Chapter 2: Training, Communication, Professionalism, & Systems-Based Practice

The process of medical education and surgical training in the United States is overseen by an interconnected group of organizations. Each of these organizations has their specific focus; however, the common theme is continuous process improvement encouraged by intermittent external review (Table 2–1). The ultimate goal is the provision of a consistent, qualified, and professional workforce for medical care in the United States.

Medical Student Education

The Liaison Committee on Medical Education (LCME) is the group that provides accreditation for medical schools in the United States and Canada. Accreditation is the process of quality assurance in postsecondary education that assesses whether an institution meets established standards. Accreditation by the LCME is effectively necessary for schools to function in the United States. Without accreditation, the schools cannot receive federal grants for medical education or participate in federal loan programs. Graduation from an LCME-accredited school enables students to sit for medical licensing examinations (the USMLE) and to achieve licensure in most states around the country. Graduation from an LCME-accredited medical school is also necessary for acceptance into an ACGME-accredited residency program (see below) for graduates of US medical schools. The authority for the LCME to provide this accreditation is delegated by the United States Department of Education in the United States and the Committee on Accreditation of Canadian Medical Schools (CACMS) in Canada.

Each accredited medical school is reviewed annually for appropriateness of their function, structure, and performance. Formal site visits are conducted periodically with more in-depth review and reaccreditation at that time. The usual period of full accreditation is 8 years. At the time of this in-depth accreditation visit, and in the intervals between, the LCME works to disseminate best practices and approve the overall quality of education leading to the MD degree.

Graduate Medical Education

The Accreditation Council for Graduate Medical Education (ACGME) is responsible for the accreditation of post MD medical training programs within the United States. Accreditation is accomplished through a peer review process based on established standards and guidelines. The member organizations of the ACGME as an accrediting group are the American Board of Medical Specialties (ABMS), the American Hospital Association (AHA), the American Medical Association (AMA), the Association of American Medical Colleges (AAMC), and the Council of Medical Specialty Societies. The ACGME oversees a variety of graduate medical education programs in specific specialties. These ACGME-accredited residency programs must adhere to the ACGME common program requirements that apply to all residencies, as well as specific program requirements that apply to each training program. The ACGME also accredits institutions to house the residency training programs. There are thus also institutional requirements that must be met for overall accreditation of the institution to house training programs.

The ACGME has identified six general competency areas that must be addressed during every graduate residency training program (Table 2–2). The specific application of these competency areas varies widely among training programs. However, each rotation of each residency must include attention to, and assessment of, progress in fulfilling the general competency requirements.

The review and accreditation of specialty residency programs is undertaken by a committee specific for that field. In surgery, the group is the Residency Review Committee for Surgery (RRC-S). The RRC-S assesses program compliance with accreditation standards both at the common program requirement level, and at the program specific level. Programs are typically fully accredited on a five year cycle, with annual updates and questionnaires in the interim. Early site visits can be triggered by a variety of events including significant changes in the program or its leadership. The Residency Review Committees also control the number of positions that each program is accredited to have. This effectively sets the maximum number of graduates that can finish from a given training program in any given year.

American Board of Surgery

The American Board of Surgery (ABS) is an independent, nonprofit organization with the purpose of certifying individual surgeons who have met defined standards of education, training, and knowledge. The distinction between the ACGME and the ABS is that the ACGME accredits training programs, while the ABS certifies individuals. This distinction is similar for specialty boards in other disciplines as well. The ABS also recertifies practicing surgeons, and is making a fundamental philosophical change from periodic retesting for recertification to a more continuous maintenance of certification (MOC) plan.

The ACGME and the specialty boards interact. The success of individuals in achieving board certification is considered an important measure of graduate medical education program success, and the measures that can be required of an individual for board certification must somehow also reflect the education that is offered to them through their graduate medical education. Thus though these entities have different purposes, they must, optimally, mesh their efforts constructively.

Board certification within a defined period after completing residency is necessary for privileging to perform surgery in many hospitals in the United States. Thus the most straightforward route into surgical practice in the United States includes graduation from an LCME-accredited medical school, completion of an ACGME-accredited residency training program, and satisfactory completion of the Qualifying Examination (written boards), and Certifying Examination (oral boards) of the American Board of Surgery.

