Professionalism in Healthcare: What and Why? – PediaCast CME 111

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Show Notes

Description

Dr Ashley Fernandes visits the studio as we consider professionalism in healthcare. It’s a core value in medicine… but what does it mean and why does it matter? We explore the nature of professional behavior, including its ethical foundations and potential harms when neglected. We hope you can join us!

Instructions to obtain CME/CE Credit

1. Read this information page.
2. Listen to the podcast.
3. Complete the post-test at Nationwide Children’s CloudCME.

• CME credit expires 3 years from this episode’s release date.
• You can view your transcript and print a certificate of completion at Cloud CME.
• Need help creating a Cloud CME account? Click Here.
• Still have questions? Contact CMEOffice@nationwidechildrens.org

Topics

Professionalism in Healthcare
Medical Ethics

Presenters

Dr Mike Patrick
PediaCast and PediaCast CME
Nationwide Children’s Hospital

Dr Ashley Fernandes
Primary Care Pediatrics
Director of Faculty Professionalism
Nationwide Children’s Hospital

Learning Objectives

At the end of this activity, participants should be able to:

1. Define core principles and ethical foundations of professionalism in healthcare.
2. Describe how unprofessional behavior can harm patients and institutions.
3. Explain practical strategies for addressing and remediating unprofessional behavior.
4. Identify ways to promote a positive professional culture within clinical and academic settings.

Links

Medical Professionalism in the New Millennium: A Physician Charter
Pediatrics in Review: Professionalism

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No one in a position to control content has any relationships with ACCME-defined ineligible companies.

Commercial Support

Nationwide Children’s has not received any commercial support for this activity.

CME/CE Accreditation Statement

In support of improving patient care, Nationwide Children's Hospital is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the American Nurses Credentialing Center (ANCC),  and the Accreditation Council for Pharmacy Education (ACPE), to provide continuing medical education for the healthcare team.

AMA Statement
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Nationwide Children's Hospital has been authorized by the American Academy of Physician Associates (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credits. PAs should only claim credit commensurate with the extent of their participation. 

APA Statement
Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs.  Nationwide Children's Hospital designates this activity for 1.0 continuing education credits.

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Episode Transcript

[Dr Mike Patrick]
This episode of PediaCast CME is brought to you by Nationwide Children's Hospital. 

Hello everyone and welcome once again to PediaCast CME. We are a continuing medical education podcast for healthcare practitioners.

This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It's episode 111 and we're calling this one professionalism in healthcare, what and why.

I want to welcome all of you to the program. So, this is a really, really important episode for you this week. And it's one that pertains really to everybody who works in healthcare, regardless of your title, your training, your role, whatever it is, professionalism is extremely important for all of us who take care of patients and families and children, especially.

It's a core value in medicine, professionalism, but what does it mean exactly? And why does it matter? Today, we explore the nature of professional behavior in healthcare, including its ethical foundations, potential harms when professionalism is neglected, and how we can build a positive culture rooted in virtue and integrity.

Our guest today is Dr. Ashley Fernandes. He is director of faculty professionalism at Nationwide Children's Hospital. He's going to provide us with insight examples and practical advice for all of us from trainees to seasoned faculty in all disciplines of healthcare.

Before we get to him, I do want to remind you that after listening to this episode, you can claim free category one CME or CE credit. Really easy to do. Just head over to the show notes for this episode.

You'll find those at pdacastcme.org. Find a link to the post-test in the show notes for this episode, which is 1-11. That'll be in the show notes with a link.

It's going to take you to CloudCME. So, if you've not been there before, you'll have to sign up for a free account. Once you are there, you're going to click on the materials tab and taken past the post-test, the category one credit then is yours.

And we do offer credit to many pediatric professionals, including doctors, nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. And it's because we are accredited by all of those professional organizations that we can offer the credits you need to fulfill your state's continuing medical education requirements. Of course, you want to be sure the content of the episode matches your scope of practice, which again, in today's case really is for everybody.

Complete details on the credit and all of our other podcast episodes, all that's available over at pediacastcme.org. Also want to remind you the information presented in our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.

Also, your use of this audio program is subject to the PediaCast CME Terms of Use Agreement, which you can find at pediacastcme.org. So, let's take a quick break. We'll get Dr. Ashley Fernandes settled into the and then we will be back to explore the importance of professionalism in healthcare. It's coming up right after this. 

Dr. Ashley Fernandes is a primary care pediatrician at Nationwide Children's Hospital and a professor of pediatrics at the Ohio State University College of Medicine. He serves as director of faculty professionalism and director of resident ethics education at Nationwide Children's and is director of professionalism competency for the College of Medicine at Ohio State.

