December 2018
From the Editor - Janet de Groot
Dear Readers,

Healthcare learners, the next generation, are central to articles in our first anniversary issue of the Professionalism Formation newsletter.
The authors present the use of various modalities to facilitate education for ethics and professionalism.
In the area of boundaries, Fernanda Patrícia Soares Souto Novaes is effectively supporting medical students’ reflection on various aspects of boundaries in patient relationships. Videos are used to introduce potential real-life scenarios that challenge us in maintaining respectful boundaries. In a safe space, the students respond through dramatization and making their own videos to enhance their capacity to address boundary issues.
Books remain central to our continual learning. This month, Rebekah Apple provides a book review facilitated by an interview with the author Ira Bedzow. His book “ Giving Voice to Values as a Professional Physician: An Introduction to Medical Ethics” addresses the hierarchy in medicine and how best to educate medical students to convey their values when they observe behavior that does not fit their perspectives of professionalism.
Reflection and narratives are also valuable to learning about professionalism and our professional identity. A medical educator and scholar, Marco Antonio de Carvalho Filho bravely role models reflection through his narrative on the challenges of supporting the educational alliance when one is time pressured in providing patient care. He shows how taking the time and reflective space to consider when we are not at our best, that solutions can be developed for the next time.
All the best in the holiday season. Thank you to all of our colleagues who continue to work during this time.

Janet de Groot, MD, FRCPC, M.Med.Sc.- Founding Editor, APHC-PFO Newsletter
APHC Annual Meeting
May 15 to 17, 2019
New Orleans
Social Justice and Professionalism:
Exploring the Challenges and Opportunities

The 2019 APHC annual meeting will explore social justice in health professions education and practice. Social justice is emphasized as a key value in The Charter on Medical Professionalism, Code of Ethics for Social Work, and the Code of Ethics for Nursing.

We will address:
• What does our experience with healthcare in the 21st century tell us about successes, failures, and opportunities in embracing social justice as a professional value?
• What is our path moving forward?

Keynote Speakers Announced
Thomas LaVeist, Ph.D.
Dean and Professor
School of Public Health and Tropical
Medicine, Tulane University
Rebekah Gee, M.D.
Secretary, Louisiana Department of Health
Camille Burnett, R.N., Ph.D.
Associate Professor of Nursing
Academic Director,
Community Engagement and Partnerships,

University of Virginia School of Nursing
Ayelet Kuper, M.D., DPhil
Associate Director, Wilson Centre;

