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Rapidly Recurring Keratoacanthoma
To the Editor:
A 61-year-old man with a medical history of type 2 diabetes mellitus presented to us with a 2.5×3.0-cm erythematous, ulcerated, and exophytic tumor on the right dorsal forearm that had rapidly developed over 2 weeks. A tangential biopsy was performed followed by treatment with electrodesiccation and curettage (ED&C). Histology revealed a squamous cell carcinoma (SCC), keratoacanthoma (KA) type. Over the next 11 days the lesion rapidly recurred and the patient returned with his own daily photodocumentation of the KA’s progression (Figure). The lesion was re-excised with 5-mm margins; histology again revealed SCC, KA type, with deep margin involvement. Chest radiograph revealed findings suspicious for metastatic lesions in the right lung. He was referred to oncology for metastatic workup; positron emission tomography was negative and ultimately the lung lesion was found to be benign. The patient underwent adjuvant radia-tion to the KA resection bed and lymph nodes with minimal side effects. The patient has remained cancer free to date.
Keratoacanthomas are rapidly growing, typically painless, cutaneous neoplasms that often develop on sun-exposed areas. They can occur spontaneously or following trauma and have the propensity to regress with time.1-3 They are described as progressing through 3 clinical stages: rapid proliferation, mature/stable, and involution. However, KAs can be aggressive, becoming locally destructive; therefore, KAs are typically treated to avoid further morbidity. Keratoacanthomas may be considered a subtype of SCC, as some have the potential to become locally destructive and metastasize.3-5 There are reports of spontaneous resolution of KAs over weeks to months, though surgical excision is the gold standard of treatment.3,5
Reactive KA is a subtype that is thought to develop at the site of prior trauma, representing a sort of Köbner phenomenon.3,4 We demonstrated a case of a recurrent KA in the setting of recent ED&C. Several reports describe KAs developing after dermatologic surgery, including Mohs micrographic surgery, laser resurfacing, radiation therapy, and after skin grafting.3,4,6 Trauma-induced epidermal injury and dermal inflammation may play a role in postoperative KA formation or recurrence.6
Keratoacanthoma recurrence has been reported in 3% to 8% of cases within a few weeks after treatment, as seen in our current patient.3,5 In our case, the patient photodocumented the regrowth of his lesion (Figure). Treatment of reactive KAs may be therapeutically challenging, as they can form or worsen with repeated surgeries and may require several treatment modalities to eradicate them.4 Treatment options include observation, ED&C, excision, Mohs micrographic surgery, radiation, cryosurgery, laser, isotretinoin, acitretin, imiquimod, 5-fluorouracil, methotrexate, interferon alfa-2b, or bleomycin, to name a few.3,4,7
Combination therapy should be considered in the presence of recurrent and/or aggressive KAs, such as in our case. Our patient has remained disease free after a combination of surgical excision with radiation therapy.
1. Schwartz R. Keratoacanthoma. J Am Acad Dermatol. 1994;30:1-19.
2. Kingman J. Keratoacanthoma. Arch Dermatol. 1984;20:736-740.
3. Goldberg L, Silapunt S, Beyrau K, et al. Keratoacanthoma as a postoperative complication of skin cancer excision. J Am Acad Dermatol. 2004;50:753-758.
4. Hadley J, Tristani-Firouzi P, Florell S, et al. Case series of multiple recurrent reactive keratoacanthomas developing at surgical margins. Dermatol Surg. 2009;35:2019-2024.
5. Karaa A, Khachemoune A. Keratoacanthoma: a tumor in search of a classification. Int J Dermatol. 2007;46:671-678.
6. Chesnut GT, Maggio KL, Turiansky GW. Letter: re: case series of multiple recurrent reactive keratoacanthomas developing at surgical margins. Dermatol Surg. 2011;37:884-885.
7. Lernia V, Ricci C, Albertini G. Spontaneous regression of keratoacanthoma can be promoted by topical treatment with imiquimod cream. J Eur Acad Dermatol Venereol. 2004;18:626-629.
To the Editor:
A 61-year-old man with a medical history of type 2 diabetes mellitus presented to us with a 2.5×3.0-cm erythematous, ulcerated, and exophytic tumor on the right dorsal forearm that had rapidly developed over 2 weeks. A tangential biopsy was performed followed by treatment with electrodesiccation and curettage (ED&C). Histology revealed a squamous cell carcinoma (SCC), keratoacanthoma (KA) type. Over the next 11 days the lesion rapidly recurred and the patient returned with his own daily photodocumentation of the KA’s progression (Figure). The lesion was re-excised with 5-mm margins; histology again revealed SCC, KA type, with deep margin involvement. Chest radiograph revealed findings suspicious for metastatic lesions in the right lung. He was referred to oncology for metastatic workup; positron emission tomography was negative and ultimately the lung lesion was found to be benign. The patient underwent adjuvant radia-tion to the KA resection bed and lymph nodes with minimal side effects. The patient has remained cancer free to date.
