#31 Taking a fresh, SOAP-y Approach to Professionalism

May 16, 2023 | By Era Kryzhanovskaya

Audio

Video

With Dr. Andi Marmor

Join us as we talk with Andi Marmor, MD (UCSF)  as we dive deep into professionalism in health professions education.   We define professionalism,  discuss assessment, and review concrete methods for approaching a professionalism conversation.   Learn to use the SOAP framework you are already familiar with from your clinical work to help address a professionalism concern in a learner!

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Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner
• Picks of the Week
• Case from Kashlak Memorial
• Defining Professionalism 
• Assessing Professionalism 
• Domains of Professionalism
• SOAP Approach to Professionalism Conversations 
• GROWS framework
• Challenges
• Bias in Professionalism Assessment 
• Take Home Points
• Outro

Highlighting our Guest

Dr. Andi Marmor is a pediatrician, medical educator, coach and faculty developer. She is clinically based at SF General, and teaches at UCSF School of Medicine. She loves learning from and teaching absolutely all levels of learner, from her daughter’s 4th grade class to fellow faculty. 

A SOAP-y Approach to Professionalism Pearls

1. Professionalism at its core is a set of shared values that our profession should uphold, regardless of our varied backgrounds and beliefs.
2. Be conscious of bias! Bias has played–and continues to play– a large role in professionalism assessment.
3. Use the SOAP framework for assessing professionalism: what are your Subjective responses and thoughts regarding the professional lapse, what are the Objective behaviors witnessed and what domains of professionalism do they fall under, Assess both a differential diagnosis for the cause of a professionalism lapse and the learner’s insight and readiness to change, and make a concrete Plan.
4. The GROWS framework from coaching can be helpful: Goals- find a shared goal; Reality- where are we now; Options- find several, Way forward- choose a next step, Success- plan a time to follow up on this.
5. If you see something, say something!  As the student’s preceptor, mentor, or academic coach, you truly are the best person to have a professionalism conversation with a learner. 

A Fresh, SOAP-y Approach to Professionalism

Defining Professionalism 

Professionalism at its core is a set of shared values that our profession should uphold, regardless of our varied backgrounds and beliefs.

While these values have a tendency to remain relatively consistent, they represent a subjective set of shared values that have evolved over time due to the changing backgrounds of individuals within our profession.

Dr. Marmor notes that it is important to acknowledge the negative connotations associated with the concept of professionalism in medicine.  Professionalism has historically been used to exclude members of marginalized groups from the medical profession.  It is imperative to recognize that our assessment of professionalism is prone to bias, thus minority and underrepresented populations are more likely to experience challenges and disciplinary actions (Alexis 2020). 

Assessment in Medical Education

Educational Domains

When looking to assess professionalism in learners, it is helpful to identify behavioral domains that can be objectively observed.  Dr. Marmor endorses using the framework of professional behavior outlined by Wilkinson et al. which includes the following domains (Wilkinson 2009):  

1. Communication/interaction with other health professionals  
2. Interactions with patients 
3. Reliability – showing up and doing what you said you would do 
4. Ethical behavior 
5. Self-maintenance (or self-improvement) 

Translating Domains into Competencies for Assessment

Translating broad domains into specific competencies (expected specific observable behaviors) can help with assessment.  Some professionalism domains are easy to translate into competencies, for example reliability is easily measured (were notes closed on time, did the learner show up to sessions).  Others are more challenging to translate into competencies such as patient interactions.  

Dr. Marmor notes that one challenge is that these domains can be in conflict with one another.  For example, seeing a patient that has multiple concerns that need to be addressed may cause conflict between interacting with patients and interacting with colleagues that are waiting for you to start rounding.  Importantly, learners are at a disadvantage when it comes to making decisions when these domains are in conflict due to lack of power in the medical hierarchy and lack of experience in navigating these situations. 

Another noteworthy caveat is that lapses in professionalism are inevitable. It is critical that we normalize lapses in professionalism for our students and allow our learners to make mistakes. 

SOAP Approach 

Dr. Marmor outlines her SOAP structure for framing a conversation with a learner about issues pertaining to professionalism.

Subjective:

1. What is bothering me as related to professionalism?
2. How do my identity, background, previous experiences, and relationship to the learner affect how I may respond in this situation? 

Objective: bring in the professionalism domains

1. What specific behaviors did I observe in this learner? Important to not make assumptions about intent behind behaviors.
2. What professionalism domains are at play in this situation? 
3. Determine the scope – is this an isolated incident or is this a pattern?
4. Are there other perspectives that would be important? Should I hear these other perspectives before or after meeting with the learner?