Associate Professor, Department of Medicine,

University of Toronto
Contribution of Videos to the Development of Professional Boundaries in the Doctor-Patient Relationship. Experience Report
by Fernanda Patrícia Soares Souto Novaes
The doctor-patient relationship has peculiarities inherent to the affection that permeates the individuals involved. Physicians should balance professional boundaries and empathy in the doctor-patient relationship. Medical students can develop profiles for “behavior within professional boundaries,” while continuing to show trust, esteem and affection for their patients.
Our objective here is to report on an innovative, educational experience in a Brazilian institution. We made use of the Portuguese version of an online American medical education program which included videos, in-person classes and videos produced by students, to address the module “Professional Boundaries.”
We report on a teaching-learning experience in an elective course titled Communication in Healthcare. It is offered every six months during the fourth year of undergraduate study in Medicine at the Federal University of São Francisco Valley (UNIVASF, Petrolina, Pernambuco, Brazil). The starting point of this class was the “DocComBrasil,” an audiovisual educational teaching tool used to stimulate basic and advanced communication skills in health professionals. It was created by professors from Drexel University in Philadelphia and 10 modules were translated to Portuguese by professors from Santa Catarina University in Brazil. Twenty medical students enrolled in this class formed a group for debate and reflection on “Professional Boundaries.” The students from 2015.2 class produced four educational videos on the following dilemmas in the doctor-patient relationship: self-revelation, gifts, invitations and touch. This discussion resulted in different perspectives on professional behavior.
The video about “self-revelation” showed a consultation during which a patient asked the physician if he had ever practiced unprotected sex. Students reflected on the extent to which it would be beneficial for the doctor to disclose such personal information to the patient. Most of the participants observed that kindly declining to reveal personal information would be the best attitude, unless the information would benefit the patient.
In the video about “gifts,” the acts of receiving and giving gifts were analyzed. Students dramatized with monetary gifts. One part of the class did not agree to accept the gifts, whereas the other part thought that it would be acceptable, provided it resulted in something useful to benefit other professionals and patients, such as a coffee maker.
Regarding the video on “invitations,” students staged a scene in which a patient invites the doctor to go out. Most of the students thought that socializing with patients outside the office could be interpreted as a dubious relationship and that it would be wise to avoid or to pass the case on to another doctor.
Regarding “touches,” the students enacted a scene in which a patient hugs a doctor from another culture. It has been argued that people react differently to hugs and other forms of touch depending on their culture. Brazilian culture allows embracing respectfully while standing within professional boundaries and recognizes that hugs can be therapeutic.
Combining online classes, watching and producing videos and clinical situations on medical professionalism makes it possible for students to anticipate clinical experiences in the classroom environment and improves their abilities to place themselves in other people’s situations. It stimulates communication skills, decision-making, empathy and ethical principles to strengthen professional identity and is an excellent teaching-learning strategy in medical education.

Fernanda Patrícia Soares S. Novaes, Physician, PhD(c), Institute of Integral Medicine Professor Fernando Figueira (IMIP), and National Institute of Social Security (INSS) – Brazil


The English version of DocComBrasil is available at . For a free 30-day trial subscription, contact Barbara Lewis at
Educational Alliance and the Challenges of Role Modeling
by Marco Antonio de Carvalho Filho
2 am. Emergency Department. After seeing more than 50 patients in 7 hours, I am tired. The intern comes to me with another case to discuss. He is a bright young man, 22 years old, also tired, and fails to provide me with organized data so that I can reason about the woman who supposedly is fighting to breathe. My eyebrows blow with frustration; I let the anger step in and eat my words in silence. Next second, with the file in my hands, I go to the office to interview the patient by myself. The intern comes along and, inside the examination room, he looks to the ground; his soul is not there anymore. I crushed him. I try to forgive myself, after all, it is 2 am.

Role modeling is a tough job. We need to deal with the patient, the team, the environment, the students and the residents while guaranteeing patient safety and the learning outcomes. We need to solve conflicts, make decisions, balance values, inspire and remediate. We need to smile, be moral and bring hope. Do you already feel the pressure? And I did not mention the emotions involved. Paraphrasing the great Stan Lee: With great power, comes great responsibility, and a runaway truck loaded with all sort of emotions.

Let s be honest: within those complex tasks, mistakes and lapses are commonplace. Considering that patients well-being and safety are our primary concern, neglecting students and residents needs is a real risk. Recently, Telio et all (1) offered the concept of the educational alliance as a strategy to ground learning encounters in the real clinical scenario and improve feedback acceptance by students and residents. The educational alliance concept encourages teachers to establish a relationship with students based on trust and credibility. Building a relationship depends on teachers acknowledging the presence and the needs of the students while exploring their worldviews, opinions and ideas. Trust requires teachers to commit first and foremost with students development explicitly, putting aside any hidden agenda. Credibility is related to teachers expertise and beneficence towards students. Admittedly, a relationship based on respect, as demanded by the educational alliance principle, needs time to grow and is easier to establish during longitudinal programs.