There are other entry points into surgical practice in the United States, most prominently by physicians who have graduated from medical schools in countries outside the United States and Canada. These graduates can be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). Once an individual graduate has been certified by the ECFMG, then he or she is eligible to train in an ACGME-approved residency training program, and can thus be eligible for board certification.

American College of Surgeons

The American College of Surgeons (ACS) is a scientific and educational association of surgeons whose mission is to improve the quality of care for the surgical patient by setting high standards for surgical education and practice. The ACS has members, known as fellows, who are entitled to use the letters FACS after their name. Membership as a fellow implies that the surgeon has met standards of education, training, professional qualifications, surgical competence, and ethical conduct. However, despite these requirements, the ACS is a voluntary professional membership group, and does not certify individuals for practice. The ACS does sponsor a wide variety of educational and professional support programs both for practicing surgeons and trainees. In addition, they have membership categories for surgeons in training (Resident Membership) and students (Medical Student Membership), and for those surgeons who have completed training but have not yet met all the requirements for fellowship (Associate Fellow). The ACS also engages in important advocacy roles on behalf of patients and the surgeon members.

Efficient and effective communication skills are a critical resource for all clinicians including surgeons. A surgeon must be capable of establishing a rapport with the patient and family quickly and reliably. This mutual respect is critical to a therapeutic relationship. The patient and family must be confident of the competence of the surgeon in order to participate in the recommended management and recovery. Judgments about surgeon competence frequently come within the first few moments of interaction based on the surgeon’s ability to communicate. In addition to communicating with patients, clinicians must communicate with referring and collaborating physicians, and also within their own health care teams.

Communicating With Patients

Communication with patients requires attention to several aspects. First, the clinician must demonstrate respect for the patient as a person. Second, the clinician must display effective listening to the patient’s message, followed by demonstrated empathy to their situation or concerns. Finally, the clinician must have clarity in the response. If any of these items are omitted, then the interaction will be less effective than it could be. Many surgeons try to jump straight to a very clear concise statement of the plan; however, unless the first three steps have occurred, the patient may not listen to the plan at all.

Respect

It is critically important to show respect for the patient and family as persons. The health care environment is often inconvenient and encountered during a time of stress. The patients are out of their normal venue and zone of comfort. They are often frightened by the prospect of what they may learn. Showing respect for their identity will place the patient at more ease and encourage their trusting communication with the clinician. Failing to show respect will have the contrary effect. Thus meeting an adult for the first time and addressing them by their first name can immediately put many patients on guard with respect to their personal independence and control. Similarly, referring to the mother of a pediatric patient as “Mom” rather than using her name implies lack of attention to her as an individual worthy of learning her identity. On initial meetings, the clinician should use the patient’s last name preceded by an honorific title (Mr. Smith, or Ms. Jones). If you are not certain if a woman prefers Mrs. or Ms, then ask her. In contemporary US society, a woman over 18 years of age is never referred to as Miss.

In addition, engaging in brief small talk regarding some aspect of a patient’s life other than the medical matter at hand can additionally put them at ease (“It must be interesting to be a dog trainer. What is your favorite breed?”). These efforts will be rewarded by a more trusting patient and a more efficient interview, with a better therapeutic relationship over the long term.

Listening

Listening to the patient is critical to establishing a correct diagnosis and appropriate therapeutic plan for the individual. Every patient who comes to the medical system with a problem has a story that they have thought through and decided to tell. It is important to let them do so. Not only is the patient likely to reveal critical issues regarding the clinical matter, but they are also often determined to tell the story eventually, whether they are allowed to do so at the outset or not. Allowing, and in fact encouraging them, to tell the story at the beginning of the interview relieves them of this burden of information, and allows the clinician to move on to interpretation.

Listening should be an active, engaged activity. The clinician should appear comfortable, settled, and upon as much of an even eye level with the patient as possible. It is important not to appear rushed, inattentive, or bored by their account. Interjecting questions for clarity or intermittent, brief verbal encouragements will let the patient know that the clinician is engaged with the problem.

It may be helpful at the outset of the listening phase to let the patient know what materials have been reviewed; for example, telling the patient that the clinician has reviewed the referral letter from the primary physician, the results of the last two operations, and their recent laboratory work may help the patient to be more concise in their discussion.

Empathy

Once the patient has recounted their history and the other aspects of examination and data review have been completed, it is important to review this material with the patient in a way that demonstrates empathy with their situation. A surgeon’s understanding of the problem is important for the patient, but the problem is not confined to the medical issue, the problem must be understood in the context of the patient. For this reason demonstration of empathy is important to the patient’s trust of the physician. Establishing this connection with the patient is crucial to their engagement in the process of care.