He's going to help us explore the concept of professionalism in healthcare. But before we dive in, let's offer a warm PediaCast CME welcome to our guest, Dr. Ashley Fernandes. Thank you so much for stopping by today.

[Dr Ashley Fernandes]
Oh, thanks for having me. It's my pleasure.

[Dr Mike Patrick]
Yeah, we really, really appreciate you taking the time to chat with us. You describe professionalism as squishy, and I love that. So, what do you mean by professionalism being a squishy thing?

[Dr Ashley Fernandes]
Well, I think that it's something that people have a perception about that professionalism is squishy. So let me back up by saying, as you probably know, and your audience probably knows, I have a PhD in philosophy, and part of my study is focused on medieval philosophy. And one of the great axiomatic nuggets the philosopher monks of the Middle Ages gave us was this, never deny, seldom affirm, always distinguish.

And I think that really applies to this word professionalism. All of us tend to associate it with something positive in healthcare, but defining it is so much different. And it's different because of the different roles we play in medicine, nurses versus doctors versus other health professionals.

But typically, what happens if you ask someone, well, what is professionalism? They'll recite kind of a laundry list of values or virtues, but even those can differ from person to person. So, when I say professionalism is squishy, it's sort of tongue-in-cheek.

It's squishy in the sense that it's challenging to define. And if you think about that, it means if it's challenging to define, it must be really challenging to teach, to measure, and sometimes to hold us to what we hope to believe, what we want to believe, our objective standards for professionalism.

[Dr Mike Patrick]
Yeah. You know, as I think about sort of the picture that I get in my mind when I think about professionalism in healthcare, it may be different from one person to another, or even from one location to another. You know, maybe there is a medical place where the doctors are expected to wear a tie and a white coat, and in other places you may be able to dress more casually.

And both of those would be considered professional based on the context of where you are. So, is professionalism just whatever we say it is at our given location? You know, how do we really define it?

[Dr Ashley Fernandes]
Yeah, I mean, that's such an excellent question. And the example you gave is actually really good. There have been a couple of articles recently, I was thinking one in the New York Times from about two years ago, that talked about how even between races and ethnicities, you can have a different conception of what professionalism is.

The point of that article was really to say, hey, should we toss the whole idea of an objective standard for professionalism? I mean, just taking something like aesthetics and dress. Tattoos used to be really forbidden in healthcare, or considered a taboo.

And you can see that we have a lot of people, including medical students, physicians, that now have tattoos. So that's on the one hand. But on the other hand, professionalism can't just be whatever we say it is.

Because if you look at the history of medicine, where we've gotten into trouble, where our profession has cast aside the idea that professionalism has some objective standard, we can get into a lot of trouble. Here, I'm specifically thinking of one of the things I study is Nazi medicine and what physicians did during the Holocaust. And that's an example of redefining the objective standards of professionalism to suit ideological ends.

But on the other hand, we also have to have a professionalism that isn't dogmatized, that doesn't change with the times. That is to say, where we can never question the professionalism standard of the moment. And to have that, we have to have some transparency, we have to have freedom of speech, we have to be able to have civil discussion to talk about professionalism, what really is at the core of it, and what's different.

And there's a physician out at the University of Colorado named Dr. Wynia, and I love his definition of professionalism. He says he and his colleagues defined it as a system of beliefs that healthcare practitioners profess publicly. So, professing it publicly is a really important part of professionalism.

And we profess it publicly both to our individual patients and secondarily to society. And I think that's a really important concept that when we say we are professionals, healthcare professionals, we're not just keeping standards for ourselves, but we're also making a promise to society as a whole. Getting into the nuts and bolts of that, a lot of times people will start listing sort of humanistic virtues like integrity, humility, compassion, empathy, and so forth, excellence in our standards.

And I think that's true. I think at the heart of professionalism are virtues and values that individual professions have chosen to codify and to put down as this is our standard. Now to me, all of professionalism could be encompassed in just two virtues, integrity and humility.

And that's what I try to teach. The knowledge part, the excellence part, those can be subsumed even under those two virtues. But what's important about professionalism is to say that whether you're a nurse, whether you're a doctor, whether you're a physical therapist, whether you're a counselor, your profession puts forward to the public a set of standards that the public then expects that you will hold.

And because of that mutual promise, they give you certain rights and abilities in society. That's really important to our patients and families.

[Dr Mike Patrick]
Yeah. What then are the foundational pillars of medical professionalism? So, you know, you mentioned that things may be a little different in some respects, like dress, as we had said, tattoos, hair color.

But there are some foundational pillars of medical professionalism that we really want to keep in mind. What are those?

