating through pediatrics, was assigned to present a patient for morning report. She did not admit the patient herself and was told about this task 10 minutes before rounds began. She walked into the pediatrics library to find that the chairman was sitting in for rounds that day. Mary presented the case with the limited information provided by the resident’s history and physical. The chairman asked her questions that escalated from historical questions to more probing questions that she clearly did not know the answer to. He continued to push her until she began to cry. After rounds, the chairman apologized, stating that in medicine “we learn by feeling stupid sometimes. That’s the way it is.”
Case from the AAMC-Organization of Student Representatives “Draw the Line” Project.
Case 3: “You speak their language...”
Roberto is a Hispanic, fourth-year student at RMS (Random Medical School). He is applying for medicine and has completed his core rotations. He did his medicine rotation at Hospital X, an institution that serves a primarily Spanish-speaking community. Roberto received the site assignment for his Family Medicine rotation, discovering that he was assigned to the same hospital. He decided to talk to the course director who oversees both the third-year rotation and Family Medicine about the possibility of switching sites, so that he could have a more diverse experience. The course director was shocked that Roberto came to him, saying “You speak their language, don’t you? I thought you would relate well to them. You are Puerto Rican aren’t you?”
Case from the AAMC-Organization of Student Representatives “Draw the Line” Project
Case 4: Ignored
Janice was rotating through Neurology with Tom and Victor. A percentage of the grade in this rotation was based on performance in teaching rounds. The subjects of these rounds were published in the syllabus, so the students were responsible for preparing before the fact. The three students met with the attending every other day. In all of those days, the attending never asked Janice any questions while he constantly asked Tom and Victor questions. The trend continued for the whole rotation. Janice felt ignored.
Case from the AAMC-Organization of Student Representatives “Draw the Line” Project
Case 5: Not welcome
A fellow graduate student is gay and has a longtime partner; this is well known in the department. You notice that for departmental social occasions, other students are invited as “John Doe and Guest” to accommodate spouses or dates, but this student receives invitations in his name alone. He has told you that because of this, he avoids attending these events, which greatly enhance collegial contacts useful now and in the future.
What, if anything, should you do?
Developed by Kathy Kreutzer and Laurie Lyckholm, Bioethics and Humanities, VCU School of Medicine.
Faculty, housestaff and students should:
Cases for teaching and discussion:
Case 1: Inappropriate gesture
You are on your Internal Medicine rotation and your service has been especially busy this month. On all of your other rotations you have done a great job and you are seen by others as a very good student. However, this month you are having trouble keeping up with your patients and feel as though you are "winging it" on rounds and other times when you have to answer questions or make decisions. There is a resident who is friendly and organized and you are tempted to talk to him/her about how to get better organized and manage your patient and study workload, but you're afraid that this might hurt your grade on this month of Medicine, especially since you have a reputation for being such a good student. What should you do?
Developed by Kathy Kreutzer and Laurie Lyckholm, Bioethics and Humanities, VCU School of Medicine.
Discussion:
It is not uncommon for medical students to have an "off" rotation at some point. Fatigue and burnout throughout each year can cause a medical student to develop these behaviors. It is important that the medical student seek help when this situation continues. The Division of Student Accessibility and Educational Opportunity and the Special Services for Students Disability Service Provider can work with the student on a one-on-one basis to get back on track. The service is free and confidential. Any enrolled student can call or stop by the office to make an appointment to see the Director.
(Information/comments from: Cheryl Chesney-Walker, M.Ed., Director and Coordinator, Student Academic Support Services and Services for Students with Disabilities, VCU Medical Center; Contact: Ruth Dennis-Phillips, Academic Skills Coordinator, Student Academic Support Services, Room 301, VMI Building, 1000 East Marshall Street (10th & Marshall Streets); Phone: 804-828-9782, TTY: 804-828-4608, Fax: 804-828-4609; [E-mail]: rdennisp@vcu.edu.)
In the best of all situations, the student would talk to the resident. However, the concern about the impact on his/her grade is common. There are many resources the student could use if talking to the resident is a concern. These include counseling from the clerkship director, M3 rotation coordinator, Curriculum Office, Office of Student Academic Support Services and the Office of Student Affairs. Counseling through one of these resources may help the student to overcome the concerns about approaching the resident, or plan for how to get better organized.
