University of California San Francisco
UCSF School of Medicine UCSF Medical Center

SOAP Framework for Professionalism

SOAP (an approach to assessment and diagnosis of a struggling learner)

S (SUBJECTIVE/SELF): The judgment/sense that there’s a problem; locate your self
  • Important to acknowledge, but only a starting point. Should initiate the process, but not the assessment
  • Recognize what you bring to the table: emotional state, assumptions, historical or current power/privilege, past experiences, implicit biases and other factors.  
  • Identify structural biases that might impact the way the trainee performs, or the way you assess them
  • Consider, is this actually unprofessional?
  • Definitions:
    • Structural competency: “The trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases (e.g., depression, hypertension, obesity, smoking, medication “non-compliance,” trauma, psychosis) also represent the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, or even about the very definitions of illness and health” (Metzl 2014)
    • Cultural humility: “A lifelong process of self-reflection and self-critique whereby the individual not only learns about another’s culture, but one starts with an examination of her/his own beliefs and cultural identities” (Tervalon & Murray-Garcia, 1998)

Tool: Definitions of Professionalism

Physician Charter on Medical Professionalism (ABIM 2002): Four core values

  1. Compassionate, respectful and collaborative orientation: focus on being “in service” of the patient
  2. Integrity and accountability
  3. Pursuit of excellence
  4. Fair and ethical stewardship of health care resources

Dr. Catherine Lucey (2010): “… not an innate quality but a skill developed with deliberate practice over time…Demonstrated through a set of behaviors, observed in two key domains: 

  1. Individual interactions with patients, family members and colleagues in the health care team, 
  2. Organizational interactions in the management and governance of care delivery settings and in professional organizations.”

ABMS (2012): “…a belief system about how best to organize and deliver health care, which calls on group members to jointly declare (“profess”) what the public and individual patients can expect regarding shared competency standards and ethical values and to implement trustworthy means to ensure that all medical professionals live up to these promises.”

Dr. Stephen Ludwig, 2020: “… a lifelong developmental process that informs the effective, ethical, and safe practice of the healing skills”. 

Tool: Domains of Professionalism

Wilkinson (2009) defined 5 domains of professionalism in the health professions:

  1. Adherence to ethical practice principles
  2. Effective interactions with patients and those important to patients
  3. Effective interactions with people working in the health care system
  4. Reliability
  5. Commitment to autonomous maintenance/improvement in self, others 
  6. and systems

Tip: consider how each of these might be expressed in different settings 

Tool: Professionalism as a Competency

  From → To
Genesis Character Trait → Lifelong Process
Educational Approach Rules, Roles, Models → Individual Development
Evaluation Assumption → Assessment
Lapse Flaw → Opportunity
Reaction Discipline & Removal → Coaching & Prevention

O (OBJECTIVE/OTHER): Review objective information (behaviors, data, patterns) and consider other perspectives (including the trainee’s) that will help define the problem, and develop hypotheses
  • Gather objective information to further categorize the problem (i.e.: domain, scope)
  • Observe over time, collect specific examples
  • Other perspectives: consider the risks/benefits of “feed forward” vs “nothing about me without me”
  • SOURCES OF INFORMATION to consider (*all may be subject to/introduce bias)
    1. Supervisor observation of clinical encounters
    2. Interdisciplinary team members’ collated views of trainee (360 review)
    3. Critical incidents/Records of professionalism lapses
    4. Patient opinions/feedback
    5. Academic records/exam scores
    6. Self-administered rating scales
    7. Trainee perspective (see below)
  • Have a timely initial conversation with the learner (*See last page of handout for helpful tips*)
    • Do not delay this too long, even if you are still collecting information
    • The purpose of the conversation is to hear their perspective, test/gather new hypotheses, and to assess the learner’s insight and adaptability (Mak-van der Vossen, 2016)

Tool: Opening the Conversation

  • Be direct, honest and kind
  • Show respect, trust and appreciation (“you are important to me, and your success is important to us both”)
  • Can start open-ended, such as: “How are things going from your perspective?”
  • Alternatively, could describe the performance/behaviors that you have observed, without assigning personality or motivation 
  • Stay on message. Don’t expect appreciation or gratitude!

Tool: ABCD’s of Coaching Conversations

  • Ask permission
  • Describe the Behavior
    • Use real examples, and focus on behavior and its impact, not person
    • Use “I” rather than “you” statements
  • Anticipate Common responses and pause for response/reflection
  • Dialogue: Facilitate action-focused reflection

A (ASSESSMENT): Refinement of hypotheses and assessment of the learner’s insight and adaptability
  •  Consider the differential diagnosis and objective data, as well as its limitations
    • What is the leading hypothesis? Are there other possibilities? How will you distinguish between them?
    • What information don’t you have access to (prior performance, personal circumstances)
    • Be sure to consider mental and/or physical health and well-being

P (PLAN): Plan should be based on your assessment of the scope/severity of the incident, the explanation/ motivation for the behavior, as well as the insight and adaptability of the learner 

Tool: Plan Based on Readiness for Change (Insight vs Adaptability

  • High insight/high adaptability
    • Example: Learner is aware of behaviors and understands they need to change. Likely to drive plan somewhat independently and can be supported in setting own goals and achieving them. 
  • Low insight/high adaptability
    • Example: Learner may need additional support to further understand the impact of behaviors. May need guidance and support in developing a plan and meeting goals, but prognosis is good
  • High insight/low adaptability
    • Example: Learner is aware of behaviors and their impact, but is unwilling/unable to change them. Needs very explicit guidance, and may need to be met at a mutually agreed-upon middle ground
  • Low insight/low adaptability
    • Example: Learner neither recognizes why behaviors need to change, nor is open to change. May only respond to external forces/regulations. Needs concrete measures and consequences, and extremely close supervision 

