H. Dominic Covvey, National Institutes of Health Informatics
This is an article about work in progress that begs for improvement. This article is also an appeal for your thoughts and criticism. I’d greatly appreciate your feedback, and will recognize any contributions in a succeeding article.
A Danger of Credentialing
It is incumbent on our Health Informatics programs that we regularly assess what we produce, and our product is our graduates. What happens if we ask those who employ our graduates: “How are we doing?” I expect that the answer generally is a positive one perhaps moderated with a bit of constructive criticism. But sometimes the answer might not be what we hoped for.
Recently I learned that one program was taking to heart a criticism that some of its graduates exhibited arrogance that their employers found to be counterproductive. I won’t go into the details here as the finding may be spurious. However, my concern, from my own experience, is that this isn’t an isolated problem.
I expect that pretty well any credential can endow certain personalities with an excuse to be overly proud of their achievements and to act in overbearing ways…and maybe that’s just human. However, in this instance, the arrogance is consistent with certain stereotypes and indicates a real problem.
What was good about hearing of this problem was that it stimulated me to do some thinking about a crucial area of competency. Usually, when we enumerate competencies, we stop at knowledge (what we need to know), skills (what we must be able to do), and experience (practice in applying our knowledge and skills). However, there are two other components of competency: attitudes and values. Here I’ll focus on attitudes, as these underpin the problem cited above.
How Can We Identify the Attitudes We Expect of Health Informaticians?
Dictionaries define ‘attitude’ (in the sense of an emotion) as: the way that you think and feel about somebody or something, or the way that you behave towards somebody or a thing. [Oxford Advanced Learner’s Dictionary and Dictionary.com]. So attitudes need to be expressed as being exhibited towards someone or something.
Having a reasonably useful definition, I then snooped around and contacted a number of people regarding previous work on the definition of attitudes required of Health Informaticians. The search came up pretty dry, with only a few sections of articles addressing the identification of required attitudes. Even more disappointing, I found and virtually nothing suggesting a methodological approach to defining or deriving attitudes. However, I didn’t do a scientific search, and some of you might have material that I should consider. For now I’ll tell you where my thinking is regarding attitudes.
Given that I didn’t find a methodology, I decided to do a kind of ‘stakeholder analysis’ wherein I identified the types of people or things that would be exposed to the Health Informatician’s attitudes. I then asked myself the question: “What are the attitudes I should be expected to exhibit to each type of individual?”
The ‘stakeholders’ I identified to which I expose my attitudes are:
- Self and Family.
- Other People I Impact, e.g., applies to all types of people, or specifically to employer, clients (including patients), staff/colleagues, students.
- My Work/Teaching/Research.
- Others’ Work/Teaching/Research.
- Organizations and Their People, e.g., the healthcare process/system, healthcare providers, Professional Associations.
- The Discipline, e.g., the advancement of the knowledge base of HI itself; teaching, lecturing, speaking, mentoring.
- My Code of Ethical Behavior.
- The Law, Regulation and Standards of Morality, e.g., related to fraud, plagiarism, crimes of various types, abusive behavior.
This is just a framework for thinking. Some attitudes apply to all of these, while some apply to a few of them or just one. At the end of the exercise I’ll throw this away and aggregate the items I come up with, but the framework needs to be reasonably complete. I would love to hear from you about any perspectives I’ve missed.
When I fill in the attitudes associated with each of the above, this is what I’ve gotten so far.
The competent Health Informatician will have the following attitudes towards ‘stakeholders’:
Towards One’s Self and Family:
- Having appropriate self-esteem and personal security.
- Maintaining one’s health.
- Protecting and preserving one’s relationships.
- Avoiding arrogance/hubris and the statements and behaviors that indicate arrogance lines.
Towards Other People (applies to all types of people, or specifically to employer, clients – including patients – staff/colleagues, students):
- Holding others in respect and treating them with respect.
- Valuing others’ contributions.
- Communicating in ways that actually reach and involve others.
- Creating a positive and productive environment.
- Avoiding, managing and redirecting conflict.
- Listening actively and internalizing others’ communications.
- Being able to engage others in a way that helps them to realize personal value from the activity.
- Always shouldering the ‘burden of the proof’ when it comes to assertions.
- Delivering on your and your employer’s mutual understanding of your role and functions.
- Delivering on your and your clients’ mutual understanding of your role and functions.
- Recognizing and delivering on the expectations that are associated with collaboration.
- Recognizing students as progeny and the hope of the future.
- Taking the responsibility for instilling a commitment to excellence (and other crucial virtues) in one’s students.
- Fulfilling the responsibilities of one’s role as a teacher.
- Mentoring students and guiding their advancement and careers.
Towards One’s Work/Teaching/ Research (e.g. with respect to quality, completeness, timeliness, accuracy, etc):
- Being evidence-based.
- Being methodology-driven.
- Being appropriately skeptical.
- Being honest and truthful with respect to one’s work.
- Developing and sustaining a deep sense of curiosity.
- Aspiring to contribute meaningfully to the knowledge and experience base of the discipline of HI.
- Promoting only work and results that have been properly evaluated.
- Performing agreed-upon work and functions to the best of your ability.
Towards Others’ Work/Teaching/ Research (e.g. with respect to quality, completeness, timeliness, accuracy, etc):
- Being supportive and constructive when dealing with the work of others.
Towards Organizations and Their People (e.g., the healthcare process/ system, healthcare providers, professional associations):
- Adhering to the code of ethical conduct of your professional association.
- Holding the organization’s goals as one’s own.