[Dr Ashley Fernandes]
Yeah, I just want to point to, at least in medicine, in physicians, here I'm speaking as a physician myself, but the American Board of Internal Medicine back in 2002 sort of put out what's called, they put out what's called the Charter for Medical Professionalism. And in that charter, which is sort of cited literally thousands of times by other professional bodies, subspecialties, etc., they point to three pillars of medical professionalism. And I think we can expand this to nursing and other health care professions.

But the first one is the primacy of patient welfare. And I'm going to talk just really briefly, just sort of defining that out. That means your own wishes and desires are secondary to the patient's well-being.

Okay. In order to do that, you have to build trust between the patient and family and yourself. So, the key to that primacy is that the patient and family believe that you have their best interests in mind at all times.

The second pillar is autonomy and respecting the autonomy of the patient. In our case, because we're pediatricians, it's the family, right? It's autonomy by proxy in most cases.

In the case of adolescents, I think there is an important point about giving them more and more autonomy as they progress developmentally. But one of the key things that the American Board of Internal Medicine points out is that autonomy isn't absolute. So, if you go to medical ethics classes in undergrad, they'll just say you do what the patient wants.

But as any practicing physician or nurse or health care professional knows, that's simply not the case. In medicine, there are limits to autonomy. Patients and families can't demand unscientific treatment, for example.

They can't demand treatments that will actually reduce the dignity of the human person. And they can't ask for things that go against the conscience and beliefs of the practitioner themselves. That's why I like to say that I'm a medical practitioner, not a medical provider.

And I try to avoid the use of the word provider, just because medicine is so much more than providing someone with something they ask for. It's a mutual covenant of trust between the families and us. And so, practitioner to me is a better word.

The last pillar I just want to point out quickly is social justice. And the American Board of Internal Medicine talked about this 20 plus years before that term became mainstream, as it were. And they said it has to be an integral part.

It's one of the three central pillars of professionalism, and that physicians have a duty to actively seek out the equity and to actively seek out equality and to actively work to reverse unjust structural barriers in society. I think that's important.

[Dr Mike Patrick]
Yeah, absolutely. As you were going through those pillars, I was thinking about immunizations and that, you know, as pediatric practitioners, we believe in immunizations and that those really are to the benefit and the welfare of the patient. But then we do have families who are also interested in the welfare of their children and, you know, they have concerns about the potential safety of vaccines.

And then we also want to want to respect their autonomy. But is that one of those situations where I mean, I know pediatric practices that will not let families stay in their practice if they don't get their vaccinations on time? I would think that's a little bit of an ethical dilemma there.

[Dr Ashley Fernandes]
It definitely is. The AAP does have a statement on this. And from now again, the AAP is a professional organization.

They are not a dogmatic organization, or they shouldn't be. So, every pediatrician should look to them to look to these statements for guidance, but again, have to use their own moral conscience and their own ethical judgment in deciding these things on a case-by-case basis. I will say the AAP suggests not to fire patients from their practice, and they do so understanding full well that vaccinations are essential to pediatric health and well-being.

I believe that as well. But at the same time, the way to bring patients into that belief, the way to talk to them, is to build trust. If we, and in the case of pediatrics, right, our patients are children.

So, when you fire a family from your practice, it's, you know, the person that does not benefit from this at all is the child. And if you build trust with the patient, there is a chance that down the road that family will trust you enough to listen to what we know to be objective evidence of vaccines efficacy and safety. And I think again, going back to those two virtues that are at the core of professionalism, integrity, which is truth-telling, you know, part of integrity is truth-telling and transparency.

If a family refuses a vaccine, you can't just be silent either. It's your duty to talk to them in the kindest way possible. And there's the humility part.

I'm your doctor. I care about you. And I'm not talking down to you.

But this is what I believe. This is why I believe it's good for your health. When I have patients that refuse vaccines, I, you know, I will accept it after talking to them.

But I say to them, look, I'm a doctor. And my duty is that every time you come in here, we're going to have this conversation again, if it's okay with you.

[Dr Mike Patrick]
Yeah, I think that's really important. And I have done that myself and find that parents are open to that. And when you have a relationship with them, you know, it may take a few years, but oftentimes things do kind of turn around.

As you sort of model professional behavior. Another phrase that you like to use is that there is a duty to be professional. In fact, you just mentioned that moments ago.

What do you mean by we have a duty to be professional?

[Dr Ashley Fernandes]
Well, I'm going to put my moral philosophy cap on here and say, we use words like duties and rights very loosely in our society. I was thinking of when I grew up in the eighties, the Beastie Boys had a song called, you have to fight for your right to party. Okay.

So, there's an America where you write. I remember that one. Yeah.

Okay. Right. Right.

So, so, you know, there are rights and duties, and we use these words very loosely, but in moral philosophy, duties and rights are absolutely correlated. So, every time we say I have a duty to something, or I have a right to something, we have to think about the correlative piece. So, let's just take duty.

