A Tale of Two Countries: Innovation and Collaboration Aimed at Changing the Culture of Medicine in Uruguay.

This is a case study of a program to address professionalism at the Universidad de la República in Uruguay. We describe a five-year ongoing international collaboration. Relevant characteristics of the context, the program components, activities, and results were analyzed. The expected outcomes were to introduce standards of professional practices in the curricula of medical students and residents and the implementation of a program that might lead to a significant change in the culture of medicine in the University. Traditional didactics, interactive theater, and professional development workshops, issues such as teamwork and communication, professional behavior, and the culture of medicine, and physician wellness were addressed. A total of 359 faculty members, general practitioners, stakeholders, and other healthcare professionals (nurses, psychologists, social workers) participated in the intervention. The process led to specific achievements including new content in the curricula, the use of educational innovations to address issues of professionalism, a growing institutional culture of accountability, and the establishment of new rules and regulations. The strategies and interventions followed in the case of Uruguay can serve as a model to other developing countries to promote physician professionalism, wellness, and joy.

Substance use and attitudes on professional conduct among medical students: a single-institution study.

OBJECTIVE: This study sought to examine how specific substance-use behavior, including nonmedical prescription stimulant (NPS) use, among U.S. medical students correlates with their attitudes and beliefs toward professionalism. METHOD: An anonymous survey was distributed to all medical students at a private medical university (46% response rate). Participants were asked to report alcohol and marijuana use patterns, NPS use, stress levels, and history of suicidal ideation. RESULTS: Over one-third of medical students reported excessive drinking during the past month, and 5% reported NPS use during the past year. Students who endorsed such behavior were significantly less likely to view it as unprofessional and warranting intervention. A large number of students seemed unfamiliar with how to help a classmate with an NPS use problem. CONCLUSIONS: Medical students' substance use behaviors appear to influence attitudes and beliefs toward professional issues regarding substance use.

Transformative learning in a professional development course aimed at addressing disruptive physician behavior: a composite case study.

Disruptive physician behavior presents a challenge to the academic medical center. Such behaviors threaten the learning environment through increasing staff conflict, role modeling poor behaviors to trainees, and, ultimately, posing a risk to patient safety. Given that these physicians are often respected and valued for their clinical skills, many institutions struggle with how to best manage their behaviors. The authors present a composite case study of an academic physician referred to a professional development program for his disruptive behavior. They outline how transformative learning was applied to the development of concrete learning objectives, activities, and assessments for a curriculum aimed at promoting behavior change. Important themes include a safe group process in which the physician's assumptions are critically examined so that through experiential exercises and reflection, new roles, skills, and behaviors are learned, explored, and practiced. Timely feedback to the physician from the institution, colleagues, and administrators is critical to the physician's understanding of the impact of his or her behavior. Ultimately, the physician returns to practice demonstrating more professional behavior. Implications for medical education, prevention, and other professional development programs are discussed.

The role of family of origin in physicians referred to a CME course.

Few studies exist which look at psychological factors associated with physician sexual misconduct. In this study, we explore family dysfunction as a possible risk factor associated with physician sexual misconduct. Six hundred thirteen physicians referred to a continuing medical education (CME) course for sexual misconduct were administered the FACES-II survey, a validated and reliable measure of family dynamics. The survey was part of a self-learning activity. We collected data from February 2000 to February 2009. Participants were predominantly white, middle-aged males who represented the full range of medical specialties. Their results were compared against a sample of 177 physicians. The FACES-II is a self-report test that measures family of origin (the family in which one was raised) dynamics on two dimensions (1) flexibility, ranging from too flexible (chaotic) to not flexible enough (rigid) and (2) cohesion ranging from too close (enmeshed) to not close enough (disengaged). The most common family pattern observed among physicians accused of sexual misconduct was rigid flexibility paired with disengaged cohesion, indicative of unhealthy family functioning. This pattern was significantly different than the pattern observed in the comparison group. Physicians who engage in sexual misconduct are more likely to have family of origin dysfunction. Ethics is developmental and learned in one's family of origin. Family of origin dynamics may be one risk factor predisposing one to ethical violations. These findings have important implications for screening, education, and treatment across the medical education continuum.

Drug use and receipt of highly active antiretroviral therapy among HIV-infected persons in two U.S. clinic cohorts.