Keratoacanthomas are rapidly growing, typically painless, cutaneous neoplasms that often develop on sun-exposed areas. They can occur spontaneously or following trauma and have the propensity to regress with time.1-3 They are described as progressing through 3 clinical stages: rapid proliferation, mature/stable, and involution. However, KAs can be aggressive, becoming locally destructive; therefore, KAs are typically treated to avoid further morbidity. Keratoacanthomas may be considered a subtype of SCC, as some have the potential to become locally destructive and metastasize.3-5 There are reports of spontaneous resolution of KAs over weeks to months, though surgical excision is the gold standard of treatment.3,5
Reactive KA is a subtype that is thought to develop at the site of prior trauma, representing a sort of Köbner phenomenon.3,4 We demonstrated a case of a recurrent KA in the setting of recent ED&C. Several reports describe KAs developing after dermatologic surgery, including Mohs micrographic surgery, laser resurfacing, radiation therapy, and after skin grafting.3,4,6 Trauma-induced epidermal injury and dermal inflammation may play a role in postoperative KA formation or recurrence.6
Keratoacanthoma recurrence has been reported in 3% to 8% of cases within a few weeks after treatment, as seen in our current patient.3,5 In our case, the patient photodocumented the regrowth of his lesion (Figure). Treatment of reactive KAs may be therapeutically challenging, as they can form or worsen with repeated surgeries and may require several treatment modalities to eradicate them.4 Treatment options include observation, ED&C, excision, Mohs micrographic surgery, radiation, cryosurgery, laser, isotretinoin, acitretin, imiquimod, 5-fluorouracil, methotrexate, interferon alfa-2b, or bleomycin, to name a few.3,4,7
Combination therapy should be considered in the presence of recurrent and/or aggressive KAs, such as in our case. Our patient has remained disease free after a combination of surgical excision with radiation therapy.
To the Editor:
A 61-year-old man with a medical history of type 2 diabetes mellitus presented to us with a 2.5×3.0-cm erythematous, ulcerated, and exophytic tumor on the right dorsal forearm that had rapidly developed over 2 weeks. A tangential biopsy was performed followed by treatment with electrodesiccation and curettage (ED&C). Histology revealed a squamous cell carcinoma (SCC), keratoacanthoma (KA) type. Over the next 11 days the lesion rapidly recurred and the patient returned with his own daily photodocumentation of the KA’s progression (Figure). The lesion was re-excised with 5-mm margins; histology again revealed SCC, KA type, with deep margin involvement. Chest radiograph revealed findings suspicious for metastatic lesions in the right lung. He was referred to oncology for metastatic workup; positron emission tomography was negative and ultimately the lung lesion was found to be benign. The patient underwent adjuvant radia-tion to the KA resection bed and lymph nodes with minimal side effects. The patient has remained cancer free to date.
Keratoacanthomas are rapidly growing, typically painless, cutaneous neoplasms that often develop on sun-exposed areas. They can occur spontaneously or following trauma and have the propensity to regress with time.1-3 They are described as progressing through 3 clinical stages: rapid proliferation, mature/stable, and involution. However, KAs can be aggressive, becoming locally destructive; therefore, KAs are typically treated to avoid further morbidity. Keratoacanthomas may be considered a subtype of SCC, as some have the potential to become locally destructive and metastasize.3-5 There are reports of spontaneous resolution of KAs over weeks to months, though surgical excision is the gold standard of treatment.3,5
Reactive KA is a subtype that is thought to develop at the site of prior trauma, representing a sort of Köbner phenomenon.3,4 We demonstrated a case of a recurrent KA in the setting of recent ED&C. Several reports describe KAs developing after dermatologic surgery, including Mohs micrographic surgery, laser resurfacing, radiation therapy, and after skin grafting.3,4,6 Trauma-induced epidermal injury and dermal inflammation may play a role in postoperative KA formation or recurrence.6
Keratoacanthoma recurrence has been reported in 3% to 8% of cases within a few weeks after treatment, as seen in our current patient.3,5 In our case, the patient photodocumented the regrowth of his lesion (Figure). Treatment of reactive KAs may be therapeutically challenging, as they can form or worsen with repeated surgeries and may require several treatment modalities to eradicate them.4 Treatment options include observation, ED&C, excision, Mohs micrographic surgery, radiation, cryosurgery, laser, isotretinoin, acitretin, imiquimod, 5-fluorouracil, methotrexate, interferon alfa-2b, or bleomycin, to name a few.3,4,7
Combination therapy should be considered in the presence of recurrent and/or aggressive KAs, such as in our case. Our patient has remained disease free after a combination of surgical excision with radiation therapy.
1. Schwartz R. Keratoacanthoma. J Am Acad Dermatol. 1994;30:1-19.
2. Kingman J. Keratoacanthoma. Arch Dermatol. 1984;20:736-740.
3. Goldberg L, Silapunt S, Beyrau K, et al. Keratoacanthoma as a postoperative complication of skin cancer excision. J Am Acad Dermatol. 2004;50:753-758.
4. Hadley J, Tristani-Firouzi P, Florell S, et al. Case series of multiple recurrent reactive keratoacanthomas developing at surgical margins. Dermatol Surg. 2009;35:2019-2024.
5. Karaa A, Khachemoune A. Keratoacanthoma: a tumor in search of a classification. Int J Dermatol. 2007;46:671-678.
6. Chesnut GT, Maggio KL, Turiansky GW. Letter: re: case series of multiple recurrent reactive keratoacanthomas developing at surgical margins. Dermatol Surg. 2011;37:884-885.
7. Lernia V, Ricci C, Albertini G. Spontaneous regression of keratoacanthoma can be promoted by topical treatment with imiquimod cream. J Eur Acad Dermatol Venereol. 2004;18:626-629.
1. Schwartz R. Keratoacanthoma. J Am Acad Dermatol. 1994;30:1-19.
2. Kingman J. Keratoacanthoma. Arch Dermatol. 1984;20:736-740.
3. Goldberg L, Silapunt S, Beyrau K, et al. Keratoacanthoma as a postoperative complication of skin cancer excision. J Am Acad Dermatol. 2004;50:753-758.
4. Hadley J, Tristani-Firouzi P, Florell S, et al. Case series of multiple recurrent reactive keratoacanthomas developing at surgical margins. Dermatol Surg. 2009;35:2019-2024.
5. Karaa A, Khachemoune A. Keratoacanthoma: a tumor in search of a classification. Int J Dermatol. 2007;46:671-678.
6. Chesnut GT, Maggio KL, Turiansky GW. Letter: re: case series of multiple recurrent reactive keratoacanthomas developing at surgical margins. Dermatol Surg. 2011;37:884-885.
