key: cord-1001717-iu82oida authors: Wright, Wyatt H.; Gunderman, Richard B. title: Pandemic Lessons: Online Professionalism Education date: 2020-10-08 journal: Acad Radiol DOI: 10.1016/j.acra.2020.09.015 sha: 22a20c51b45ca4534dd00e0416fe17195816c5a1 doc_id: 1001717 cord_uid: iu82oida nan Wyatt H. Wright, BA, Richard B. Gunderman, MD, PhD P rofessionalism is one of the six competencies that ACGME-accredited residencies are expected to teach and assess. Some residency and fellowship programs have developed solid programs in this area, but despite the passage of two decades since the competencies were established, others still struggle with professionalism education. These difficulties have been compounded by the COVID-19 pandemic, which has forced many programs to move much of their education to an online format, where education in professionalism can present special challenges. It is vital that both educators and learners understand these challenges if professionalism education is to thrive, especially during the pandemic. Broadly speaking, the ACGME has described professionalism as encompassing multiple attitudes and patterns of conduct in daily medical practice: Compassion, integrity, and respect for others; responses to patient needs that supersede self-interest; respect for patient privacy and autonomy; accountability to patients, society, and the profession; and sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation (1) . As this description implies, professionalism education places a premium on interpersonal interaction and relationships. Here arises one of the central challenges of online professionalism education. Though real-time interaction between educators and learners and between learners themselves is still possible, our experience with online education has been that it is less interactive. Educators seem likelier to do more of the talking, and levels of learner participation and interaction seem to be reduced, a problem exacerbated when each is not visible to the other. Professionalism is at least as much about a sense of identity as a set of practices, and to promote identity formation, it is important for participants in online professionalism education to see one another. In the online setting, wherever possible, video should be utilized. Of course, the audiovisual capabilities of online education generally lag the degree of communication that in-person education can provide. People communicate not only with words but also through more subtle cues (2) . Nuanced changes in facial expression may be poorly captured by online platforms, and the same goes for subtle variations in vocal intonation and inflection. Moreover, most video feeds capture only the participants' heads, often failing to convey hand gestures and changes in posture. The combination of audio and video is better than audio alone, but key aspects of in-person communication may still be left out. Another challenge centers on responsibility. People tend to feel less responsible to one another if they feel less personally connected. For example, they may make harsh comments to one another via text messages or e-mail that they would not make if they were talking in real time over the phone, and they may say things over the phone that they would not say faceÀto-face. Since professionalism hinges in part of a strong sense of responsibility, professionalism education needs to strive to create personal connection. For example, time should be devoted to encouraging participants to get to know one another. Because professionalism is not merely a set of rules but also a stable disposition of perceiving, understanding, and feeling, learners need opportunities to test it out and practice it. No one should suppose that simply because residents attend an online lecture, they will act professionally. In daily interactions with patients and families, residents and fellows, and colleagues, faculty members need to serve as role models of professionalism. Material covered in online education will seem relevant and important to learners to the degree that it seems connected with the work they do. In other words, when it comes to professionalism, online education alone is generally not enough. The insufficiency of lectures, whether online or in person, highlights what is often referred to as the informal or implicit curriculum of radiology education. The formal curriculum appears in learning objectives, lecture slides, and assessment instruments, but the implicit curriculum is what learners determine they need to know and do without having formally been told so (3, 4) . It does little good to promote the highest ideals of professionalism if learners observe unprofessional conduct in daily practice. In fact, such inconsistency or even hypocrisy may inflict a great deal of harm. Educators must speak out in support of professionalism but also follow through by exemplifying it. For related reasons, the best place to teach professionalism is often the point of care, where radiologists are interacting in real time with patients and referring health professionals. When challenges to professionalism arise in such settings, educators can share with learners what they are attending to, thinking about, and feeling, and ask them questions about their own responses. The same applies where opportunities arise to embody high ideals of professionalism, such as going above and beyond the minimum required to protect patients and others. Online educational curricula can prime the pump so to speak, but the actual work of professionalism takes place in practicing radiology. On the other hand, a formal online curriculum can simulate such point-of-care experiences in helpful ways. For example, learners can be presented with scenarios drawn from real life and challenged to identify key aspects, outline alternative responses, and formulate their own approach to each situation. Such scenarios might involve such features of professionalism as integrity, compassion, respect, and dedication. Many online platforms allow participants to be placed into small groups, in which they can discuss such cases and then report their perspectives and recommendations to the larger group. Such interaction fosters collegiality and cooperative learning, both of which are crucial for professionalism. In some respects, online formats can even promote professionalism education. Suppose, for example, that learners are based at multiple different sites sufficiently distant from one another that it would be difficult or impossible for them to assemble in person (5) . In such a situation, the online approach may permit interaction that otherwise could not take place. Online interaction is generally not as robust as in-person interaction, but even an inferior form of a good opportunity is generally superior to its absence. If such online sessions are well configured and facilitated, at least a portion of the format's inherent limitations can be overcome. As many programs discovered at the onset of the COVID-19 pandemic, residency and fellowship programs that had platforms available for online education enjoyed an advantage over those that did not, as did programs that already had experience with their use. Such experience can come in handy in other situations, too, such as residents and fellows who are traveling, injured, or ill, and therefore prevented them from attending in-person education sessions. Learners who might otherwise miss out on sessions on professionalism and other topics can often continue to participate online, whether or not other participants are gathered in person. In sum, necessity is the mother of invention, and in the face of the COVID-19 pandemic, many residency and fellowship programs rapidly developed or acquired the ability to provide online opportunities for education that had formerly taken place in person. To make optimal use of such online platforms, both educators and learners need to understand their strengths and weaknesses, as well as their risks, costs, and benefits. In many respects, teaching professionalism online involves inherent disadvantages compared to in-person education, but those who understand it well can take steps to mitigate and, in some settings, even improve on them to offer a superior educational experience. Chapter 7: new standards for resident professionalism: discussion and justification. In: The Accreditation Council for Graduate Medical Education (ACGME) What we don't know we are teaching: unveiling the hidden curriculum Designing a curriculum for professionalism and ethics within radiology: identifying challenges and expectations Conversations across continents: teaching business ethics online