Assessment:

1. Have a differential prior to entering the room: think of three entirely different potential explanations for the learner’s behavior.
   1. Consider things like imposter syndrome, mental or physical health issues, stress, wellbeing, etc.
   2. Having a wide differential helps the mentor enter the conversation with compassion, kindness, and an open mind. 
2. Goal of the conversation is to assess two things in the learner:
   1. What is the learner’s level of insight? Do they realize their behaviors are potential professionalism issues?
   2. Is the learner motivated to change, improve, or do something different next time? 

Plan: 

1. Next steps are largely based on assessment of learner insight and adaptability.
   1. Ideally agree on simple concrete steps and a specific time to check back in/reassess
2. Utilize the GROWS Coaching Framework: Goals, Reality, Options, Way forward, and evaluating Success (Whitmore 1992).

Tips for what to Actually Say- Dr Marmor’s Role Play with Our Case

Jake is a second year medical student meeting with Dr. Marmor, his longitudinal coach, as a check-in during one of their intercession weeks. Jake recently had an encounter with a group facilitator that rubbed him the wrong way, and he is meeting with you to debrief the situation. Prior to the session, Jake had not read any of the prep material. During the encounter, Jake felt he was asked a targeted question by the group facilitator, and he abruptly left the small group. 

Remember that Jake is coming to Dr. Marmor first in this scenario which gives her an opening to have this conversation. 

1. Start with a nice open-ended question, just like we do with our patients.
   1. “Gosh, Jake, it sounds like you had a really tough time. Tell me what happened. Tell me how you felt.” 
   2. In this case, Dr. Marmor is Jake’s longitudinal coach. Her primary role is supporting Jake. Listen and validate Jake’s feelings. 
2. Assess Jake’s insight.
   1. “Can you tell me more about what’s concerning you?”
   2. “Did you consider how this situation may have impacted others in the small group? What about the small group leader?”
3. Assessing readiness to change.
   1. “What might be some next steps for you?” 
   2. “How could a situation like this be avoided in the future?” 
   3. “How can I help you think about what to do next time?” 
   4. Work with the learner to brainstorm solutions. 

Dr. Marmor states the same framework can be applied in conversations with a resident: try to set aside assumptions that residents are more knowledgeable and try to apply the same level of openness and compassion to residents as with medical students (disclaimer: these are for minor lapses in professionalism).

Potential Obstacles 

• Learner lacking insight: have compassion for the learner, draw on cultural humility and structural competency, get to know the learner better, and consider aspects of their background at play.
• Learner lacking both insight and adaptability: be explicit and concrete in expectations of the rotation.
• Concerns that are more biased (eg. interpersonal relationships): be open, inclusive, and supportive in conversations with the learner, recognizing that the concerns may be based in misalignment of how to express values.
• Finding appropriate time and private space for feedback conversations.  Dr Marmor encourages educators to take the time to discuss this before a learner goes off rotation, and if there are significant concerns, she likes to give the learner a heads up before the conversation.

After the Conversation

Document!  Document the concern(s) and your feedback conversation in the learner’s evaluation, ideally.  Include the date you talked to the student and what was discussed.  The purpose of this documentation is to help future mentors or others in leadership positions evaluate learner progress or identify a pattern in behaviors.

Why we Care

Professionalism concerns in training are associated with increased disciplinary actions by medical boards after graduation (Papadakis 2005, Papadakis 2008). 

Take Home Points

There is a difference in being professional and in assessing professionalism.  As assessors, we need to be aware of where we are coming from and that the definition of professionalism is based on a certain historical version of the medical profession.

Have the conversation!  If you see something, say something.  The SOAP framework will help you prepare for the conversation, with a focus on assessing insight and adaptability, and build the plan from there.

Links

1. Dr. Marmor’s Book Recommendation: Of Boys and Men by Richard Reeves 
2. Dr. Era Kryzhanovskaya’s Pick of the Week (Movie): A Man Called Otto
3. Teach for UCSF’s Using SOAP for Learner Professionalism materials
4. Wilkinson TJ, Wade WB, Knock LD. A blueprint to assess professionalism: results of a systematic review. Acad Med. 2009;84(5):551-558. doi:10.1097/ACM.0b013e31819fbaa2
5. Whitmore J. Coaching for Performance. Nicholas Brealey Publishing; 1992. 
6. Whitmore, John. Coaching for Performance: GROWing People, Performance and Purpose. 3rd ed. London ; Naperville, USA: Nicholas Brealey, 2002.

Goal

Listeners will appreciate the complexity of defining, teaching, and assessing professionalism in medicine. 

Learning objectives

After listening to this episode listeners will…

1. Recognize the evolving role of professionalism health professions’ education broadly and medical education specifically 
2. List definitions and key components of professionalism  
3. Describe an approach to assessing professionalism in medical education 

Disclosures

Andi Marmor, MD reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Marmor A, Kryzhanovskaya E, Heublein M. “#31 Taking a Fresh, SOAP-y Approach to Professionalism . The Curbsiders Teach Podcast. https://thecurbsiders.com/teach. May 16, 2023