Does the educational alliance principle work for short clinical rotations? We can compare a learning encounter in a short clinical rotation with a clinical consultation in the emergency department. It is always challenging to build trust during brief clinical relationships. As an emergency physician, I had to develop a strategy to establish trust in the middle of a complex, sometimes chaotic and uncontrollable environment. It goes without saying that time is a rare commodity in the Emergency Department. My secret is to be honest, always explicit, as objective as possible and empathic. Above all, I had to learn to say, I am sorry, with my soul, with the message coming directly from my heart. If during a consultation, we say or accidentally do something improper, the person in front of us will communicate with their eyebrows, clearly showing that we made a mistake. We need to be ready to read the message. We need to be ready to apologize and to restart. We can do the same with students.

In a short clinical rotation, clinical teachers can start with an open conversation to set the rules of engagement. At the beginning of the day, clinical teachers may invite students to share their particular learning goals. Then, teachers can be explicit about their methods, feedback style, learning goals, and commitment to students development. Teachers can also share the characteristics of the clinical activities that were planned, and how the clinical activities may influence the learning activities and outcomes. We should not forget that medical students want to become doctors; they also know that patients needs come first. At the end of the clinical activities, we can provide a wrap up session to address issues that were not solved or were misunderstood. Eventual tensions can be relaxed by a debriefing session in which the teacher steps down or reduces the traditional hierarchy to communicate with students as colleagues. We should not be afraid of sharing our difficulties; even the challenges related to role modeling.
Mistakes are universal. Maybe we should look for the bright side of being imperfect. Mistakes and lapses offer opportunities to share with students our strategy to deal with the ultimate challenge of being alive: we are all vulnerable. Clinical teachers able to acknowledge, share, reflect on, apologize and remediate their mistakes show students our commitment to a human value or trait that Rousseau called perfectibility. After all, being wrong is the first step towards being right.

I would like to go back in time and apologize to the intern in my story. I would like to share with him my frustration with failures of Brazil s healthcare system and how health professionals feel obligated to compensate for the lack of structure with their sweat. I would like to invite him to interview the patient again, with my support, gathering the correct piece of information and sharing the enlightening moment of insight related to getting to the final diagnosis and therapeutic plan. After completing our care of the patient, we would have a cup of coffee together, both chilling as partners and getting ready for the next patient.
 Marco Antonio de Carvalho-Filho, MD, PhD, is Associate Professor of Emergency Medicine - School of Medical Sciences - State University of Campinas - Brazil and Research Fellow in Medical Education - Center for Education Development and Research in Health Professions (CEDAR) - University Medical Center Groningen - The Netherlands

.The "educational alliance" as a framework for reconceptualizing feedback in medical education. Telio S, Ajjawi R, Regehr G. Acad Med. 2015 May;90(5):609-14. doi: 10.1097/ACM.0000000000000560.
Giving Voice to Values as a Professional Physician: An Introduction to Medical Ethics
Book Review by Rebekah Apple
The enculturation process is at once exciting and arduous to most medical students. Moving from didactic to clinical settings introduces a host of challenges, including self-doubt and fear. Stone, Charette, McPhalen and Temple-Oberle (2015, p. 751) identified four “domains of concern” for students, including uncertainty regarding expectations, insufficient knowledge, technical skills and anticipated negative experiences. Being afraid to speak up may be one of the most profoundly negative experiences for a medical student. They may experience confusion by a decision made or action taken by someone in authority. Worse still, they may disagree with such decisions or actions, without feeling able to speak up about it. The hierarchy naturally creates intimidation, leaving students feeling as though they cannot or should not speak up.

A new text by Ira Bedzow, PhD, Giving Voice to Values as a Professional Physician: An Introduction to Medical Ethics (2018), seeks to provide students with the tools to address such situations without fear of damaging important relationships.