Clarity

Having established respect for the patient, heard and understood their story, and empathized with their situation, the physician must speak clearly and in a vocabulary understood by the individual, about the recommendations for further evaluation or care. This portion of the conversation should include a clear distinction between what is known about the patient’s diagnosis or condition and what is not known but might be anticipated. When appropriate, likelihoods of various outcomes should be estimated in a way that the patient can grasp. The recommended approach to next steps should be listed clearly, along with alternative approaches. Patients always have at least one alternative to the recommended choice, even if this is only to decide not to have further medical care. This portion of the conversation can be augmented with illustrations or models that may improve the patient’s understanding. Often reviewing radiological studies directly with the patient or family at this time can help their understanding.

The risk taken by failing to establish this relationship with the patient is great. This can lead to errors in judgment about diagnosis or management. It also precludes the opportunity to engage the patient as an ally in his or her care. If things go badly, it also can make subsequent communication about problems or complications difficult or impossible. Finally, the surgeon who communicates poorly excludes him- or herself from enjoying a personally and professionally satisfying physician-patient relationship.

Communication With Collaborating Physicians

Surgeons often work with other physicians in collaboration of care for patients. Communication in these settings is important to the overall patient outcome, particularly when the surgeon will be involved in the patient’s care for some defined interval which has been preceded and will be followed by the ongoing care provided by the primary care physician. The communication in these settings can be separated into two basic types: routine and urgent. Routine communication can take place in a variety of ways depending on the health care setting. This communication is typically asynchronous and written. It may take the form of a note in the patient’s electronic medical record, or a letter sent to the physician’s office. This is an appropriate way to communicate reasonably expected information that does not need to be acted on urgently. For example, a patient who is referred to a surgeon for cholecystectomy and who has a plan made for cholecystectomy can have routine communication back to the referring physician.

Urgent communication should occur to the collaborating physicians when there are unexpected or adverse outcomes. Again, there are a variety of communication modes that may be utilized for this, but the communication is more often synchronous via a direct conversation either in person or by telephone. The communication is more than courtesy to the collaborating physician, as knowledge of these events allows them to participate constructively on behalf of the patient. Examples of situations that warrant more urgent communication include new diagnosis of significant cancers, life-altering complications from interventions, and certainly death of the patient.

Clarity in transfer of care responsibility is critical to the continuous optimal care of the patient. For that reason, any communication with the collaborating physicians should indicate either the ongoing role of the surgeon in the patient’s care, or the deliberate transfer of responsibility for ongoing care issues back to other collaborating physicians.

Communications Within Teams

Surgical care is often provided in a team setting. Current surgical teams typically include physicians, nonphysician mid-level providers (often physician assistants or nurse practitioners), and a variety of students. The student trainees may include students in medical school, physician assistant programs, or nursing school. These teams have become increasingly complex, and the information that they manipulate as a team to provide patient care is voluminous. In addition, the transfer of information from one provider to another as shifts or rotations change is recognized as a weak point in the patient care continuum.

With these complex teams and extensive information, the keys to efficient and effective team processes appear to be clarity of roles and designing processes that involve only writing things down once. The advent of electronic medical records has allowed the generation of electronic tools to transfer information from team member to team member. This may be useful to facilitate this process. Careful attention to transfers of care from one provider to another and explicit recognition that this is a potential time for errors is important.

Professionalism denotes a series or group of behaviors that demonstrates that a person has achieved status as a professional. A professional in this context is implied to possess the specialized knowledge and have gone through long and intensive academic preparation for their vocation. These behaviors affect the interactions that professionals have both with patients and with other health care professionals. For optimal effectiveness, the surgeon should behave in a professional way both with patients and within their health care institutions. The American Medical Association has promulgated a set of medical ethical principles that apply equally well to surgical practice, and that can help to guide professional behavior (Table 2–3).

The ethics of surgical practice are complex, and can be approached from a variety of theoretical frameworks. The most commonly applied framework for the evaluation of ethical dilemmas for individual patient decisions in medicine, known as “The Principles Approach,” involves four principles: Autonomy, Beneficence, Nonmaleficence, and Justice, as promulgated by Beauchamp and Childress (Table 2–4). A detailed analysis of these principles is beyond the scope here; however, the need for a code of medical ethics that is distinct from general societal ethics is the basis for medical professionalism. The following are five features of medical relationships that provide the moral imperatives underlying the profession and the requirement for a separate ethical code from other forms of business.