7. Lernia V, Ricci C, Albertini G. Spontaneous regression of keratoacanthoma can be promoted by topical treatment with imiquimod cream. J Eur Acad Dermatol Venereol. 2004;18:626-629.
Promoting Professionalism
Unprofessional behavior in the inpatient setting has the potential to impact care delivery and the quality of trainee's educational experience. These behaviors, from disparaging colleagues to blocking admissions, can negatively impact the learning environment. The learning environment or conditions created by the patient care team's actions play a critical role in the development of trainees.[1, 2] The rising presence of hospitalists in the inpatient setting raises the question of how their actions impact the learning environment. Professional behavior has been defined as a core competency for hospitalists by the Society of Hospital Medicine.[3] Professional behavior of all team members, from faculty to trainee, can impact the learning environment and patient safety.[4, 5] However, few educational materials exist to train faculty and housestaff on recognizing and ameliorating unprofessional behaviors.
A prior assessment regarding hospitalists' lapses in professionalism identified scenarios that demonstrated increased participation by hospitalists at 3 institutions.[6] Participants reported observation or participation in specific unprofessional behaviors and rated their perception of these behaviors. Additional work within those residency environments demonstrated that residents' perceptions of and participation in these behaviors increased throughout training, with environmental characteristics, specifically faculty behavior, influencing trainee professional development and acclimation of these behaviors.[7, 8]
Although overall participation in egregious behavior was low, resident participation in 3 categories of unprofessional behavior increased during internship. Those scenarios included disparaging the emergency room or primary care physician for missed findings or management decisions, blocking or not taking admissions appropriate for the service in question, and misrepresenting a test as urgent to expedite obtaining the test. We developed our intervention focused on these areas to address professionalism lapses that occur during internship. Our earlier work showed faculty role models influenced trainee behavior. For this reason, we provided education to both residents and hospitalists to maximize the impact of the intervention.
We present here a novel, interactive, video‐based workshop curriculum for faculty and trainees that aims to illustrate unprofessional behaviors and outlines the role faculty may play in promoting such behaviors. In addition, we review the result of postworkshop evaluation on intent to change behavior and satisfaction.
METHODS
A grant from the American Board of Internal Medicine Foundation supported this project. The working group that resulted, the Chicago Professional Practice Project and Outcomes, included faculty representation from 3 Chicago‐area hospitals: the University of Chicago, Northwestern University, and NorthShore University HealthSystem. Academic hospitalists at these sites were invited to participate. Each site also has an internal medicine residency program in which hospitalists were expected to attend the teaching service. Given this, resident trainees at all participating sites, and 1 community teaching affiliate program (Mercy Hospital and Medical Center) where academic hospitalists at the University of Chicago rotate, were recruited for participation. Faculty champions were identified for each site, and 1 internal and external faculty representative from the working group served to debrief and facilitate. Trainee workshops were administered by 1 internal and external collaborator, and for the community site, 2 external faculty members. Workshops were held during established educational conference times, and lunch was provided.
Scripts highlighting each of the behaviors identified in the prior survey were developed and peer reviewed for clarity and face validity across the 3 sites. Medical student and resident actors were trained utilizing the finalized scripts, and a performance artist affiliated with the Screen Actors Guild assisted in their preparation for filming. All videos were filmed at the University of Chicago Pritzker School of Medicine Clinical Performance Center. The final videos ranged in length from 4 to 7 minutes and included title, cast, and funding source. As an example, 1 video highlighted the unprofessional behavior of misrepresenting a test as urgent to prioritize one's patient in the queue. This video included a resident, intern, and attending on inpatient rounds during which the resident encouraged the intern to misrepresent the patient's status to expedite obtaining the study and facilitate the patient's discharge. The resident stressed that he would be in the clinic and had many patients to see, highlighting the impact of workload on unprofessional behavior, and aggressively persuaded the intern to sell her test to have it performed the same day. When this occurred, the attending applauded the intern for her strong work.
A moderator guide and debriefing tools were developed to facilitate discussion. The duration of each of the workshops was approximately 60 minutes. After welcoming remarks, participants were provided tools to utilize during the viewing of each video. These checklists noted the roles of those depicted in the video, asked to identify positive or negative behaviors displayed, and included questions regarding how behaviors could be detrimental and how the situation could have been prevented. After viewing the videos, participants divided into small groups to discuss the individual exhibiting the unprofessional behavior, their perceived motivation for said behavior, and its impact on the team culture and patient care. Following a small‐group discussion, large‐group debriefing was performed, addressing the barriers and facilitators to professional behavior. Two videos were shown at each workshop, and participants completed a postworkshop evaluation. Videos chosen for viewing were based upon preworkshop survey results that highlighted areas of concern at that specific site.
Postworkshop paper‐based evaluations assessed participants' perception of displayed behaviors on a Likert‐type scale (1=unprofessional to 5=professional) utilizing items validated in prior work,[6, 7, 8] their level of agreement regarding the impact of video‐based exercises, and intent to change behavior using a Likert‐type scale (1=strongly disagree to 5=strongly agree). A constructed‐response section for comments regarding their experience was included. Descriptive statistics and Wilcoxon rank sum analyses were performed.