If there's a duty to be professional, then there has to be a correlative right. And what is that right? So, I think in medicine, we start to answer that question by asking to whom is the primary duty to be professional.

I mean, there are a lot of good candidates out there. Is it to society? Do we have a duty to be professional because NCH has one team values, and they want us to be?

Do we have a duty to the legal system? There are a lot of good candidates out there. And while I think all of those are probably legitimate secondary duties, almost all of us in healthcare would agree that our primary duty to be professional is to the child and the family that we serve as pediatricians, which means upholding their health and dignity.

And if it's true, if that's true, then what kind of right do those patients and families have? And I think it's what in philosophy we call a positive right. So, we make these distinctions here.

I'm going to be the medieval monk again and put on my distinction hat. There are two kinds of rights. There are positive rights, which means that we have a duty to actively help the patient and family to achieve that right.

And then there are negative rights, which means we have the patient, and family has a right not to be interfered with in their pursuit of a right. And so, I would say the duty to be professional is for our patients and families, for their health and dignity. But we are called to actively work to help empower them to achieve that goal.

And that can be done no other way than through our own professional behavior.

[Dr Mike Patrick]
Yeah. And there are certainly great things that come out of professional behavior where we're really taking care of children who are vulnerable and families who, you know, there may not be a lot of health literacy there and we really can make a big impact in their quality of life and in health outcomes. The opposite of that is also true that unprofessional behavior can harm patients.

Can you give us some examples of how that can happen? And then do we have evidence that unprofessionalism causes real harm?

[Dr Ashley Fernandes]
Yeah, actually, do you have a spare couple of days? I can do I can give a lot of examples. But what I'll try to do is I'll just give your listeners some sort of three common mundane examples that at first, we might think, oh, this is no big deal.

They can really have larger ramifications. So let me start with like medical student or trainee behavior. In my role at the College of Medicine, for example, I'm a leader in professionalism remediation, which means that when unprofessional students are sent there, it means that they're sent to me so that I can try to help them to rehabilitate.

And sometimes these are these look like small behavior. So, cheating on a test, using artificial intelligence to plagiarize or to write reflections, copying and pasting chart notes. These are all things that I've seen at the medical school level.

But what they do show is a lack of integrity. Even if it's in the moment, that small lack of integrity will translate into a lack of integrity in patient care. There's a really famous study.

The author's last name is Papadakis and her colleagues. They showed they looked at California, the state of California, and they looked at medical board complaints for professionalism from practicing physicians. And what they found was a strong correlation between those medical board complaints and medical school failures for professionalism.

So, in short, breaches during medical school and training will eventually translate to breaches in practice, and that will harm patient care. A second example is just, you know, every day we're on the wards or in the clinic, we have interpersonal or even interprofessional communication with nurses, staff, etc. But we also see and witness bickering, miscommunication, misunderstandings that are not resolved or show a lack of respect on the floor or in the clinic.

Sometimes it's small, but these it's sort of death by a thousand cuts, right? These are common, but they're serious. And it undermines trust between the health care team and eventually becomes evident in interactions with the patient and family.

I've seen that myself, both in my former practicing as a hospital pediatrician and then also in primary care. And the third thing is just something we might not ever think about, but our own lack of balance sometimes between work and life. So that work-life balance that we all strive for, but as dedicated health professionals that are, you know, passionate about the health of children, sometimes we overstep.

Sometimes we work more than we should. We don't take the time for self-care. Data does show that that can lead to burnout.

And my experience in professionalism and professionalism remediation shows a lot of times that leads to overstepping boundaries and an inability in the long run to care for others. So, it can lead to this sort of messiah complex that only I know my patients, only I can sort of save them and the only one that can heal that patient. But we really have to have a good work-life balance and promote self-care in order to help us be the best pediatricians we can be, and then also to build trust between our team, which promotes professionalism.

So, your second question was, is there evidence that it causes real harm? Data does suggest this. So, the Joint Commission, which accredits all medical schools, residency programs, they published in 2008 a statement on this, but they've updated in 2021.

And I just want to read this quote. They said, unprofessional and quote, intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to prevent and to preventable adverse outcomes. It increases the cost of care and causes qualified clinicians, administrators, and managers to seek new positions in more professional environments, end quote.

They also actually even talk about unprofessional behavior contributing to the nursing shortage that we're seeing nationwide in this country, because I hate to say this, but the good ones leave. If we don't promote a professional environment in the workplace, the good ones will seek employment elsewhere and that's going to be trouble for all of medicine. So, there can be direct harms to patients.

And I would urge, you know, your listeners to look at that Joint Commission paper that is now updated in 2021. And I just want to briefly tell you guys this personal, more personal story. When I was at my prior institution, I was the director in a similar position.

