CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
105 cases with questions provide starting point for discussion
September 2020—Professionalism in Pathology and Laboratory Medicine is a new book now out from CAP Publications. It provides a basic understanding, educational and assessment tools, 105 cases specific to pathology and laboratory medicine, guidance in recognizing and addressing lapses in behavior, discussions on best practices and legal and ethical aspects, and much more.
Ronald E. Domen, MD, of Penn State College of Medicine and Hershey Medical Center, is editor. His co-editors are Richard M. Conran, MD, PhD, JD, of Eastern Virginia Medical School; Robert D. Hoffman, MD, PhD, of Vanderbilt University School of Medicine; Cindy B. McCloskey, MD, of the University of Oklahoma Health Sciences Center; and Suzanne Zein-Eldin Powell, MD, of Houston Methodist Hospital.
CAP TODAY spoke with Dr. Domen in July about the book. Here is what he had to say. (See chapter, below.)
Why this book and why now?
Professionalism, writ large—ethics, integrity, respect, accountability, diversity, et cetera—has increasingly been recognized as a cornerstone in the practice of medicine. Articles published in the medical literature, and in the lay press, showed there was room for improvement in the medical profession in the area of professionalism. In the late 1990s the ACGME [Accreditation Council for Graduate Medical Education] made professionalism one of the six core competencies of residency and fellowship training. Since then, concerted efforts have been made to enhance educational efforts around professionalism. Specific to pathology, the CAP Graduate Medical Education Committee [GMEC] started looking at this issue in a meaningful way around 10 years ago. It published papers, gave workshops and led roundtables, and conducted surveys. As these efforts grew, it became obvious that a first-of-a-kind book on professionalism—focused on pathology and laboratory medicine—was needed. Most of the authors and coauthors of the chapters in the book are current or past members of the GMEC.
How does your book differ from what has been available until now on professionalism, and will it be applicable to all practice settings?
This book was designed to be applicable to all practice settings in pathology and laboratory medicine and the first with a slant toward pathology and laboratory medicine. In addition, professionalism has common themes across all fields of medicine, so those outside of pathology will also find a great deal of useful information in the book.
You write that unprofessional behavior in the workplace is one of the most difficult aspects of management, and one reason is that it is rarely clear-cut. Can you tell me more about that difficulty?
While some unprofessional behavior is fairly straightforward—physical or sexual harassment or assault, for example—a lot can be less clear-cut. It may occur without witnesses, it may be subtle, people often are afraid to report it for fear of retaliation, policies are often lacking or vague, it may be sporadic or without a defining pattern. Also, remediation or dismissal is not a one-size-fits-all approach, and guidelines or methods to address unprofessional behavior are often lacking. In addition, teaching and modeling professionalism must be a top-down endeavor. If hospital administration and attending physicians are not held accountable, how can residents, medical students, hospital and laboratory staff, et cetera, be expected to uphold the ideals and principles of professionalism?
More than 100 cases are provided, with questions for each. How are you intending readers to use these cases?
The cases were developed by current or past members of the CAP GMEC and most are actual or modified case scenarios from real situations. They show the wide range of possible situations where lapses in professionalism or ethics may be encountered in pathology and laboratory medicine, and it is anticipated that they will serve as prompts for discussion and educational efforts.
You have 17 contributing authors. How were they selected?
Many of them are past or current members of the CAP GMEC who also recruited the nonmembers based on their expertise. So this is truly a CAP committee effort.
Three of the authors point out in their chapter, on recognizing and remediating lapses in ethical and professional behavior, that there is an entrenched culture in medicine that unfortunately can support and perpetuate bad behavior on the part of the physician, and while things have changed, residual hierarchies exist. How common a problem is this today?
Culture change typically occurs slowly. I have seen unprofessional behaviors today, and throughout my career, that I saw 40-plus years ago when I was a resident. So work still needs to be done. The eight years that I was associate dean for GME at Penn State [2005–2013] afforded me a unique opportunity to also see and address unprofessional behavior across a number of departments and specialties that included both residents and attending physicians. But things have definitely changed for the better, and all of us in medicine are being held to a higher standard of professional behavior. I refer to the ongoing effort as continuous professionalism improvement.
You write in the final chapter that practicing professionalism in an environment that doesn’t promote ethical and professional conduct can be a source of stress leading to burnout. Can you comment on that?
There is a whole chapter in the book devoted to professionalism and physician health and wellness. The latest iteration of the professionalism milestones developed by the ACGME also includes assessing and educating trainees on self-awareness, well-being, and help-seeking. Therefore, an environment that does not take seriously the importance of a culture of professionalism will not take seriously the adverse impact unprofessional behavior can have on one’s well-being. Even under ideal working conditions, physicians and other health care professionals are under stress that could lead to depression, suicide, and other health issues. Burnout is a real issue in medicine, and pathology is not exempt.
What is the one most important thing about the book you would like potential readers to know?