(Information/comments from: Isaac K. "Ike" Wood, M.D., F.A.A.C.A.P., Senior Associate Dean for Medical Education and Student Affairs, Associate Professor of Psychiatry and Pediatrics, Director of Undergraduate Medical Education in Psychiatry, VCU SOM; Phone: 804-827-1262; [E-mail]: iwood@vcu.edu.)
Case 2: Heal thyself?
A fellow resident has been having a lot of personal problems lately and seems to have become very depressed. She is often absent and cannot be reached by beeper, but when confronted by the attending has been clever at making excuses for this. The other residents are angry and resentful that this person is not doing her share of work but no one has talked to her directly. When you asked another resident if someone should talk to her about getting some help, the resident said, "Doctors need to learn how to handle their own problems. Besides, if it gets on her record that she has been depressed that could hurt her career. She'll get it together soon." What, if anything, should you do?
Developed by Kathy Kreutzer and Laurie Lyckholm, Bioethics and Humanities, VCU School of Medicine.
Discussion:
We know that the incidence of depression is elevated among medical students compared to peers of similar age and educational backgrounds. Many medical students who experience depression, anxiety, substance abuse concerns and stress-related symptoms do not seek psychological care. Often, students are concerned about issues related to confidentiality and how seeking treatment may affect their professional standing.
Medical students are sometimes surprised to learn that seeking assistance not only resolves their mental health concerns but also increases their capacity as an emerging physician. They develop a greater capacity to be aware of, and utilize, their feelings and emotional responses. They display greater empathy towards human suffering. They have a greater appreciation that, in order to provide intensive care for others, one must care for self.
University Counseling Services (UCS) is a resource available to medical students who are experiencing psychological or personal concerns. We are committed to creating an environment that fosters student growth, development and psychological well-being. UCS services are provided at no cost to enrolled students.
Confidentiality is taken very seriously at UCS. Clinical records at UCS are NOT part of any other university record. Information disclosed in clinical sessions is confidential and may not be released voluntarily to anyone outside of UCS without the student's written permission. UCS adheres to professional, legal and ethical guidelines established by professional organizations and state law. Legal and ethical exceptions to confidentiality include: (1) when there is a clear and present danger to oneself or others; (2) when there is knowledge or suspicion of abuse or neglect of children or elderly persons; (3) when a court subpoenas clinical records; (4) when an individual cites his/her treatment/clinical record in a legal proceeding; (5) as otherwise required by law.
Initial appointments are scheduled in advanced by dropping into either of our offices (Medical Campus or Monroe Park Campus) and completing paperwork.
University Counseling Services
University Student Commons
907 Floyd Ave., Room 225, Box 842525
Richmond, Va. 23284-2525
Phone: 804-828-6200
Hours: 8:00 a.m. - 5:00 p.m. Monday - Friday; Summer Hours 8:00 a.m. - 4:30 p.m.
Hunton Hall
323 N. 12th St. (12th and Broad streets)
Box 980238
Richmond, Va. 23298-0238
Phone: 804-828-3964
Hours: 8:00 a.m. - 5:00 p.m. Monday, Wednesday, Friday; 11:00 a.m. - 8:00 p.m. Tuesday; Summer Hours 8:00 a.m. - 4:30 p.m.
(Information/comments from: Charles Klink, Ph.D., Director, University Counseling Services, Division of Student Affairs & Enrollment Services, VCU.)
First and foremost, our obligation is to the safety and well-being of our patients. If, for whatever reason, a physician is impaired in his or her ability to provide a professional level of care, we must intervene. The biggest misconception is that it is a sign of weakness to ask for help. Contrary to this belief, the literature demonstrates that healthcare providers who ask for help when in distress function more effectively. The resident may seek mental health care from any private or public provider. HIPAA guidelines are very strict about the confidential nature of this information. Licensing boards are very enlightened now about the need to encourage healthcare providers to seek help when they have a mental health problem, rather than acting in a way that would be detrimental to the resident's career.
(Information/comments from: Isaac K. "Ike" Wood, M.D., F.A.A.C.A.P., Senior Associate Dean for Medical Education and Student Affairs, Associate Professor of Psychiatry and Pediatrics, Director of Undergraduate Medical Education in Psychiatry, VCU SOM; Phone: 804-827-1262; [E-mail]: iwood@vcu.edu.)