Bedzow, assistant professor of medicine at New York Medical College and director of the Biomedical Ethics and Humanities Program, wrote the book for students to use as a framework to act upon ethical principles while forming their professional identities. According to Bedzow, it is reasonable for medical students to feel apprehensive about speaking up. “Many times, the fear of misspeaking creates a self-fulfilling prophecy of not being able to speak up,” says Bedzow. “Yet students can learn how to communicate their values and ask questions effectively. It just takes appropriate practice and proper guidance by faculty and peers.” He believes learning how to act ethically in clinical and interprofessional settings mirrors clinical training: the more they practice, the better they will become. In his classes at New York Medical College, Bedzow delivers more than ethics content; he works with students on communication, anticipating situations, and creatively addressing dilemmas.

The approach used in his book is based on a methodology created by Mary Gentile, professor of practice at the University of Virginia Darden School of Business and senior advisor at the Aspen Institute Business and Society Program. Giving Voice to Values is a values-driven leadership curriculum designed to equip professionals with tools to positively impact their environments through ethical behavior. “I saw its value for new initiates in healthcare,” explains Bedzow. Noting the importance for medical students to balance the expectations others have of them with those they have of themselves, Bedzow’s book is intended to guide students as they develop realistic strategies and action plans. As in his classes, the book calls upon students to examine decisions and then explore techniques for offering alternatives. In discussing how to improve students’ skills for ethical action, the key, he says, for effective peer and faculty guidance is to shift from critiquing the person to critiquing his or her strategy of action.

Bedzow feels traditional approaches to ethics education miss the mark, focusing extensively on what should be done in a particular situation, without including what students would actually do if they were faced with an ethical challenge themselves. “What I love about the Giving Voice to Values methodology is that it reinforces students’ desire to advocate for their own beliefs and for their own growth, (and) forces them to consider how to do so … by thinking about their own capabilities and limitations as well as the opportunities and potential hindrances they may encounter from others.”
The text covers topics including bias, patient autonomy, rationalizations, and addressing patient complaints, among others. “Even though in traditional medical ethics courses students learn about what should be done, they often leave class at a loss about what actual steps to take,” says Bedzow. This book aims to change that, moving students from examining moral theory exclusively to include learning what it takes to act on one’s moral decisions in practice. This is a skill that must be honed, states Bedzow, as opposed to “shooting from the hip. The hardest thing in ethics education in medical school is getting people to realize that improvement is possible. If they don’t think it’s possible, then they are going to be afraid to make mistakes rather than being willing to make mistakes in order to grow.”

The book is published by Routledge/Greenleaf Publishing and has received positive reviews from faculty at institutions including Harvard Medical School, Johns Hopkins Berman Institute of Bioethics, and the University of Colorado.

Rebekah Apple, MA, DHSc, is the Director of Student Affairs and Programming, American Medical Student Association.
1.Stone, J.P., Charette, J.H., McPhalen, D.F., & Temple-Oberle, C. (2015). Under the knife: medical student perceptions of intimidation and mistreatment. Journal of Surgical Education, 72 (4), 749-753. 7
Listen to the ACH/DocCom Podcast with Ira Bedzow, PhD 

The Academy of Communication in Healthcare and DocCom teamed up to sponsor a podcast – Healthcare Communication: Effective Techniques for Clinicians. Launched in late January, the 25-minute weekly podcast has over 7,000 downloads on over 40 topical subjects. Check out the list of released episodes on the link or on your favorite podcast platform
Professional Formation Newsletter Associate Editors :

Alya Heirali
Babu Krishnamurthy
David Doukas
Fernanda Patrícia Soares Souto Novaes – Professional Formation and Communication in Healthcare
Hanke Dekker
Janet de Groot
John Spandorfer
Julie Agris
Leann Poston – book and film reviews
Lorena Novaes
Marco Filho
Nazia Viceer
Patrick Herron
Preston Reynolds – biographies
Raul Perez
Rebekah Apple – bios and professionalism news
Sally Fortner
Stephen Gambescia – interdisciplinary issues
Tyler Gibb – ethics, law and professionalism
Virginia Bartlett
Please contact Janet de Groot if you'd like to contribute articles to this newsletter.
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