I was the director of professionalism, sort of remediation for this institution. And we had a student, medical student, that had been, that had multiple infractions for professionalism. In his third year of medical school, he said in front of his team about a rape victim he was seeing on the psychiatry rotation that, I don't know why she's upset.

Rape only causes PTSD for the man. Okay. I hope I didn't shock your listeners by saying that, but this is the kind of person that was in already his third year of medical school.

We tried to get him sort of out of the school at that point because he failed the rotation, and that was deeply concerning. But they continued to push him on. In his fourth year, this person forged a letter of recommendation from a deceased physician.

And at that point, he was finally expelled. But the university overturned that expulsion, and he graduated. And I remember an official telling me, because I was very upset, and an official told me, Ashley, he's never going to get a residency position.

Okay. He'll graduate, but he's done. Okay.

Well, this bothered me a lot. So, a couple of years later, I googled this person, and guess what? He got a residency position, and he was practicing medicine.

And then as a second-year resident, he was arrested for arson and attempted murder for trying to burn his girlfriend's apartment down. And this is just a personal example, but it does show we cannot tolerate behavior that threatens the profession and threatens patients. And if we let it go in small things, what are considered to be now relative to what this individual did in the future, if we let that go in small things, it will turn into larger things.

It's a good cautionary tale.

[Dr Mike Patrick]
Yeah. Yeah, absolutely. There are going to be instances of unprofessional behavior that may not rise to that level where you're like, okay, something definitely needs to be done.

But you may witness behavior that is in that gray zone. How do you recognize that? And then what do you do?

Like, do you confront the person about their unprofessionalism? I'm sure that, you know, I probably have been unprofessional from time to time. We've done some episodes on emotional intelligence and, you know, really giving yourself some self-care and recognizing that we don't always do everything perfectly.

That may keep us maybe from saying something to someone for more of a squishy infraction. So how do you deal with the gray zone and who do you talk to about it?

[Dr Ashley Fernandes]
Yeah, that's a great question. So, in the gray zone, and this happens to us every day, right? And it also happens because some things we may feel not rise to the level in our conscience that something needs to be said about it.

So, I think I would suggest that, especially with our co-workers, I think, you know, just develop a kind, again, from the point of view of these two virtues, integrity and humility. If that's at your core, when you approach someone, come from that point of view. So, don't say you did this, but hey, I noticed that this was said, and I'm curious, do you think that might have been an offensive way to phrase that?

Or do you think that that was the best way to get that point across? I would encourage people, especially in the gray zone, to at least build relationships with people and talk to people about it. If I was unprofessional in front of one of my nurses, I think I have a good enough relationship with them where they would be able to talk to me about it, where we could still have a conversation.

Maybe you think it's unprofessional, but maybe there's an explanation for it. Or maybe the explanation doesn't justify the infraction, but will help you to understand, hey, this is out of character for this person, they were having a bad day, and you guys can talk about it. What we really, obviously, if unprofessional behavior acutely endangers patient care or is unlawful, then we have to intervene immediately to stop or prevent that behavior.

And our fear of a conflict really can't be a reason to stay silent. One of the reasons I was attracted to coming to Nationwide Children's in the first place is that there are one team values. The very first one is do the right thing.

And if you look at that on the website, they're committed to health equity for all children, integrity, kindness, empathy, honesty. They're inclusive and respectful. That's what we're talking about.

That's projected first and foremost in one team values. And NCH has a very robust Office of Corporate Integrity. Kathleen Dunn, I believe, is the vice president that runs that.

It's very robust. It has mechanisms for reporting any suspected breach of integrity or ethics, including being able to do that anonymously. And those will be followed up on.

But I would encourage listeners to never tolerate unprofessional behavior, even in the gray zone, or feel like and just realize that there are protections in place to help those people who speak out. I feel like the culture of silence, if we have a culture of silence, that is the number one enemy of a culture of safety and equality and really a freedom. If we don't feel in the place where we work that we have the ability to speak out and to speak truthfully and approach our colleagues, that's a problem.

And so, I don't think we have that culture here. I think we have a culture at NCH, or at least we aspire to one where people feel comfortable talking to their colleagues. And I would start with that.

And then we have mechanisms in place for higher breaches that I would encourage people to use. Don't stay silent.

[Dr Mike Patrick]
With your hat on as someone who works with students and perhaps some of your colleagues as well, when unprofessional behavior comes up and remediation is needed, I would imagine that when you're faced with that as the student or as the faculty member, that you'd be a little defensive about your behavior. How do you get past that and really try to get folks to understand that you're trying to help them to be a better person and to embrace professionalism?