RESULTS
Forty‐four academic hospitalist faculty members (44/83; 53%) and 244 resident trainees (244/356; 68%) participated. When queried regarding their perception of the displayed behaviors in the videos, nearly 100% of faculty and trainees felt disparaging the emergency department or primary care physician for missed findings or clinical decisions was somewhat unprofessional or unprofessional. Ninety percent of hospitalists and 93% of trainees rated celebrating a blocked admission as somewhat unprofessional or unprofessional (Table 1).
| Behavior | Faculty Rated as Unprofessional or Somewhat Unprofessional (n = 44) | Housestaff Rated as Unprofessional or Somewhat Unprofessional (n=244) |
|---|---|---|
| ||
| Disparaging the ED/PCP to colleagues for findings later discovered on the floor or patient care management decisions | 95.6% | 97.5% |
| Refusing an admission that could be considered appropriate for your service (eg, blocking) | 86.4% | 95.1% |
| Celebrating a blocked admission | 90.1% | 93.0% |
| Ordering a routine test as urgent to get it expedited | 77.2% | 80.3% |
The scenarios portrayed were well received, with more than 85% of faculty and trainees agreeing that the behaviors displayed were realistic. Those who perceived videos as very realistic were more likely to report intent to change behavior (93% vs 53%, P=0.01). Nearly two‐thirds of faculty and 67% of housestaff expressed agreement that they intended to change behavior based upon the experience (Table 2).
| Evaluation Item | Faculty Level of Agreement (StronglyAgree or Agree) (n=44) | Housestaff Level of Agreement (Strongly Agree or Agree) (n=244) |
|---|---|---|
| The scenarios portrayed in the videos were realistic | 86.4% | 86.9% |
| I will change my behavior as a result of this exercise | 65.9% | 67.2% |
| I feel that this was a useful and effective exercise | 65.9% | 77.1% |
Qualitative comments in the constructed‐response portion of the evaluation noted the effectiveness of the interactive materials. In addition, the need for focused faculty development was identified by 1 respondent who stated: If unprofessional behavior is the unwritten curriculum, there needs to be an explicit, written curriculum to address it. Finally, the aim of facilitating self‐reflection is echoed in this faculty respondent's comment: Always good to be reminded of our behaviors and the influence they have on others and from this resident physician It helps to re‐evaluate how you talk to people.
CONCLUSIONS
Faculty can be a large determinant of the learning environment and impact trainees' professional development.[9] Hospitalists should be encouraged to embrace faculty role‐modeling of effective professional behaviors, especially given their increased presence in the inpatient learning environment. In addition, resident trainees and their behaviors contribute to the learning environment and influence the further professional development of more junior trainees.[10] Targeting professionalism education toward previously identified and prevalent unprofessional behaviors in the inpatient care of patients may serve to affect the most change among providers who practice in this setting. Individualized assessment of the learning environment may aid in identifying common scenarios that may plague a specific learning culture, allowing for relevant and targeted discussion of factors that promote and perpetuate such behaviors.[11]
Interactive, video‐based modules provided an effective way to promote interactive reflection and robust discussion. This model of experiential learning is an effective form of professional development as it engages the learner and stimulates ongoing incorporation of the topics addressed.[12, 13] Creating a shared concrete experience among targeted learners, using the video‐based scenarios, stimulates reflective observation, and ultimately experimentation, or incorporation into practice.[14]
There are several limitations to our evaluation including that we focused solely on academic hospitalist programs, and our sample size for faculty and residents was small. Also, we only addressed a small, though representative, sample of unprofessional behaviors and have not yet linked intervention to actual behavior change. Finally, the script scenarios that we used in this study were not previously published as they were created specifically for this intervention. Validity evidence for these scenarios include that they were based upon the results of earlier work from our institutions and underwent thorough peer review for content and clarity. Further studies will be required to do this. However, we do believe that these are positive findings for utilizing this type of interactive curriculum for professionalism education to promote self‐reflection and behavior change.
Video‐based professionalism education is a feasible, interactive mechanism to encourage self‐reflection and intent to change behavior among faculty and resident physicians. Future study is underway to conduct longitudinal assessments of the learning environments at the participating institutions to assess culture change, perceptions of behaviors, and sustainability of this type of intervention.
Disclosures: The authors acknowledge funding from the American Board of Internal Medicine. The funders had no role in the design of the study; the collection, analysis, and interpretation of the data; or the decision to approve publication of the finished manuscript. Results from this work have been presented at the Midwest Society of General Internal Medicine Regional Meeting, Chicago, Illinois, September 2011; Midwest Society of Hospital Medicine Regional Meeting, Chicago, Illinois, October 2011, and Society of Hospital Medicine Annual Meeting, San Diego, California, April 2012. The authors declare that they do not have any conflicts of interest to disclose.
- Liaison Committee on Medical Education. Functions and structure of a medical school. Available at: http://www.lcme.org/functions.pdf. Accessed October 10, 2012.
- , , , , . Residents' perceptions of their own professionalism and the professionalism of their learning environment. J Grad Med Educ. 2009;1:208–215.
- Society of Hospital Medicine. The core competencies in hospital medicine. http://www.hospitalmedicine.org/Content/NavigationMenu/Education/CoreCurriculum/Core_Competencies.htm. Accessed October 10, 2012.
- The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. 2008;(40):1–3. http://www.jointcommission.org/assets/1/18/SEA_40.pdf. Accessed October 10, 2012.
- , . A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008;34:464–471.
- , , , et al. Participation in unprofessional behaviors among hospitalists: a multicenter study. J Hosp Med. 2012;7(7):543–550.
- , , et al. Participation in and perceptions of unprofessional behaviors among incoming internal medicine interns. JAMA. 2008;300:1132–1134.
- , , , et al., Changes in perception of and participation in unprofessional behaviors during internship. Acad Med. 2010;85:S76–S80.
- , , , et al. Perspective: beyond counting hours: the importance of supervision, professionalism, transitions of care, and workload in residency training. Acad Med. 2012;87(7):883–888.
- , . The role of the student‐teacher relationship in the formation of physicians: the hidden curriculum as process. J Gen Intern Med. 2006;21:S16–S20.
- , , , et al. Evidence for validity of a survey to measure the learning environment for professionalism. Med Teach. 2011;33(12):e683–e688.
- . Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice Hall; 1984.
- , . How can physicians' learning style drive educational planning? Acad Med. 2005;80:680–84.
- , . Twenty years of experience using trigger films as a teaching tool. Acad Med. 2001;76:656–658.
Unprofessional behavior in the inpatient setting has the potential to impact care delivery and the quality of trainee's educational experience. These behaviors, from disparaging colleagues to blocking admissions, can negatively impact the learning environment. The learning environment or conditions created by the patient care team's actions play a critical role in the development of trainees.[1, 2] The rising presence of hospitalists in the inpatient setting raises the question of how their actions impact the learning environment. Professional behavior has been defined as a core competency for hospitalists by the Society of Hospital Medicine.[3] Professional behavior of all team members, from faculty to trainee, can impact the learning environment and patient safety.[4, 5] However, few educational materials exist to train faculty and housestaff on recognizing and ameliorating unprofessional behaviors.
A prior assessment regarding hospitalists' lapses in professionalism identified scenarios that demonstrated increased participation by hospitalists at 3 institutions.[6] Participants reported observation or participation in specific unprofessional behaviors and rated their perception of these behaviors. Additional work within those residency environments demonstrated that residents' perceptions of and participation in these behaviors increased throughout training, with environmental characteristics, specifically faculty behavior, influencing trainee professional development and acclimation of these behaviors.[7, 8]
Although overall participation in egregious behavior was low, resident participation in 3 categories of unprofessional behavior increased during internship. Those scenarios included disparaging the emergency room or primary care physician for missed findings or management decisions, blocking or not taking admissions appropriate for the service in question, and misrepresenting a test as urgent to expedite obtaining the test. We developed our intervention focused on these areas to address professionalism lapses that occur during internship. Our earlier work showed faculty role models influenced trainee behavior. For this reason, we provided education to both residents and hospitalists to maximize the impact of the intervention.
We present here a novel, interactive, video‐based workshop curriculum for faculty and trainees that aims to illustrate unprofessional behaviors and outlines the role faculty may play in promoting such behaviors. In addition, we review the result of postworkshop evaluation on intent to change behavior and satisfaction.
METHODS
A grant from the American Board of Internal Medicine Foundation supported this project. The working group that resulted, the Chicago Professional Practice Project and Outcomes, included faculty representation from 3 Chicago‐area hospitals: the University of Chicago, Northwestern University, and NorthShore University HealthSystem. Academic hospitalists at these sites were invited to participate. Each site also has an internal medicine residency program in which hospitalists were expected to attend the teaching service. Given this, resident trainees at all participating sites, and 1 community teaching affiliate program (Mercy Hospital and Medical Center) where academic hospitalists at the University of Chicago rotate, were recruited for participation. Faculty champions were identified for each site, and 1 internal and external faculty representative from the working group served to debrief and facilitate. Trainee workshops were administered by 1 internal and external collaborator, and for the community site, 2 external faculty members. Workshops were held during established educational conference times, and lunch was provided.
Scripts highlighting each of the behaviors identified in the prior survey were developed and peer reviewed for clarity and face validity across the 3 sites. Medical student and resident actors were trained utilizing the finalized scripts, and a performance artist affiliated with the Screen Actors Guild assisted in their preparation for filming. All videos were filmed at the University of Chicago Pritzker School of Medicine Clinical Performance Center. The final videos ranged in length from 4 to 7 minutes and included title, cast, and funding source. As an example, 1 video highlighted the unprofessional behavior of misrepresenting a test as urgent to prioritize one's patient in the queue. This video included a resident, intern, and attending on inpatient rounds during which the resident encouraged the intern to misrepresent the patient's status to expedite obtaining the study and facilitate the patient's discharge. The resident stressed that he would be in the clinic and had many patients to see, highlighting the impact of workload on unprofessional behavior, and aggressively persuaded the intern to sell her test to have it performed the same day. When this occurred, the attending applauded the intern for her strong work.
A moderator guide and debriefing tools were developed to facilitate discussion. The duration of each of the workshops was approximately 60 minutes. After welcoming remarks, participants were provided tools to utilize during the viewing of each video. These checklists noted the roles of those depicted in the video, asked to identify positive or negative behaviors displayed, and included questions regarding how behaviors could be detrimental and how the situation could have been prevented. After viewing the videos, participants divided into small groups to discuss the individual exhibiting the unprofessional behavior, their perceived motivation for said behavior, and its impact on the team culture and patient care. Following a small‐group discussion, large‐group debriefing was performed, addressing the barriers and facilitators to professional behavior. Two videos were shown at each workshop, and participants completed a postworkshop evaluation. Videos chosen for viewing were based upon preworkshop survey results that highlighted areas of concern at that specific site.
Postworkshop paper‐based evaluations assessed participants' perception of displayed behaviors on a Likert‐type scale (1=unprofessional to 5=professional) utilizing items validated in prior work,[6, 7, 8] their level of agreement regarding the impact of video‐based exercises, and intent to change behavior using a Likert‐type scale (1=strongly disagree to 5=strongly agree). A constructed‐response section for comments regarding their experience was included. Descriptive statistics and Wilcoxon rank sum analyses were performed.
