Construction And Application Of A Medical Professionalism Training Program During Standardized Residency Training

Objective: Medical professionalism is the soul of medical practice,which is mainly manifested as respect for patients,primacy of patient welfare and maintenance of medical justice.The standardized residency training is a particular and necessary educational period for cultivating physicians,which has an irreplaceable significance for improving healthcare quality and ensuring patient safety.Residents in the standardized training(hereinafter referred to as residents),as the new force of the medical profession,are the backbone of the future medical profession.Therefore,it is of great significance to cultivate and improve their professionalism for the development of modern medical services.Based on the standardized residency training,the collection of professionalism dilemma scenarios and analysis of the present status of professionalism dilemmas were as the research starting point,and the construction of medical professionalism training program and teaching case set was as the research core.In the stage of admission education,a medical professionalism course was developed as an important measure to initially implement the training program.The teaching intervention experiment was carried out and the effect of the course was evaluated.Through the scientific construction and implementation of the training program,this study was committed to cultivating residents into physicians with lofty professionalism.Methods: 1.Through the structured retrieval of the Chinese and foreign databases of Web of Science,CNKI and WANFANG,papers on professionalism dilemmas were collected,the dilemma scenarios described in the enrolled literature were summarized into dilemma items,and the first version of the checklist of professionalism dilemmas was constructed with the directed content analysis framework of the Evaluation Framework and Instrument for the Professionalism of Chinese Physicians.Through two rounds and five groups of focus group interviews with 50 residents in a standardized residency training base(hereinafter referred to as the training base)in Liaoning province,the items of professionalism dilemmas were revised and enriched,and the final version of the checklist of professionalism dilemmas was formed.According to the per capita GDP of cities in Liaoning province in 2020,a stratified cluster sampling survey was conducted on 945 residents in four training bases in three cities in Liaoning province to comprehensively understand the status of professionalism dilemmas.2.Based on literature research,the transformative learning theory and situated learning theory were used as theoretical basis,the basic process of medical education curriculum development was followed,and the first version of the medical professionalism training program was constructed.Through the conference consultation with seven experts in medical professionalism and the two rounds of Delphi consultation with 16 experts in medical education,hospital administration and clinical medicine,the final version of the training program formed.Following the guide of case study and taking the professionalism dilemma scenarios collected earlier as situational materials,the teaching cases were developed.Through one-on-one in-depth interviews with 18 clinicians and three medical ethics teachers,the teaching case description was revised,and teaching case analysis materials were collected,including the core contradictions,coping strategies and causes of the professionalism dilemmas involved in the teaching case,to form the final version of the teaching case set of medical professionalism.3.According to the training program constructed in the early stage,with reference to its developmental standards and combined with the actual need of China Medical University,the medical professionalism course in the stage of admission education during standardized residency training was developed.The quasi-experimental research design was adopted and the three-step intervention method of medical education was followed.The residents of grade 2021 and 2022,who were transferred from the undergraduate education to the graduate education of clinical medicine speciality(“5+3”integrated)of China Medical University,were selected as the control group and experimental group to carry out the teaching intervention experiment.The teaching effect of this course was assessed from the perspectives of residents,observer team and teaching team.The mixed research method and the triangulation strategy were used to examine the changes in the understanding,attitude and behavior of residents’ professionalism before and after the teaching intervention experiment.The triangulation strategy includes questionnaire survey before and after the teaching intervention experiment(open-ended questions,attitude and behavior scale of professionalism),reflective writing and thematic report.Results: 1.A total of 56 papers on professionalism dilemmas were included in the document analysis.The first version of the checklist of professionalism dilemmas covered four domains: “Compassion,respect,communication and collaboration”,“Integrity,incorruptibility,and strong sense of duty”,“Pursuit of excellence”,and “Fair stewardship of health care resources,humanitarianism,and adherence to ethical codes”,and 11 sub-domains,including 53 items.The final version of checklist of professionalism dilemmas covered four domains and 12 sub-domains,including 61 dilemmas.In the survey of moral distress following professionalism dilemmas among residents in Liaoning province,798 questionnaires were collected and 645 were valid,with an effective rate of 81.1%.Results showed that for different professionalism dilemmas,the proportion of suffering distress reported by residents ranged from 58.4% to 90.6%,and the proportion of suffering severe distress reported by residents ranged from 3.7% to23.8%.Professionalism dilemmas caused by patients were the most distressed type of dilemmas.There were statistically significant differences in the distress intensity of residents with different gender,age,type of residents,training base and specialty(P<0.05),on the whole,residents who were female and majoring in medical technology suffered more serious distress intensity.2.The first version of the training program included eight sections: training objects,training period and mode,training objectives and requirements,curriculum and teaching plan,education strategy and teaching method,evaluation and feedback,education environment and curriculum management,and others.For the first version of the training program,the expert meeting put forward 14 revised suggestions;For the revised version of training program,46 suggestions were put forward in two rounds of Delphi consultation.After the second round of Delphi consultation,the overall scientificity score(9.67±0.49 vs.9.06±0.68)and feasibility score(9.20±0.68 vs.8.50±1.21)of the training program were significantly higher than those of the first round,and the index of expert positive coefficient,authority coefficient,degree of concentration,and degree of coordination was good.The main contents of the final version of the training program included:(1)The training objects were residents in the standardized training.