How I Teach Professionalism With Ariela Marshall, MD

Ariela Marshall, MD
Assistant Program Director, Hematology Fellowship, Mayo Clinic; First-year faculty member for the ASH Medical Educators Institute (MEI)

Ariela Marshall, MD, talks about modeling professional communication for trainees by respecting patients’ and colleagues’ differences in gender identity, culture, ethnicity, sexual orientation, and ability.


In your opinion, what is meant by “professionalism?”

As physicians, we are expected to treat our patients and each other with compassion, respect, and dignity. In order to do that, we must be sensitive to individual differences in gender, culture, ethnicity, sexual orientation, and ability, taking them into account when communicating.

We tend to think of professionalism as the way we interact with patients, but the way we treat one another is important as well. Academic medicine has a hierarchical structure, so those teaching and leading others especially need to model respectful, professional behavior.

Describe the importance of language in conveying that level of professionalism and respect.

Language is primarily how we communicate and interact, and how we get teaching or clinical points across to our patients and peers. We need to use language to convey what we think and feel, and ultimately to transmit what we are modeling to our trainees and our patients.

A recent study published in the Journal of Clinical Oncology looked at speaker introductions at a large international oncology conference and found that female speakers are less likely to be introduced by their professional titles than male speakers.1 People introducing female speakers were more likely to call them by their first names, while they were more likely to call the male physicians “Doctor.”

Interestingly, that difference was only seen when the person doing the introductions was male. If a woman was doing the introduction, she was just as likely to call a female physician “Doctor” as a male physician.

We tend to think of professionalism as the way we interact with patients, but the way we treat one another is important as well.

I don’t think anyone is trying to be disrespectful on purpose, but if you aren’t paying careful attention, unconscious biases can slip out. We need to make a conscious effort to ask, “How am I going to treat my peers with respect? What do they want to be called?”

How do you model professionalism and respect? Is it a difficult concept to teach?

In a clinical setting, we typically introduce ourselves when we walk into a patient’s room. For instance, I would say, “I’m Dr. Marshall. Nice to meet you,” and the patient might respond with, “I’m Barb.” It’s a good practice to check in with the patient and ask, “Is that what you prefer to be called, or do you like Mrs. Jones?”

In addition to introductions at conferences by peers, I’m sure many of my fellow women in medicine find themselves in situations where patients are more likely to call us by our first names. When this happens, especially when we’re teaching and have trainees with us, it’s important to model that behavior so that they feel comfortable doing the same thing in the future. For instance, if a patient calls me by my first name, I might say, “Thank you, Mrs. Jones. I would prefer to be called Dr. Marshall just because that’s my professional title.”

I think there are always going to be some patients who still want to call you by your first name or don’t feel it’s appropriate to call you “Doctor.” I understand their perspective, and if you have a good relationship with the patient that may be fine with both of you, but by the same token, we’ve done the training and earned that title, so when we model these discussions with trainees we should be cognizant of the language we use.

Sometimes, we might feel awkward introducing ourselves as “Doctor,” which can lead to awkward interactions. I felt uncomfortable calling myself “Doctor” as a trainee, but over time, I’ve come to understand that it’s not bragging or conveying a difference in power. Instead, it’s setting up a respectful, professional interaction between you and your patient. You’re not there for the main purpose of being a “pal” to your patients. You can certainly develop a close relationship over time, but ultimately you’re there to offer the best medical care possible.

Is it common for trainees to feel uncomfortable with titles?

It depends on the individual. I’ve had some trainees who introduce themselves by their first names. Afterward, I usually take them aside to say, “I know you want to be approachable to your patients, but it’s more professional to introduce yourself as Doctor.”

It’s not just a name issue. We’ve also had situations where patients have made inappropriate comments about their physician’s ethnicity, especially if the physician is internationally trained. For example, the patient would ask, “Where are you from?” and when the physician responds, “I’m from Georgia,” the patient asks, “No, where are you really from?” Another instance is when a patient says they don’t understand a physician’s accent when they don’t actually have much of an accent. These interactions might sound harmless, but they can wear on people if they hear them time after time from many patients. If I observe this behavior, I always try to intervene in a way that’s respectful to the patient.

You don’t want to yell at anyone, but it’s important to make them aware of the consequences of what they’re saying. These can be awkward conversations, but as responsible physicians and educators who are trying to model professionalism for our patients and trainees, it’s our job to jump in so both our trainees and patients know that the behavior is not accepted. Many institutions are coming up with codes of conduct for how to treat each other respectfully. Mayo Clinic is leading the way on this with their “5-Step Policy for Responding to Bias Incidents.”

Should professionalism and respect be included in medical school curricula?

Yes, and the Accreditation Council for Graduate Medical Education (ACGME) already does a fairly good job of this. The six ACGME Core Competencies are:

  • Practice-Based Learning and Improvement
  • Patient Care and Procedural Skills
  • Systems-Based Practice
  • Medical Knowledge
  • Interpersonal and Communication Skills
  • Professionalism

Of course, there’s always room for improvement. We could step up our efforts around peer-to-peer interactions as well as those hierarchical attending-to-student/trainee interactions. I also think it’s important that we cover what to do if a patient, colleague, or somebody in a position of leadership is behaving unprofessionally.

How did you learn about professionalism and respect in language? Did you ever have to adjust your own ideas about it?

Over the course of my career, I’ve become more aware of implicit bias and microaggressions and started to feel more comfortable responding to them. While medical schools do a decent job of teaching cultural competency – being aware of patients’ differences that might affect their care – we’re not yet at the point of talking about what can happen to you as a physician that’s unprofessional and the best ways to respond. I’ve been on the receiving end of unprofessional behavior and, during my first few years as a trainee, I responded by brushing it off or letting it go. Now, as these issues are coming to light, people are more aware and more apt to step up and do something about it.

I’ve gotten more comfortable saying something if something happens to myself or, especially, to one of my trainees. Even when we might feel awkward speaking up for ourselves, we have a moral obligation to our trainees, so it’s much easier to say something if we see something unprofessional or inappropriate happening to one of them.

For example, a patient once said to one of my trainees, “I don’t want any foreign doctor. I don’t feel comfortable with that.” At the end of the visit, I said, “I want to address something you said at the beginning of this visit about not wanting to see a foreign doctor. Can you tell me about that? Why did you say that? Because that could make some people feel uncomfortable.” That led to a conversation that was eye-opening for both the patient, who realized that this wasn’t an appropriate thing to say, and the trainee, who otherwise might have just vented to their peers about it later.

References

  1. Duma N, Durani U, Woods CB, et al. Evaluating unconscious bias: Speaker introductions at an international oncology conference. J Clin Oncol. 2019;37(suppl):10503.
  2. Warsame R M and Hayes S N. Mayo Clinic’s 5-Step Policy for Responding to Bias Incidents. AMA J Ethics. 2019;21:E521-529. https://journalofethics.ama-assn.org/article/mayo-clinics-5-step-policy-responding-bias-incidents/2019-06
  3. NEJM Knowledge+ Team. Exploring the ACGME Core Competencies: Professionalism (Part 7 of 7). NEJM Knowledge+. January 12, 2017. https://knowledgeplus.nejm.org/blog/acgme-core-competencies-professionalism/