RESULTS
Forty‐four academic hospitalist faculty members (44/83; 53%) and 244 resident trainees (244/356; 68%) participated. When queried regarding their perception of the displayed behaviors in the videos, nearly 100% of faculty and trainees felt disparaging the emergency department or primary care physician for missed findings or clinical decisions was somewhat unprofessional or unprofessional. Ninety percent of hospitalists and 93% of trainees rated celebrating a blocked admission as somewhat unprofessional or unprofessional (Table 1).
| Behavior | Faculty Rated as Unprofessional or Somewhat Unprofessional (n = 44) | Housestaff Rated as Unprofessional or Somewhat Unprofessional (n=244) |
|---|---|---|
| ||
| Disparaging the ED/PCP to colleagues for findings later discovered on the floor or patient care management decisions | 95.6% | 97.5% |
| Refusing an admission that could be considered appropriate for your service (eg, blocking) | 86.4% | 95.1% |
| Celebrating a blocked admission | 90.1% | 93.0% |
| Ordering a routine test as urgent to get it expedited | 77.2% | 80.3% |
The scenarios portrayed were well received, with more than 85% of faculty and trainees agreeing that the behaviors displayed were realistic. Those who perceived videos as very realistic were more likely to report intent to change behavior (93% vs 53%, P=0.01). Nearly two‐thirds of faculty and 67% of housestaff expressed agreement that they intended to change behavior based upon the experience (Table 2).
| Evaluation Item | Faculty Level of Agreement (StronglyAgree or Agree) (n=44) | Housestaff Level of Agreement (Strongly Agree or Agree) (n=244) |
|---|---|---|
| The scenarios portrayed in the videos were realistic | 86.4% | 86.9% |
| I will change my behavior as a result of this exercise | 65.9% | 67.2% |
| I feel that this was a useful and effective exercise | 65.9% | 77.1% |
Qualitative comments in the constructed‐response portion of the evaluation noted the effectiveness of the interactive materials. In addition, the need for focused faculty development was identified by 1 respondent who stated: If unprofessional behavior is the unwritten curriculum, there needs to be an explicit, written curriculum to address it. Finally, the aim of facilitating self‐reflection is echoed in this faculty respondent's comment: Always good to be reminded of our behaviors and the influence they have on others and from this resident physician It helps to re‐evaluate how you talk to people.
CONCLUSIONS
Faculty can be a large determinant of the learning environment and impact trainees' professional development.[9] Hospitalists should be encouraged to embrace faculty role‐modeling of effective professional behaviors, especially given their increased presence in the inpatient learning environment. In addition, resident trainees and their behaviors contribute to the learning environment and influence the further professional development of more junior trainees.[10] Targeting professionalism education toward previously identified and prevalent unprofessional behaviors in the inpatient care of patients may serve to affect the most change among providers who practice in this setting. Individualized assessment of the learning environment may aid in identifying common scenarios that may plague a specific learning culture, allowing for relevant and targeted discussion of factors that promote and perpetuate such behaviors.[11]
Interactive, video‐based modules provided an effective way to promote interactive reflection and robust discussion. This model of experiential learning is an effective form of professional development as it engages the learner and stimulates ongoing incorporation of the topics addressed.[12, 13] Creating a shared concrete experience among targeted learners, using the video‐based scenarios, stimulates reflective observation, and ultimately experimentation, or incorporation into practice.[14]
There are several limitations to our evaluation including that we focused solely on academic hospitalist programs, and our sample size for faculty and residents was small. Also, we only addressed a small, though representative, sample of unprofessional behaviors and have not yet linked intervention to actual behavior change. Finally, the script scenarios that we used in this study were not previously published as they were created specifically for this intervention. Validity evidence for these scenarios include that they were based upon the results of earlier work from our institutions and underwent thorough peer review for content and clarity. Further studies will be required to do this. However, we do believe that these are positive findings for utilizing this type of interactive curriculum for professionalism education to promote self‐reflection and behavior change.
Video‐based professionalism education is a feasible, interactive mechanism to encourage self‐reflection and intent to change behavior among faculty and resident physicians. Future study is underway to conduct longitudinal assessments of the learning environments at the participating institutions to assess culture change, perceptions of behaviors, and sustainability of this type of intervention.
Disclosures: The authors acknowledge funding from the American Board of Internal Medicine. The funders had no role in the design of the study; the collection, analysis, and interpretation of the data; or the decision to approve publication of the finished manuscript. Results from this work have been presented at the Midwest Society of General Internal Medicine Regional Meeting, Chicago, Illinois, September 2011; Midwest Society of Hospital Medicine Regional Meeting, Chicago, Illinois, October 2011, and Society of Hospital Medicine Annual Meeting, San Diego, California, April 2012. The authors declare that they do not have any conflicts of interest to disclose.
Unprofessional behavior in the inpatient setting has the potential to impact care delivery and the quality of trainee's educational experience. These behaviors, from disparaging colleagues to blocking admissions, can negatively impact the learning environment. The learning environment or conditions created by the patient care team's actions play a critical role in the development of trainees.[1, 2] The rising presence of hospitalists in the inpatient setting raises the question of how their actions impact the learning environment. Professional behavior has been defined as a core competency for hospitalists by the Society of Hospital Medicine.[3] Professional behavior of all team members, from faculty to trainee, can impact the learning environment and patient safety.[4, 5] However, few educational materials exist to train faculty and housestaff on recognizing and ameliorating unprofessional behaviors.
A prior assessment regarding hospitalists' lapses in professionalism identified scenarios that demonstrated increased participation by hospitalists at 3 institutions.[6] Participants reported observation or participation in specific unprofessional behaviors and rated their perception of these behaviors. Additional work within those residency environments demonstrated that residents' perceptions of and participation in these behaviors increased throughout training, with environmental characteristics, specifically faculty behavior, influencing trainee professional development and acclimation of these behaviors.[7, 8]
Although overall participation in egregious behavior was low, resident participation in 3 categories of unprofessional behavior increased during internship. Those scenarios included disparaging the emergency room or primary care physician for missed findings or management decisions, blocking or not taking admissions appropriate for the service in question, and misrepresenting a test as urgent to expedite obtaining the test. We developed our intervention focused on these areas to address professionalism lapses that occur during internship. Our earlier work showed faculty role models influenced trainee behavior. For this reason, we provided education to both residents and hospitalists to maximize the impact of the intervention.