(2)The training period is three years;The training mode was throughout the standardized residency training,including two stages,namely admission education and clinical department rotation.(3)The overall orientation was to carry forward the lofty professionalism of “respecting life,saving the dying and helping the wounded,being willing to contribute,and great love without boundaries”.The training objectives and requirements were determined to be three domains of “quality,knowledge and ability”around the overall orientation,with 12 descriptions.(4)Based on two stages(admission education and clinical department rotation)vertically,and three curriculum types(formal,informal and hidden curriculum)horizontally,the curriculum objectives,themes and contents were determined.The teaching plan is 40 credit hours for basic standard and 48 credit hours for developmental standard.(5)The education strategy emphasized transformative learning,situational learning and self-directed learning.According to the specific objectives of the course,the appropriate teaching mode and teaching method were determined.(6)The evaluation included diagnostic,formative and summative evaluation of residents in two stages and three curriculum types.The feedback included the feedback for the residents,the immediate feedback for the course and the periodic feedback for the training program.(7)The educational environment,course management and construction of teaching staff emphasized the cooperation of the training base,postgraduate training units and the teaching team.3.The first version of the teaching case set included 63 teaching cases,which were classified into 29 low-level and 34 high-level teaching cases according to the milestone standard of professionalism.The final version of the teaching case included 63 teaching cases,covering six specialties including internal medicine,surgery,obstetrics and gynecology,pediatrics,emergency medicine,imaging medicine and nuclear medicine.General guidelines for clinicians’ coping strategies for professionalism dilemmas involved in teaching cases showed a positive state,which was reflected in seven themes,such as “clarify your duties and correctly position yourself”,“exercise strict self-discipline,and adhere to professionalism standards”,“analyze rationally and actively seek help”,“take the initiative to report and give authentic feedback” and “reflect critically and improve yourself”.According to four categories and six sub-categories of professionalism dilemmas,the coping strategies proposed by clinicians included 27 themes.Five teaching cases that distressed residents deeply or with controversial expert opinions were taken as typical teaching cases for example analysis.4.The medical professionalism course in the stage of admission education during standardized residency training included 18 themes and was allocated 32 credit hours.The teaching team was composed of nine teachers and the researcher.The quantitative and qualitative results of the teaching intervention experiment showed that the understanding,attitude and behavior of professionalism of residents in the experimental group(n=180)were better than those in the control group(n=170),including following aspects:(1)The frequency of mentioning all the domains and themes of professionalism in the experimental group increased before and after the intervention,most of the differences were statistically significant(P<0.05);There was no such trend in the control group.(2)The score of the scale of professionalism attitude(120.05±14.73 vs.116.00±16.77,P=0.017)and its all domains in the experimental group increased before and after the intervention,most of the differences were statistically significant(P<0.05).There was no such trend in the control group.(3)The scores of the scale of professionalism behavior(176.53±20.35 vs.167.45±21.67,P<0.001)and its all domains in the experimental group increased before and after the intervention,all the differences were statistically significant(P<0.05);There was no such trend in the control group.(4)The reflective diary revealed that the changes of coping strategies of the experimental group was reflected in six themes,such as “Reformulate or adjust and optimize coping strategy according to the code of professionalism”,“changing from passive to active”,and “evolving from individual to hospital,society and nation levels”.(5)The thematic report revealed the harvest and perception of residents in the experimental group were reflected in seven themes,including “understanding the concept and category of medical professionalism deeply”,“practicing the guidelines of professionalism in clinical practice consciously” and “promoting professional identity formation”.The changes in the understanding of professionalism were reflected as “from abstract to concrete,from shallow to deep,from one-sided to comprehensive,and from theoretical knowledge to clinical practice”.The changes were reflected in nine themes,such as “clarified the profound meaning of primacy of patient welfare”,“physician-patient relationship expanded to the relationship between medical practitioners,between physician and society,and between physician and enterprise”,and “gave the new meaning to the profession of physician”.The evaluation results of the intervention process showed that,for all course sessions,the scores of residents’ course evaluation and teaching evaluation were both higher than 95,and the scores of observers’ teaching evaluation were higher than 85.Based on the feedback,the teaching team put forward corresponding improvement strategies to realize the continuous improvement of teaching quality.Conclusion: 1.Residents inevitably witnessed or participated in a wide range of professionalism dilemmas with different distress intensity during standardized residency training.The checklist of professionalism dilemmas provided important references for medical educators to carry out targeted professionalism education,and also provided important paths for standardized residency training bases to understand the existing problems of professionalism dilemmas in their institutions from the perspective of residents and to make targeted improvement.2.It was the first time that the medical professionalism training program during standardized residency training was constructed in the whole country and proved to be scientific and feasible,which provided important guidance for the training bases to implement scientific,standardized and systematic professionalism education.The professionalism teaching case set proved to provide important teaching content supports for the professionalism education of residents.3.It was the first time that the professionalism course in the stage of admission education during standardized residency training was developed in the whole country and proved to enrich and deepen the understanding of professionalism for residents,update the attitude of professionalism,and improve the fulfillment of professionalism behaviors,which provided important references for training bases or graduate training units to develop professionalism courses.