OBJECTIVE: Drug use and receipt of highly active antiretroviral therapy (HAART) were assessed in HIV-infected persons from the Comprehensive Care Center (CCC; Nashville, TN) and Johns Hopkins University HIV Clinic (JHU; Baltimore, MD) between 1999 and 2005. METHODS: Participants with and without injection drug use (IDU) history in the CCC and JHU cohorts were evaluated. Additional analysis of persons with history of IDU, non-injection drug use (NIDU), and no drug use from CCC were performed. Activity of IDU and NIDU also was assessed for the CCC cohort. HAART use and time on HAART were analyzed according to drug use category and site of care. RESULTS: 1745 persons were included from CCC: 268 (15%) with IDU history and 796 (46%) with NIDU history. 1977 persons were included from JHU: 731 (35%) with IDU history. Overall, the cohorts differed in IDU risk factor rates, age, race, sex, and time in follow-up. In multivariate analyses, IDU was associated with decreased HAART receipt overall (OR = 0.61, 95% CI: [0.45-0.84] and OR = 0.58, 95% CI: [0.46-0.73], respectively for CCC and JHU) and less time on HAART at JHU (0.70, [0.55-0.88]), but not statistically associated with time on HAART at CCC (0.78, [0.56-1.09]). NIDU was independently associated with decreased HAART receipt (0.62, [0.47-0.81]) and less time on HAART (0.66, [0.52-0.85]) at CCC. These associations were not altered significantly whether patients at CCC were categorized according to historical drug use or drug use during the study period. CONCLUSIONS: Persons with IDU history from both clinic populations were less likely to receive HAART and tended to have less cumulative time on HAART. Effects of NIDU were similar to IDU at CCC. NIDU without IDU is an important contributor to HAART utilization.

The relationship between injection and noninjection drug use and HIV disease progression.

BACKGROUND: Injection drug use is associated with poor HIV outcomes even among persons receiving highly active antiretroviral therapy (HAART), but there are limited data on the relationship between noninjection drug use and HIV disease progression. METHODS: We conducted an observational study of HIV-infected persons entering care between January 1, 1999, and December 31, 2004, with follow-up through December 31, 2005. RESULTS: There were 1,712 persons in the study cohort: 262 with a history of injection drug use, 785 with a history of noninjection drug use, and 665 with no history of drug use; 56% were White, and 24% were females. Median follow-up was 2.1 years, 33% had HAART prior to first visit, 40% initiated first HAART during the study period, and 306 (17.9%) had an AIDS-defining event or died. Adjusting for gender, age, race, prior antiretroviral use, CD4 cell count, and HIV-1 RNA, patients with a history of injection drug use were more likely to advance to AIDS or death than nonusers (adjusted hazard ratio [HR] = 1.97, 95% confidence interval [CI] = 1.43-2.70, p < .01). There was no statistically significant difference of disease progression between noninjection drug users and nonusers (HR = 1.19, 95% CI = 0.92-1.56, p = .19). An analysis among the subgroup who initiated their first HAART during the study period (n = 687) showed a similar pattern (injection drug users: HR = 1.83, 95% CI = 1.09-3.06, p = .02; noninjection drug users: HR = 1.21, 95% CI = 0.81-1.80, p = .35). Seventy-four patients had active injection drug use during the study period, 768 active noninjection drug use, and 870 no substance use. Analyses based on active drug use during the study period did not substantially differ from those based on history of drug use. CONCLUSIONS: This study shows no relationship between noninjection drug use and HIV disease progression. This study is limited by using history of drug use and combining different types of drugs. Further studies ascertaining specific type and extent of noninjection drug use prospectively, and with longer follow-up, are needed.

A continuing medical education approach to improve sexual boundaries of physicians.

INTRODUCTION: Physician sexual boundary violations are a public health problem. Few resources exist to address physicians who behave inappropriately with patients. In response, the Center for Professional Health at Vanderbilt University developed a three-day continuing medical education (CME) course about proper professional sexual boundaries in 2000. The mission of this CME course is to offer an educational intervention for those physicians whose professional sexual misconduct has required such education as part of a larger accountability sanction. Previous studies suggest that when such education is offered through non-traditional medical education, it is effective in promoting behavioral change. This paper describes the three-day intensive educational experience offered by a CME course with a particular focus on lessons learned from more than 7 years of experience working with these physicians. METHODS: Over 381 physicians from 40 states and Canada have attended. Data about course participants was collected by self-report and aggregated into three categories: demographics, results of assessment tools administered, and quality of the experience. Assessment tools used include the Family Adaptability and Cohesion Evaluation Scale II (FACES II), the Trauma Symptom Inventory (TSI) and the Sexual Addiction Screening Test (SAST). RESULTS: Most physicians were referred to the course from physician health programs and boards of medical examiners. The majority of physician participants were male and in group or solo practice. A full range of medical specialties was represented with most physicians being internists, psychiatrists, obstetricians and surgeons. Results of assessment tools administered indicate that physicians referred for sexual boundary violations often come from dysfunctional families and demonstrate symptoms indicative of trauma related problems and possible sexual addiction. Physician attendees report being highly satisfied with the new knowledge attained in this course. DISCUSSION: Curriculum aimed at addressing sexual boundary violations should address family of origin issues, trauma coping skills and sexual acting out. Satisfaction data continues to support a small group, experiential, and confidential format as an effective means for intervention. CONCLUSION: A CME course offers a model for future training experiences for faculty, residents, medical students and community physicians to teach skills that may help prevent and remediate professional boundary crossings.

A CME course aimed at addressing disruptive physician behavior.

Examine the results of a study of physicians with disruptive behavior who went through a special training program to help them better control their anger and outbursts.