[Dr Ashley Fernandes]
Yeah, I think professionalism has to be looked at as a skill that we practice. And like any skill, there's some people that can be a little or a lot deficient in it, sometimes through fault of their own and sometimes through no fault of their own. And I can give you some examples.

We have a good number of doctors that might be on the spectrum, so to speak. So, they have a little bit of trouble communicating that can come off as unprofessional, even though their heart is in the right place. That's an example of someone who it may be through no fault of their own and what they need is training or insight into their behaviors.

Then there are other people who really, you know, lack insight and lack insight, you know, sort of to a fault. And we have to approach those two differently. But what I try to do, no matter what, is to approach professionalism remediation as something that is not punitive, but is something that is there as a, I almost call it, I like to call it a gift of the institution that you're in to make you better.

Sort of like when we take CME courses to improve our understanding of pediatric endocrinology or something, which I can never understand. So, but that would help me, but that would help me. And I would look at that, hey, here's this sort of extra training you're getting.

But a person who's deficient in professionalism, not really a bad person per se, they need nurturing, coaching, they need exemplars, clinical exemplars. Sometimes they need an understanding of their own situation and insight into their own behaviors. And these are all achievable just like any other medical competency.

Now at NCH, we are very lucky, at least for faculty physicians, because we have at least two sort of branches to aid in this process. The first is the faculty coaching program. So, this was launched just last year.

Dr. Catherine Koshefsky and the Faculty Development Office under John Mann created a faculty coaching program where we have a trained cohort of people and that will help a faculty member that's either self-referred or are referred by their supervisor to the program. And this is a non-punitive six-month program of coaching. So, this is where the faculty member themselves are guided to gain insights into their own behavior.

It's facilitated. It's not really mentoring and it's not really consultation where you're telling the person what to do. The faculty person themselves, they talk with a trained faculty coach to help improve their professional behavior and communication.

And the second part is the second sort of branch and the way we can help our people here is the Director of Faculty Professionalism, which happens to be me. Again, this is a relatively new office, but I would encourage division directors, program directors who have some difficulty with professionalism in their faculty that arise to a higher level than what the faculty coaching program would have. They can send them to me for more serious unprofessional behavior.

I can be an additional resource. My suggestions in that regard, in that role, are more directive, but it still involves a lot of the principles of coaching. And again, if the behavior continues and moves up the scale even farther, then we're talking about our duty to protect the profession and the patients.

This might involve HR, the division director or supervisor or the chair. But in any of these things, I think it's important to remember that professionalism remediation has to have three qualities. One is it has to be relationship-centered.

So, the person that's helping the other physician to remediate has to have a real relationship with them of trust and confidentiality and those kinds of things, the things that build relationships. So, it has to be relationship-based. It has to be reflective, second.

It has to be able to give that person the insights that they need to use their own gifts to better themselves and to see that they have talent. They wouldn't be here at this institution if we didn't want them in the first place and if they didn't have talent. And so, part of professionalism is helping the faculty member to realize that they have talent that can be a gift to patients, but professionalism is integral to that and having that insight to understand that.

The last thing is it has to be longitudinal. From my experience, having a one-off conversation about what professionalism is, either with medical students, residents or physicians, is just not effective. They need to know that you're with them for the long haul.

And I think they also need to have accountability. They need to see you again. The same person that they talked about and said that they had insights for, they need to see you again.

And that's why, for example, the coaching program is six months long. And if someone is referred to me as the director of faculty professionalism, I usually tell them that sort of the same thing. We're going to meet four to six times over the course of many months and track your progress so that we can develop a longitudinal program.

[Dr Mike Patrick]
I wonder if there are fewer instances of the need for remediation, if this is something that has been talked about from the early days of medical school, you know, to make it part of the curriculum. So how can we nurture professionalism and trainees so that hopefully we can avoid issues down the road?

[Dr Ashley Fernandes]
Yeah, Dr. Mike, you hit on it. Just even in your question, that's very insightful. I think starting early, like any education program and really having a true integration that professionalism is at the core of medicine from early on in nursing.

I know for a fact, I know a lot of nurses and they say in their training, this is really emphasized. I wish we would do a better job in medicine. Instead in medicine, we tend to separate out ethics and professionalism from quote unquote, the real biological or medical side of things.

And I think that needs to change. It's starting to change, but that really needs to change. Ohio State College of Medicine is doing a really good job.

Ohio University here in town, they do a very good job. I think we need to integrate the concept of professionalism as central to medicine. And I tell my med students all the time, you can memorize stuff.

Congratulations. But that's the easy part of medicine. For you, for the healthcare practitioners, memorizing stuff is the easy part.

Algorithms will soon be done by AI. The hardest part of medicine is being able to take what you know and implement it into what I like to call the drama of human life. And that involves professional and ethical behavior to hold up integrity and humility, even at times you didn't expect.