ART (an approach to a supportive conversation with a learner)

ASK-RESPOND-TEACH

  • Ask: Get the learner’s perspective. 
    • Are they aware of the behaviors? 
    • Are they aware of why you are concerned? 
    • Are they aware that these behaviors are problematic and why?
    • Do they have an explanation?
  • Reflect/Respond: Show empathy, appreciation and respect for their perspective. 
    • Correct misinformation – focus on performance/behaviors that you have personally observed, and their impact
    • Ask further clarifying questions if necessary (“I didn't realize you had so much going on. How else do you feel your personal circumstances have been affecting your performance?”)
    • Ask for their ideas for how to correct the problem
  • Teach: Describe explicitly the impact of the behavior(s) and what you expect going forward
    • Describe behavior standards, if appropriate
    • Share your ideas/plan for next steps
    • Describe specific endpoints, with a reasonable timeline
    • If appropriate, discuss consequences if behavior does not change

GROWS (a coaching approach to supporting a learner in difficulty

GROWS model for coaching (Palomara, MGH)

  • G: Goal - agree on goal together, should be aspirational!
  • R: Reality – What do things look like now? What obstacles need to be overcome?
  • O: Options – brainstorm at least 3 ways to move forward/next steps
  • W: Way forward – which option makes sense for now?
  • S: Success – how will we know we have achieved the goal?

SUMMARY: Best Practices for Professionalism Coaching
  • Have the conversation
    • Strive for an empathic, trusting opening conversation (see page 5 for example)
    • Keep your differential broad
  • Provide instruction with practice, feedback and reflection
    • Critical reflection 
    • Individualized improvement plan
    • Explicit faculty mentorship and coaching
    • Reassessment and certification of competence
  • Set clear expectations and be consistent
    • Document the expectations and consequences for professionalism
    • Utilize existing frameworks (Wilkinson/Papadakis, SOAP, Vanderbilt pyramid, etc.)

REFERENCES AND RESOURCES

References: 

  1. ABIM Foundation, ACP-AIM Foundation, European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002; 136(3): 243-246
  2. Bracken RC, et al. Generational situatedness: challenging generational stereotypes in health professions education. Medical Teacher 2023; 45(4), 380-387.  
  3. Brody H. Professionalism: a framework to guide medical education. Medical Education 2014; 48: 980–987 
  4. Hauer KE, et al. Remediation of the deficiencies of physicians across the continuum from medical school to practice: a thematic review of the literature. Acad Med 2009; 84(12): 1822-32
  5. Hickson GB, Pichert JW, et al. A complementary approach to promoting professionalism: identifying, measuring and addressing unprofessional behaviors. Acad Med 2007; 82:1040-1048
  6. Guerrasio J, et al. Learner deficits and academic outcomes of medical students, residents, fellows, and attending physicians referred to a remediation program, 2006-2012. Acad Med 2014; 89:352-358
  7. Guerrasio J, et al. Long-term outcomes of a simulation-based remediation for residents and faculty with unprofessional behavior. J Grad Med Educ 2018;10(6):693-697 
  8. Jauregui J et al. Generational ’othering’: the myth of the millennial learner. Medical Education 2020; 24(1): 60-65
  9. Lesser CS, Lucey C. A behavioral and systems view of professionalism. JAMA 2010; 304(24): 2732-2737
  10. Lucey C et al. The problem with the problem of professionalism. Academic Medicine 2010; Vol. 85, No. 6 
  11. Ludwig S. Professionalism. Pediatrics in Review 2020; 41(5)
  12. Mak-van der Vossen MC, et al. Distinguishing three unprofessional behavior profiles of medical students using latent class analysis. Acad Med 2016; 91:1276-1283
  13. Papadakis MA, Teherani A, et al. Disciplinary action by medical boards and prior behavior in medical school. NEJM Dec 2005; 353(25): 2673-82
  14. Papadakis MA, Arnold GK, et al. Performance during internal medicine residency training and subsequent disciplinary action by state licensing boards. Ann Int Med June 2008; 148(11): 869-76
  15. Regehr G. “Kids these days”:  Reconsidering our conversations about millennial learners.  Medical Education 2020; 24(1): 10-12
  16. Regis T et al. Professionalism expectations seen through the eyes of resident physicians and patient families. Pediatrics 2011; 127 (2): 317-324
  17. Van Mook WNKA, et al. Approaches to professional behavior assessment: tools in the professionalism toolbox. Eur J Int Med 2009; 20:e153-e157
  18. Wilkinson, T J, Wade, W B, & Knock, L D. (2009). A blueprint to assess professionalism: results of a systematic review. Acad Med 2009; 84(5): 551-8
  19. Ziring D, et al. How do medical schools identify and remediate professionalism lapses in medical students? A study of U.S. and Canadian medical schools. Acad Med 2015; 90:913-920

Resources: 

  1. Vanderbilt Center for Patient and Professional Advocacy https://www.vumc.org/cppa/45372
  2. Center for Professionalism and Value in Health Care: https://professionalismandvalue.org/professionalism