1. The inequality in medical knowledge, and attendant vulnerability, of the patient

2. The requirement for the patient to trust the physician, known as the fiduciary nature of the relationship

3. The moral nature of medical decisions that encompass both the technical aspects of health management and the ultimate effect on the patient’s life

4. The nature of medical knowledge as a public property that physicians receive in order to apply to the practical improvement of patients’ lives

5. The moral complicity of the physician in the outcome of the prescribed care, in that no formal medical care can take place without the physician’s collusion

Because of these characteristics of the relationship between physicians and their patients, physicians must adhere to a set of ethical constraints specific to their profession.

While these imperatives are not generally understood explicitly by patients, patients can clearly grasp when these principles are in danger. They may even be suspicious that their physician or surgeon has competing motives to the patient’s best interest. One of the goals of the physician-patient interaction is to allay these fears, and construct a trusting relationship based on the patient’s needs, within the principles noted above.

Interaction With Patients

The interactions with patients should be characterized by polite and possibly somewhat formal manners. These manners will aid the professional in their communication efforts as noted above. In order to meet the patient’s expectations of what the physician or surgeon should be, proper socially acceptable manners should be observed. The purpose of these manners is to put the patient at ease that the physician is an empathetic person with the self-awareness to recognize the way that he or she appears to other people. The manners that the physician projects affect the credibility of the subsequent interactions. These conventions extend to the type of dress that is worn in a professional setting. The details of whether a physician wears a white coat or formal business clothing (suits, ties, pantsuits, blouses, skirts, etc) are best left to local custom and practice. However, the mode of dress in general should be neat, clean, and formal rather than casual, and not distracting to the interaction.

Another aspect to professionalism is the capability of the physician to do the right thing for the patient and the family even when that course is difficult or unpleasant. This includes such situations as frankly and openly disclosing errors made during care, or delivering bad news about new or unexpected diagnoses. While human nature can make these interactions difficult, the professional must rise to the task and perform it well. Avoiding the opportunity to do so not only obviates the professional’s role as advisor on the issue at hand, but affects the physician’s credibility in the remainder of that therapeutic relationship.

Interactions With Health Care Personnel

Surgeons frequently work in complex, multilayered organizations. The behavior of the surgeon within this group should always remain productive and patient-centered. In any complex organization with multiple people and personalities, conflicts arise. In that context, it is not appropriate for the surgeon to necessarily shrink from the conflict, but rather the surgeon should take up the role of constructive evaluator and team builder to resolve the issue. At all times, the surgeon must avoid personal attacks on people based upon their personal characteristics, but may legitimately criticize behavior. Professional comportment in these matters will be rewarded with progress in resolving the issue.

Reputation is a fragile and valuable commodity. All health care professionals have a reputation, and it works either for or against them in achieving their patient care and professional goals. Careful adherence to professional behavior in dress, speech, manners, and conflict resolution will create the professional reputation that is most advantageous for the surgeon. With a positive reputation, the surgeon’s behavior in ambiguous situations will be interpreted in a benevolent way. The reputation of any clinician is as valuable as their education or certification.

Systems-based practice is one of the core competencies defined by the ACGME as a necessary skill to be developed by graduate medical trainees. These residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. The process of teaching and learning, systems-based practice has been in place for many years. This is what might be considered the practical part of graduate medical training. However, it is only more recently that it has become a focus and metric for performance by training programs.

As a part of training then, residents must learn how different types of medical practice and health care delivery systems differ from one another, including methods that they use to control health care costs and allocate resources. They must use this knowledge to practice cost-effective health care and resource allocation that limits the compromise of quality of care. They must advocate for quality patient care and assist patients in dealing with complexities of the health care delivery system. They must also understand how to work with health care managers and other collaborating health care providers to assess, coordinate, and improve health care for patients.

In practice, this is easier to understand. The role of the resident in identifying both the health care needs of the patient and the capability of the system to meet those needs is well-established. Surgery residents in their senior years are often important resources for hospital systems by understanding how to manipulate the system to meet the needs of the patient. Medical students and surgical trainees must also recognize their role as a part of these complex systems.

Reference