Take COVID, for example. The reason we lost so much trust in the medical profession during that time is that the public didn't perceive us either to be humble, to say, hey, we don't know. Sometimes science just doesn't know, or a disease outpaces our advances.

And we also, they thought we weren't telling the truth and that really hurt us. So, I think we can nurture it early in education. I think later on in practice and even in education, we have to praise good behavior whenever we see it.

Like I love these e-cards that we get at NCH from time to time. And then I think we have to have early intervention with those who are struggling with professionalism standards and hold true to the standards of the institution. We can't say, oh, well, we can't, you know, dismiss this person just because they're unprofessional.

Oh, yes, you can. And sometimes you must. But I think if you start early, hopefully it will never get to that point.

I mean, for me, I think from my experience, students that are sent to me for remediation for professionalism, the unprofessional behavior that they exhibit, it's a burden for them too. It's not just a harm to the profession. For them to be sent, you know, whether it's coaching or whether it's to the faculty professionalism or whether it's in the med school, having that kind of behavior is something they don't really want, and it becomes a burden for them.

So, part of my role, and I think for faculty or supervisors, nursing supervisors who are trying to work with an unprofessional staff or faculty member, think about that. Like for most of the people that exhibit these behaviors, they feel terrible about it. They really don't want that to be how people see them.

And so that should be our approach to nurture good behavior when we see it and to do it early. Yeah.

[Dr Mike Patrick]
What are your feelings on hard days? You know, medicine can be long hours. We may not get as much sleep, especially as I'm thinking about residents that are up at night doing admissions and all those things.

It's easier to kind of flip a switch when we're stressed out and sleep deprived. How can we maintain our professionalism even when, you know, things are stressful and hard in our work life?

[Dr Ashley Fernandes]
Yes. And that is a great example of some of the root causes of some unprofessional behavior is the fact that here at NCH, everybody works hard. I mean, we're so passionate here that we work hard.

Sometimes I will, a couple of times in my life, I used to do hospital medicine, but if I wasn't on, I would pass the hospital at night. And you always see the lights on in the big hospital, and you know that there are people on call, nurses working the night shift. You know, even our janitorial staff is here working hard at night.

So, there are a lot. So, when you're tired and you're working all the time, you can have some very hard days. On top of how intellectually taxing this is, medically taxing this is, now we have to worry about being professional at all times.

Right? So, I like to tell my students that we can have very hard days in medicine. Medicine is going to be hard, but we don't have to have bad days in medicine, or at least not for the reasons we think.

When we think about that drama of human life, what our patients and families have to go through, it gives us a reason for doing what we're doing. If you're working hard and you don't see the value of that, you don't see the good in what you're doing, it makes it easy to become burned out, and it makes it easy to snap and have those unprofessional moments. But if you're constantly intentionally reminding yourself of the value that you bring, both to your patients, families, and the institution, this will help turn hard days into something meaningful.

Our patients come to see us for asthma, but they can't afford their medicines. Their eczema flares up, not because they don't have lotion, which they might not have, but because they have cockroaches in their apartment and they're too afraid to ask their landlord to fix that problem. You know, we have a parent who people complain is never at the bedside of her hospitalized child.

Why is that? Because she's got three other children at home and no help at home, and her heart is broken that she can't be at the bedside. So, the violence, the poverty, the structural oppression that many of our patients undergo is a suffering that's not going to be relieved by our intellect.

That's something our intellect can't touch. But so how do we make it through those days and still stay professional and still exhibit professional behavior? If we remind ourselves that what we do here for children is an absolute good, the healing of patients and families, so we can have hard days in medicine but never bad days if we do what we're called to do and do it with virtue and do it with an eye to that public profession that we all made, that promise to our patients and families.

Yeah.

[Dr Mike Patrick]
What is your core takeaway as we wrap up? Like, what is the one thing about professionalism that you really want to get across to the audience and why does this thing matter?

[Dr Ashley Fernandes]
What I would say, this core takeaway is this. Professionalism is a solemn, even sacred promise to our patients and the public of a commitment to integrity and humility in all that we do. And the focus of that is the absolute good of the dignity of the pediatric patient.

Professionalism matters because simply our patients, vulnerable children of every age, they matter more than anything else. And for our families to believe in us, to trust us, and to work in partnership with us, which is ultimately what we want, they have to believe that we are who we say we are, and we're committed to their good over our own self-interest.

[Dr Mike Patrick]
Yeah. So very important. This has been a really fascinating conversation.

And an important one is we really strive to be the best versions of ourselves. And being in the medical profession really is something that we can be proud of. And it's not just a job, it's a calling.

And we need to always look at it that way, right?