This book is the culmination of a lot of hard work by a number of dedicated people who truly believe that we, in pathology and laboratory medicine, can and should do better in our personal and work environments. Professionalism impacts multiple areas across the continuum of what we do and who we are, and this book, we hope, will help to educate us and give us tools to address unprofessional behavior. Additionally, it is hoped that this book will reinforce that the broad fields of pathology and laboratory medicine are not exempt from the concerns of professionalism—integrity, respect, accountability, diversity, personal and professional well-being, ethics, conflicts of interest, et cetera—and that many opportunities for pathologists to make important improvements and contributions in this field will continue to present themselves.
To order (PUB 317), call 800-323-4040 option 1 or go to www.cap.org (Shop tab) ($76 for members, $95 for others). For the ebook ($72), go to ebooks.cap.org. If you are interested in writing a book, contact Caryn Tursky at ctursky@cap.org.
At Penn State, Dr. Domen is a professor of pathology, medicine, and humanities and co-medical director of blood bank/transfusion medicine and medical director of the apheresis and hematopoietic stem cell collection unit/program.
Here, from the new book Professionalism in Pathology and Laboratory Medicine, is the chapter “Diversity and Professionalism.” Dr. Tsai is in the Department of Emergency Medicine, Yale New Haven Hospital, and Dr. Rojiani is in the Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School.
Diversity and Professionalism
Jennifer Tsai, MD, MEd
Rahil Rojiani, MD
Introduction
Professionalism and diversity have historically intersected at many levels and in widely different contexts. Indeed, the issue of diversity can be conceptualized as more of a perspective—one that can and should be considered and applied to multiple axes and considerations—rather than as a single topic of discussion. The complexities and nuances to diversity and inclusion fundamentally involve comprehension of historical legacies of supremacy, decolonization, and power dynamics. These require nuance and rarely have clear binary answers. We therefore choose to address this without defining right and wrong; rather, we seek to engage the reader by challenging the standards that society—and the medical profession in particular—has imposed upon itself. This chapter asks learners to embark upon a journey that explores how we characterize the standards of work culture, in order to interrogate what has become normative in our understanding of professionalism. In this way, we can more clearly ascertain what norms have been constructed, who has been able to construct them, what powers continue to perpetuate their stronghold, and their validity as self-imposed principles. This aids in analyzing which identities have been relegated to the status of “unprofessional” or “impermissible” and the inequities that arise and persist because of these very dynamics. Fundamentally, we ask learners to redefine professionalism in the context of a decolonial and diversity lens, and not the other way around.
Traditional medical education historically imposes the notion that biomedicine and clinical practice are apolitical objective disciplines rooted in fact and evidence. Trainees are encouraged to be identity-less, that is, to embody the assumption that the identities they bring—be it regarding race, socioeconomic status, ability, religion, gender identity, sexual orientation, or age—are inconsequential and irrelevant to the provision of medical care. Indeed, this inculcation may even imply that subjectivity is disavowed; bringing individual identities to a clinical field may be framed as harmful in its clouding of impersonal logic.
Stripping individuality from physicians is not only undesirable—for medicine is a social field mobilized through human actors—it is impossible. Any attempt to frame medicine as possibly separate from individual identity will fail or be inaccurate. Furthermore, individual experiences prove to be assets in shaping compassion, understanding, and empathy. As the world changes from one where physicians are assumed to share common identities to one of a more diversified nature, we find that we have constructed professionalism in such a way that instead of centering ethical practice, our paradigm of professionalism in fact polices appearance and behavior as an assumed representation and proxy of a person’s ethical code and competence. This comes at the expense of the well-being of those who have diversified medicine by fighting against their unconscionable historical exclusion in the field.
We begin with an exercise: Imagine a room of professionals. They are wearing professional attire, behaving professionally, speaking in professional language and in professional tones. What manifests in your mind? What would a Google image search of this idea reveal?
With each of these questions, pause and genuinely consider: What do these individuals look like? What race and gender are they? What hairstyles do they have? Style of clothing? Who has piercings, and what kind of jewelry? Are any of them in wheelchairs? How are they sharing in conversation? How are they expressing emotion?
What is apparent in the scene? What is missing? It is apparent that we can conjure and recognize a picture of professionalism, but defining its “phenotype” is more complicated. It’s an intuitive feeling, an “I know it when I see it” concept. Professionalism, in our minds, has been constructed and taught in our lives through a series of lessons—both conscious and unconscious. It looks different within other rooms, across borders, among different people. And the question becomes, who gets to decide?
Professional Appearance
What constitutes a “professional” appearance? In this image of what a professional looks like, we might explore a number of possibilities, particularly along various lines of human difference upon which value is given or not: race, gender, class, body size, ability, and religion.
Reflecting the demographics of the medical professional world, this imagined room is likely mostly white, male, and able-bodied. These individuals walk to and fro without assistance, they are not accompanied by oxygen tanks, beeping machines, or walkers. They speak with their mouths not their hands, without stutters, without pause. They are upright and clean. Perhaps they are dressed in suits, crisp trousers, patterned ties. They do not need help getting dressed. They do not need help using the restroom. There is no sign of poverty or emotional despair. They speak in technical jargon, avoid colloquialisms, and modulate their emotions without a sweat.