We present here a novel, interactive, video‐based workshop curriculum for faculty and trainees that aims to illustrate unprofessional behaviors and outlines the role faculty may play in promoting such behaviors. In addition, we review the result of postworkshop evaluation on intent to change behavior and satisfaction.
METHODS
A grant from the American Board of Internal Medicine Foundation supported this project. The working group that resulted, the Chicago Professional Practice Project and Outcomes, included faculty representation from 3 Chicago‐area hospitals: the University of Chicago, Northwestern University, and NorthShore University HealthSystem. Academic hospitalists at these sites were invited to participate. Each site also has an internal medicine residency program in which hospitalists were expected to attend the teaching service. Given this, resident trainees at all participating sites, and 1 community teaching affiliate program (Mercy Hospital and Medical Center) where academic hospitalists at the University of Chicago rotate, were recruited for participation. Faculty champions were identified for each site, and 1 internal and external faculty representative from the working group served to debrief and facilitate. Trainee workshops were administered by 1 internal and external collaborator, and for the community site, 2 external faculty members. Workshops were held during established educational conference times, and lunch was provided.
Scripts highlighting each of the behaviors identified in the prior survey were developed and peer reviewed for clarity and face validity across the 3 sites. Medical student and resident actors were trained utilizing the finalized scripts, and a performance artist affiliated with the Screen Actors Guild assisted in their preparation for filming. All videos were filmed at the University of Chicago Pritzker School of Medicine Clinical Performance Center. The final videos ranged in length from 4 to 7 minutes and included title, cast, and funding source. As an example, 1 video highlighted the unprofessional behavior of misrepresenting a test as urgent to prioritize one's patient in the queue. This video included a resident, intern, and attending on inpatient rounds during which the resident encouraged the intern to misrepresent the patient's status to expedite obtaining the study and facilitate the patient's discharge. The resident stressed that he would be in the clinic and had many patients to see, highlighting the impact of workload on unprofessional behavior, and aggressively persuaded the intern to sell her test to have it performed the same day. When this occurred, the attending applauded the intern for her strong work.
A moderator guide and debriefing tools were developed to facilitate discussion. The duration of each of the workshops was approximately 60 minutes. After welcoming remarks, participants were provided tools to utilize during the viewing of each video. These checklists noted the roles of those depicted in the video, asked to identify positive or negative behaviors displayed, and included questions regarding how behaviors could be detrimental and how the situation could have been prevented. After viewing the videos, participants divided into small groups to discuss the individual exhibiting the unprofessional behavior, their perceived motivation for said behavior, and its impact on the team culture and patient care. Following a small‐group discussion, large‐group debriefing was performed, addressing the barriers and facilitators to professional behavior. Two videos were shown at each workshop, and participants completed a postworkshop evaluation. Videos chosen for viewing were based upon preworkshop survey results that highlighted areas of concern at that specific site.
Postworkshop paper‐based evaluations assessed participants' perception of displayed behaviors on a Likert‐type scale (1=unprofessional to 5=professional) utilizing items validated in prior work,[6, 7, 8] their level of agreement regarding the impact of video‐based exercises, and intent to change behavior using a Likert‐type scale (1=strongly disagree to 5=strongly agree). A constructed‐response section for comments regarding their experience was included. Descriptive statistics and Wilcoxon rank sum analyses were performed.
RESULTS
Forty‐four academic hospitalist faculty members (44/83; 53%) and 244 resident trainees (244/356; 68%) participated. When queried regarding their perception of the displayed behaviors in the videos, nearly 100% of faculty and trainees felt disparaging the emergency department or primary care physician for missed findings or clinical decisions was somewhat unprofessional or unprofessional. Ninety percent of hospitalists and 93% of trainees rated celebrating a blocked admission as somewhat unprofessional or unprofessional (Table 1).
| Behavior | Faculty Rated as Unprofessional or Somewhat Unprofessional (n = 44) | Housestaff Rated as Unprofessional or Somewhat Unprofessional (n=244) |
|---|---|---|
| ||
| Disparaging the ED/PCP to colleagues for findings later discovered on the floor or patient care management decisions | 95.6% | 97.5% |
| Refusing an admission that could be considered appropriate for your service (eg, blocking) | 86.4% | 95.1% |
| Celebrating a blocked admission | 90.1% | 93.0% |
| Ordering a routine test as urgent to get it expedited | 77.2% | 80.3% |
The scenarios portrayed were well received, with more than 85% of faculty and trainees agreeing that the behaviors displayed were realistic. Those who perceived videos as very realistic were more likely to report intent to change behavior (93% vs 53%, P=0.01). Nearly two‐thirds of faculty and 67% of housestaff expressed agreement that they intended to change behavior based upon the experience (Table 2).
| Evaluation Item | Faculty Level of Agreement (StronglyAgree or Agree) (n=44) | Housestaff Level of Agreement (Strongly Agree or Agree) (n=244) |
|---|---|---|
| The scenarios portrayed in the videos were realistic | 86.4% | 86.9% |
| I will change my behavior as a result of this exercise | 65.9% | 67.2% |
| I feel that this was a useful and effective exercise | 65.9% | 77.1% |
Qualitative comments in the constructed‐response portion of the evaluation noted the effectiveness of the interactive materials. In addition, the need for focused faculty development was identified by 1 respondent who stated: If unprofessional behavior is the unwritten curriculum, there needs to be an explicit, written curriculum to address it. Finally, the aim of facilitating self‐reflection is echoed in this faculty respondent's comment: Always good to be reminded of our behaviors and the influence they have on others and from this resident physician It helps to re‐evaluate how you talk to people.