- Serving the organization and its clients in agreed ways.
Towards the Discipline (e.g., the advancement of the knowledge base of HI itself; teaching, lecturing, speaking, mentoring):
- Teaching in ways that enhance engagement and participation, with patience and the recognition of others’ needs and learning style.
- Speaking/teaching only from competence.
- Embracing the needed knowledge base required for excellence in HI: medical science, computer and information science, social and management sciences, and implementation science.
- Recognizing the limits of one’s knowledge and expertise.
Towards the Law, Regulation and Standards of Morality (e.g., related to fraud, plagiarism, crimes of various types, abusive behavior):
- Recognizing the work of others by proper citation.
- Informing students and other charges of the nature of fraud, plagiarism and other criminal behavior and its avoidance.
- Reporting fraud, plagiarism or other crimes to the appropriate authorities.
- Exhibiting zero tolerance for abusive behavior of any kind.
- Recognizing and avoiding the application of bias.
Some Reflections on Attitudes
I have taught many grad students, and one consistent observation is that few, if any, ever had a course or a part thereof on ethics. I have always ended up teaching a code of ethical behavior and the reactions to this have been mostly gratifying. Most have said the material made them think, but the cultural diversity of my students made some of the elements of the material lack cogency to different individuals, as different cultures have different concepts of what is ethical. So agreement on a code in a culturally diverse country like Canada is not a given.
What’s interesting is that quite a few of the elements above closely parallel an older code of ethical behavior that was published by the Canadian Information Processing Society – which was one of the best I’ve seen. It even had part of the ‘stakeholder’ breakdown that I used above; I realized this only when I was finishing the first draft. I can’t help but conclude that proper attitudes for the Health Informatician subsume CIPS’ many other codes of ethical behavior that I’ve reviewed (e.g., IEEE, ACM, COACH,…all organizations of which I’m a member). So teaching attitudes also teaches ethical behavior. Ethical behavior seems to be at least subsumed by required attitudes.
Attitudes are as much an element of competency as knowledge and skills are.
When I shared this work with a colleague known for her work on the social sciences aspects of HI, her reaction was “what’s so special about HI regarding these attitudes?” I think she’s right. They are expectations in any area of professionalism and like beyond! On might also react that these are simply expected of humans in society.
So are they taught in HI programs? Maybe, but are all addressed and explicitly so? Not that I’ve seen. However, they may be embedded in other teaching and thus invisible to the outside eye. Again, I’d like to hear about your experience and what is addressed in your education programs.
How Can One Teach Attitudes?
My sense is that there are several ways one can teach attitudes, but they are experiential ways, not factoid-transfer. I had an exchange with that same colleague on how we should teach attitudes in our HI programs.
One way is to present students with cases that illustrate attitudes or the need for them. One could present some inconsistent (numbers with incorrect statistics about those numbers) or unfounded (e.g., you must drink 8 glasses of water each day) data that drive a decision, and then elicit student reactions that depend on attitudes like appropriate skepticism, for example. One could then discuss how one can maintain an appropriately skeptical mindset.
Another way is through play-acting. A student could take the role of a salesperson and another of a client, where one or the other manipulates a situation. This could be observed by a class and then critiqued.
Videos of well-acted situations can be used in much the same way. Mini-workshops could be convened to consider attitudes with respect to particular stakeholders, like employers or students.
Whatever method is used, it must be interactive and carefully sculpted so that the issues require some thinking to be dissected out and addressed. Often there will not be just one way of addressing the matter, and creativity from the students should be rewarded. I have several very simple cases I’ve used over and over again for years. Every now and then a particularly insightful student comes up with a different way of looking at the issue. That’s very pleasing when it happens.
How Can We Deal With Attitude Problems like Arrogance?
One thing that we may need to consider is testing entrants to see which attitude-space they occupy. If we had some idea where attitudinal weaknesses existed we might be more ready and able to remediate them. In some cases, maybe there should even be a filter that prevents those with inappropriate attitudes from getting into our programs – this certainly is the case in med school admission.
During training, we could periodically test students with respect to their attitudes. We already do this for knowledge and skills, so why not for attitudes?
When we bestow a credential on a person, we empower the person for good or for not-so-good.
As students complete programs, they should be evaluated through a process that psyches out their attitudes, just to make sure they were ‘imprinted’ properly. If we do this, we reduce the likelihood of having their future employers give us bad news.
Whatever else you get out of this article, please take the following messages: (1) attitudes are real and measurable; as such they can be taught and tested, (2) attitudes are as much an element of competency as knowledge and skills are, (3) attitudes cannot be left unaddressed, un-taught; they must be part of training or we will produce graduates with the capability of doing harm, and (4) attitudes need a lot more work done on them than this article; there is still a lot of definition and completion required.
When we bestow a credential on a person, we empower the person for good or for not-so-good. We’d consider it academic incompetence to teach falsehoods or to ignore areas of required knowledge and skills. If we are to achieve the ‘good’ outcome, we need to add attitudes to our list of required competencies – and we all need to think about them, internalize them, exhibit them and teach them.
I look forward to your comments.
Dominic Covvey (FACMI, FHIMSS, FCIPS, SMIEEE, ITCP) is an Adjunct Professor at the University of Waterloo and the University of Ontario Institute of Technology. He is also the President and Director of the National Institutes of Health Informatics. He was the Founding Director of the Waterloo Institute for Health Informatics Research at the University of Waterloo (2003-2010). His research is in the representation and analysis of healthcare workflow, the definition of competencies and curricula in Health Informatics and the design of the Electronic Health Record.