Case 3: Grief
A third-year student has recently lost her father to a stroke, which involved a long hospitalization and multiple complications. She has been on the neurology rotation for a week and try as she might, all she can think about is her father, and sees him in every patient she cares for. She is not sleeping at night, and consequently is tired and distracted at rounds, and unable to study in the evenings because she falls asleep or her mind wanders. She'd like to talk with someone about this but is unsure who to turn to. She is afraid she will fail the rotation because of her inability to pay attention and to study. Her friends encourage her to talk with the clerkship director. She does not want to because she is afraid she will make her take time off, and she wants to graduate with her class.
Developed by Kathy Kreutzer and Laurie Lyckholm, Bioethics and Humanities, VCU School of Medicine.
Discussion
The Office of Student Affairs is another underutilized resource for a student who is having this type of difficulty, particularly if the student has trepidation about talking with her clerkship director. We can provide assistance in terms of academic counseling, referral for grief counseling and, in particular, developing a plan whereby if the student needs to take time off in the third year, this can be recaptured during the M4 elective period so the student graduates on time.
(Information/comments from: Isaac K. "Ike" Wood, M.D., F.A.A.C.A.P., Senior Associate Dean for Medical Education and Student Affairs, Associate Professor of Psychiatry and Pediatrics, Director of Undergraduate Medical Education in Psychiatry, VCU SOM; Phone: 804-827-1262; [E-mail]: iwood@vcu.edu.)
Many individuals experiencing bereavement benefit from the support they can receive from counseling. Having a place and a space to express and explore feelings about one's loss is often very therapeutic.
Dealing with loss is a pivotal professional theme for many medical students in their clinical work and over the course of their professional lives. Understanding one's emotions can be critical when working with dying and difficult patients.
(Information/comments from: Charles Klink, Ph.D., Director, University Counseling Services, Division of Student Affairs & Enrollment Services, VCU.)
Case 4: Toughing it Out
A fourth-year student doing his AI in the ED has invariably been assigned to work with an attending that is well known for his bad behavior with students and residents. True to form, the attending is irritable, condescending and impatient with the student. The student does not think it would look good for him to complain, as he has to work almost every shift with this attending, who is a senior member of the department. He doesn't want to talk to his friends about him, or to the M4 coordinator, as he thinks they will see him as a complainer who isn't tough enough to take this attending. Yet, he is really having a terrible experience and learning very little. He has even had an episode of having to excuse himself to go to the restroom to avoid people see him crying.
Developed by Kathy Kreutzer and Laurie Lyckholm, Bioethics and Humanities, VCU School of Medicine.
Discussion
The School of Medicine Professionalism Committee can serve as a resource in this situation. The Committee provides an informal process for addressing School of Medicine concerns regarding professionalism. If you perceive or experience instances of personal abuse or some other form of what you view as unprofessional behavior on the part of your teachers or colleagues, you are encouraged to report such incidents through normal channels for counsel and possible rectification. If this route is awkward for you, an alternative approach is consultation with a member of the SOM Professionalism Committee. For a full description of the process and the current members of the SOM Professionalism Committee, please see: Professionalism/Reporting Concerns.
(Information/comments from: SOM Professionalism Web site, Professionalism Section.)
The fear of getting involved in a situation where anyone is acting unprofessionally just perpetuates the problem. It is extremely difficult, and perhaps inappropriate, for a medical student to confront a senior attending about this type of behavior. However, the student has other resources to deal with this. Again, the Office of Student Affairs can be a resource. As the AI is an elective, we are responsible for the experiences of the students during this time. If this is prototypical behavior for the attending, we can provide counseling to the student about not taking this personally, alternatives to staying on the rotation and how to make the experience more worthwhile. We can also be a resource to act as an advocate for a student who is having these types of problems. Last, we can intervene though consultation with the attending and/or his/her supervisor.
(Information/comments from: Isaac K. "Ike" Wood, M.D., F.A.A.C.A.P., Senior Associate Dean for Medical Education and Student Affairs, Associate Professor of Psychiatry and Pediatrics, Director of Undergraduate Medical Education in Psychiatry, VCU SOM; Phone: 804-827-1262; iwood@vcu.edu.)
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