CONCLUSIONS
Faculty can be a large determinant of the learning environment and impact trainees' professional development.[9] Hospitalists should be encouraged to embrace faculty role‐modeling of effective professional behaviors, especially given their increased presence in the inpatient learning environment. In addition, resident trainees and their behaviors contribute to the learning environment and influence the further professional development of more junior trainees.[10] Targeting professionalism education toward previously identified and prevalent unprofessional behaviors in the inpatient care of patients may serve to affect the most change among providers who practice in this setting. Individualized assessment of the learning environment may aid in identifying common scenarios that may plague a specific learning culture, allowing for relevant and targeted discussion of factors that promote and perpetuate such behaviors.[11]
Interactive, video‐based modules provided an effective way to promote interactive reflection and robust discussion. This model of experiential learning is an effective form of professional development as it engages the learner and stimulates ongoing incorporation of the topics addressed.[12, 13] Creating a shared concrete experience among targeted learners, using the video‐based scenarios, stimulates reflective observation, and ultimately experimentation, or incorporation into practice.[14]
There are several limitations to our evaluation including that we focused solely on academic hospitalist programs, and our sample size for faculty and residents was small. Also, we only addressed a small, though representative, sample of unprofessional behaviors and have not yet linked intervention to actual behavior change. Finally, the script scenarios that we used in this study were not previously published as they were created specifically for this intervention. Validity evidence for these scenarios include that they were based upon the results of earlier work from our institutions and underwent thorough peer review for content and clarity. Further studies will be required to do this. However, we do believe that these are positive findings for utilizing this type of interactive curriculum for professionalism education to promote self‐reflection and behavior change.
Video‐based professionalism education is a feasible, interactive mechanism to encourage self‐reflection and intent to change behavior among faculty and resident physicians. Future study is underway to conduct longitudinal assessments of the learning environments at the participating institutions to assess culture change, perceptions of behaviors, and sustainability of this type of intervention.
Disclosures: The authors acknowledge funding from the American Board of Internal Medicine. The funders had no role in the design of the study; the collection, analysis, and interpretation of the data; or the decision to approve publication of the finished manuscript. Results from this work have been presented at the Midwest Society of General Internal Medicine Regional Meeting, Chicago, Illinois, September 2011; Midwest Society of Hospital Medicine Regional Meeting, Chicago, Illinois, October 2011, and Society of Hospital Medicine Annual Meeting, San Diego, California, April 2012. The authors declare that they do not have any conflicts of interest to disclose.
- Liaison Committee on Medical Education. Functions and structure of a medical school. Available at: http://www.lcme.org/functions.pdf. Accessed October 10, 2012.
- , , , , . Residents' perceptions of their own professionalism and the professionalism of their learning environment. J Grad Med Educ. 2009;1:208–215.
- Society of Hospital Medicine. The core competencies in hospital medicine. http://www.hospitalmedicine.org/Content/NavigationMenu/Education/CoreCurriculum/Core_Competencies.htm. Accessed October 10, 2012.
- The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. 2008;(40):1–3. http://www.jointcommission.org/assets/1/18/SEA_40.pdf. Accessed October 10, 2012.
- , . A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008;34:464–471.
- , , , et al. Participation in unprofessional behaviors among hospitalists: a multicenter study. J Hosp Med. 2012;7(7):543–550.
- , , et al. Participation in and perceptions of unprofessional behaviors among incoming internal medicine interns. JAMA. 2008;300:1132–1134.
- , , , et al., Changes in perception of and participation in unprofessional behaviors during internship. Acad Med. 2010;85:S76–S80.
- , , , et al. Perspective: beyond counting hours: the importance of supervision, professionalism, transitions of care, and workload in residency training. Acad Med. 2012;87(7):883–888.
- , . The role of the student‐teacher relationship in the formation of physicians: the hidden curriculum as process. J Gen Intern Med. 2006;21:S16–S20.
- , , , et al. Evidence for validity of a survey to measure the learning environment for professionalism. Med Teach. 2011;33(12):e683–e688.
- . Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice Hall; 1984.
- , . How can physicians' learning style drive educational planning? Acad Med. 2005;80:680–84.
- , . Twenty years of experience using trigger films as a teaching tool. Acad Med. 2001;76:656–658.
- Liaison Committee on Medical Education. Functions and structure of a medical school. Available at: http://www.lcme.org/functions.pdf. Accessed October 10, 2012.
- , , , , . Residents' perceptions of their own professionalism and the professionalism of their learning environment. J Grad Med Educ. 2009;1:208–215.
- Society of Hospital Medicine. The core competencies in hospital medicine. http://www.hospitalmedicine.org/Content/NavigationMenu/Education/CoreCurriculum/Core_Competencies.htm. Accessed October 10, 2012.
- The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. 2008;(40):1–3. http://www.jointcommission.org/assets/1/18/SEA_40.pdf. Accessed October 10, 2012.
- , . A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008;34:464–471.
- , , , et al. Participation in unprofessional behaviors among hospitalists: a multicenter study. J Hosp Med. 2012;7(7):543–550.
- , , et al. Participation in and perceptions of unprofessional behaviors among incoming internal medicine interns. JAMA. 2008;300:1132–1134.
- , , , et al., Changes in perception of and participation in unprofessional behaviors during internship. Acad Med. 2010;85:S76–S80.
- , , , et al. Perspective: beyond counting hours: the importance of supervision, professionalism, transitions of care, and workload in residency training. Acad Med. 2012;87(7):883–888.
- , . The role of the student‐teacher relationship in the formation of physicians: the hidden curriculum as process. J Gen Intern Med. 2006;21:S16–S20.
- , , , et al. Evidence for validity of a survey to measure the learning environment for professionalism. Med Teach. 2011;33(12):e683–e688.
- . Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice Hall; 1984.
- , . How can physicians' learning style drive educational planning? Acad Med. 2005;80:680–84.
- , . Twenty years of experience using trigger films as a teaching tool. Acad Med. 2001;76:656–658.