[Dr Ashley Fernandes]
Absolutely. Absolutely. And I think that's ultimately what will give us meaning and will give us the kind of motivation to hold ourselves and other people accountable to professional standards.

It's okay to question, to challenge, hey, is this really professional or is this not professional? That's part of the development of our conscience. That's part of helping to improve institutional integrity.

So, I would encourage people to still think about that and to not just be positivistic and say, oh, well, this is the rule, so I have to follow it. Think about why. Why do we have these rules here?

I mean, I was so impressed, Dr. Mike, when I first came here and I was getting a tour. They were showing me the big hospital. And I remember the patient and family getting into an elevator and everybody stepping out of that elevator.

Everybody. There was a nurse and a doctor wearing a white coat and there was a pharmacist. Everybody stepped off.

And I remember when they were pushing a patient through in a wheelchair, people would stand off to the side to give that patient room. Everybody of any rank, any administrator, they step off to the side. And I thought to myself, that is an incredible gesture of humility.

And this is the place I want to work. And it has not disappointed me. That's the kind of culture that will build professionalism here.

So, I hope it continues.

[Dr Mike Patrick]
Yeah, absolutely. And I think as long as we continue to have discussions like this and to get the word out about the importance of professionalism, I think that that's one way that we can make a difference. It is a privilege to practice medicine.

And a lot of us, when we were applying to medical school, we really wanted to get in. It's very competitive. It's a lot of hard work.

And you can really view it as a profession and that you're giving not only to patients but to society as a whole. But then in the day-to-day drudgery of our work sometimes, you sort of lose sight of that, that it's a privilege. And so, I would just encourage folks to – you're going to daydream a little bit.

Think about what life was like when you were applying to medical school, the excitement when you were accepted, how difficult it was to get through, but you did. And I think sometimes that can help, especially when we're having hard days. Absolutely.

Absolutely. I 100 percent agree. Well, we are going to have some resources in the show notes for folks.

Medical Professionalism in the New Millennium, a physician charter. That's an interesting one. And then there is a Pediatrics in Review.

And most of the pediatricians out there know what I'm talking about when I say Pediatrics in Review. But there was an issue on professionalism, and I'll put links to both of those things in the show notes over at pediacastcme.org. This is episode 111, so three ones in a row, and you'll be able to find it and have those resources there.

So once again, Dr. Ashley Fernandes, Director of Faculty Professionalism at Nationwide Children's Hospital. Thank you so much for stopping by today.

[Dr Ashley Fernandes]
Oh, thanks so much for having me. It was a great conversation.

[Dr Mike Patrick]
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast CME a part of it. Really do appreciate that. Also, thanks again to our guest this week, Dr. Ashley Fernandes, Director of Faculty Professionalism at Nationwide Children's Hospital. Don't forget, you can find us wherever podcasts are found. We're in the Apple Podcast app, Spotify, iHeartRadio, Amazon Music, Audible, YouTube, and most other podcast apps for iOS and Android. Our landing site is pediacastcme.org.

You'll find our entire archive of past programs there. Show notes for each of the episodes, our CME information, our terms of use agreement, and the handy contact page if you would like to suggest a future topic for the program, or if you just want to say hi. I love hearing from listeners.

And again, you can reach out on the contact page. Reviews are also helpful wherever you get your podcasts. We always appreciate when you share your thoughts about the show, and we love connecting with you on social media.

You'll find us on Facebook, Instagram threads, LinkedIn, BlueSky, all those places. Simply search for PediaCast. So, you have listened to this episode.

Now be sure to claim your free category one continuing medical education credit. Really easy to do. Just head over to the show notes for this episode at pediacastcme.org.

It's episode 111. You'll find a link to the post-test in the show notes. Follow that link to Cloud CME.

Click on the materials tab and take and pass the post-test and enjoy the category one credit that sure is absolutely free. And again, we do offer credit to many pediatric professionals, not only physicians, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists. Of course, you want to be sure the content of the episode matches your practice, which again, in today's case is everybody.

Complete details on the CME credit are available at pediacastcme.org. We also have an additional podcast that I host that may be of interest to many of you. It is called FAMEcast.

It is a faculty development podcast from the Center for Faculty Advancement, Mentoring, and Engagement at The Ohio State University College of Medicine. So, if you are a teacher in academic medicine or a faculty member in any of the health sciences, then this is a podcast for you. We don't really talk much about clinical medicine, but we do talk about teaching, work-life balance, promotion, all of those sorts of things, AI in teaching and in clinical care.

So, all of that is available at FAMEcast. It's at famecast.org. That's the landing site.

Also available wherever podcasts are found. Simply search for FAMEcast. Thanks again for stopping by.

And until next time, this is Dr. Mike saying, stay informed, keep it evidence-based, and take care of those kids. So long, everybody.